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Connecting for Health's billion pound suppliers: the top 10

Steve Gold — Wed, 08 Sep 2010 08:00:00 GMT

SmartHealthcare.com reveals the 20 organisations which together received £1bn from the NHS's IT agency in 2009-10

In the last financial year, NHS Connecting for Health (CfH) spent £1.1bn with suppliers, according to official data published today by SmartHealthcare.com. The largest suppliers dominate the rest: the top 100 (listed in full here) received £1.064bn and the top 20 – which we profile below – got £1,000,274,185.07, according to the Department of Health.

The two top names, BT and CSC, are not a surprise, given they now hold all the large contracts for the National Programme for IT: together, they account for 62% of all spending by the agency, which also pays for legacy work started by its predecessor, the NHS Information Authority. SmartHealthcare.com has updated its existing profiles of the two firms (article) to include this new data, and has done likewise with three other firms – Atos Origin, Emis and iSoft – that we have already profiled.

The third-largest supplier – reseller Bytes – is less expected. Two other resellers appear in the top 10, Trustmarque and Computacenter, demonstrating that this type of business may not get much publicity, but does represent significant amounts of CfH's business. Similarly, several providers of IT staff appear in the top 20, including Qi, ASE and Elan.

The Department of Health has released how much CfH spent with each supplier under Freedom of Information, but not what on – this was not included within the scope of SmartHealthcare.com's request, and it's unlikely the department would have provided such data, with commercial confidentiality usually cited in such cases. For each of the 15 new profiles below, we have mentioned known major deals between the organisation and CfH, but also other significant work for the NHS across the UK and in some cases the rest of the public sector.

1. BT
Spending by NHS Connecting for Health, 09-10: £469.9m (43% of total)
Click here for a profile of BT's work for the NHS.
Click here for SmartHealthcare.com's coverage of BT.
Company website

2. CSC
Spending: £213.2m (19%)
Click here for a profile of CSC's work for the NHS.
Click here for SmartHealthcare.com's coverage of CSC.
Company website

3. Bytes Technology Group
Spending: £57.9m (5.3%)
Despite a low profile, reseller Bytes was the largest supplier to NHS Connecting for Health in 2009-10 apart from the two surviving local service providers. Now in its third decade of operations, Bytes has its UK headquarters in Surrey, and parent operations in South Africa. The firm, which focuses on trusts in London and the south, the north west and West Midlands, focuses on online and virtual IT products plus services, including Microsoft BPOS (Business Productivity Online Suite) and VMWare. With major links with Oracle and Symantec, the firm has an NHS-specific division offering single and half-day courses on software, VMWare and other types of IT training. Bytes also offers the Centennial discovery tool as a hosted service.
Company website

4. Fujitsu Services
Spending: £37.7m (3.4%)
After having its local service provider contract for the south of England with CfH terminated by mutual agreement in May 2008, Fujitsu is still performing a significant volume of work for CfH. The Japanese-based IT services company employs 18,000 people in more than 20 countries, and its through its ownership of once-dominant UK IT firm ICL – whose name it finally dropped in 2001 – the firm has NHS IT history dating back to at least the 1980s. It has around 20 offices scattered across the UK providing a wide range of IT services to the NHS. Fujitsu has deployed PACS and RIS at around 170 locations across 38 trusts, including three trusts outside its former local service provider area: James Paget Healthcare trust in Great Yarmouth, Royal Liverpool and Broadgreen University Hospital and University Hospitals Coventry and Warwickshire.
Company website

5. Atos Origin
Spending: £36.5m (3.3%)
Click here for a profile of Atos Origin's work for the NHS.
Company website

6. Emis
Spending: £27.5m (2.5%)
Click here for a profile of Emis's work for the NHS.
Click here for SmartHealthcare.com's coverage of Emis.
Company website

7. Trustmarque Solutions
Spending: £25.1m (2.3%)
Trustmarque Solutions is an IT software and services reseller originally focusing on the north east and Yorkshire which now services trusts nationally through a Department of Health linkup. The firm, which has offices in London, York and Edinburgh, uses a consultancy, SAMpartners, to assist in trust deployments, notably of Centennial. Dating back to 1987, the firm is a Microsoft Enterprise Agreement Partner with the North East and Yorkshire and the Humber strategic health authorities, as well as for the NHS in both Scotland and Wales. With strong partner links to vendors including McAfee, Microsoft and Novell, the company claims its systems are in use by 90% of UK health trusts.
Company website

8. Cable & Wireless
Spending: £23.5m (2.1%)
With its origins in telecoms, C&W now supplies many internet, email and phone systems to the NHS. The company is the central supplier of CfH's NHSmail service, which aims to move the health service's email wholly to NHSmail by 2013. Along with BT, it was also one of the major suppliers of NHSnet, the forerunner of N3, providing a national internet service for health service organisations. It created its own national network in the 1980s covering cities across the UK, since when it has provided facilities to police forces and many UK government departments and agencies, many through the Government Secure Intranet which it provides for the Treasury's Buying Solutions unit. It has offices in London, Bracknell, Birmingham, Manchester, Leeds and Glasgow.
Company website

9. Computacenter
Spending £18.1m (1.6%)
This pan-European reseller has a long history of supplying to the NHS dating back to the 1980s and has major contracts with a number of trusts and NHS Wales. A Microsoft Enterprise NHS partner, the firm has supplied Queen Elizabeth Hospital King's Lynn, Hinchingbrooke Health Care, NHS Great Yarmouth and Waveney, and the East Kent Hospitals University Foundation Trusts.
Company website

10. Qui Imus (Qi Consulting)
Spending £12.6m (1.1%)
A specialist provider of public sector IT consultants, covering the MoD, local authorities and criminal justice as well as NHS, this firm has more than 450 consultancy staff. It has supplied Barts & the London, Basildon & Thurrock University Hospitals, Lincolnshire NHS Shared Service, the East Midlands, North West and South Central strategic health authorities as well as NHS Wales.
Company website

The 11th to 20th largest suppliers

The top 100 suppliers: full list

Comment

Steve Gold

Digital dictation: a voice for healthcare

Steve Gold — Wed, 01 Sep 2010 08:00:00 GMT

SmartHealthcare.com looks at eight of the main UK suppliers: BigHand, Dictate IT, G2 Speech, Nuance, Softech, SRC, Voice Technologies and WinScribe

Digital dictation (DD) suppliers are split broadly into two camps: those with their own platforms, and integration vendors that develop bespoke systems for clients. Most sell through resellers and partners, with support functions split between the partner and the vendor.

Most will supply an integrated system that interfaces with, for example, a patient administration system (PAS) and electronic workflow systems, but some - notably Nuance - will supply shrink-wrapped software for healthcare IT departments to deploy and customise.

The market is evolving rapidly, largely owing to the increasing speed of PCs, servers and smartphones. The following list, organised alphabetically, is not intended to be exhaustive but provides a guide to some of the major suppliers.

BigHand (site)

London-headquartered BigHand was set up in 1996, and its DD software is now used by more than 100,000 users in more than 1,000 organisations. The firm is financially backed by the private equity division of Lloyds TSB.

As well as offering a server-based DD system, the BigHand3 platform is available for the BlackBerry, iPhone and WindowsMobile smartphones in areas as diverse as legal and healthcare. In August, it launched a healthcare specific version of its suite of products, with product features designed specifically for the NHS.

The firm's latest flagship trust project is at the Mid Yorkshire Hospital trust, which services a population of 500,000, with new hospitals entering service in Pontefract and Wakefield this current financial year.

BigHand has been quite successful in signing new NHS trusts to its list of clients, including the Princess Alexandra Hospital trust and, more recently, three trusts using the Yorkshire and Humber NHS framework deal for DD: Basildon and Thurrock University Hospitals, The Ipswich Hospital and Airedale NHS foundation trust.

Dictate IT (site)

Another London-based firm, Dictate-IT has two flagship NHS trusts, Derby Hospitals foundation and Newham University Hospital, and has a platform based on software originally developed by GPs and other doctors.

With a total of 27 trusts using its technology - including Imperial College Healthcare, The Royal Free, St George's Healthcare, Barts and the London, Barnet & Chase Farm Hospitals, Guys & St Thomas Foundation, East and North Hertfordshire - the firm claims its product is unique in terms of its GP origins.

The company boasts a wide range of partnerships with Cerner, EMIS and iSoft, as well as Microsoft for Windows and Philips. The firm's DD technology interfaces with some PAS and electronic patient record (EPR) systems.

In April 2010, Barnet and Chase Farm Hospitals trust integrated Dictate IT's technology into a Cerner Millennium electronic patient record system following two years of usage. The trust is now using it general surgery, paediatrics, cardiology and 22 other specialities.

In July 2010, the company won the UK's largest ever NHS outsourced transcription contract with Barts and the London, covering an estimated 7m lines of text a year.

G2 Speech (site)

Founded in 1998 by two medical professionals, G2's technology centres on speech-to-text technology, which it claimed is up to seven times more efficient than traditional transcription systems, with a direct cost saving of 30% compared with conventional secretarial support services. The firm has offices in Belgium, Ireland and the Netherlands, as well as the UK.

The company, which unlike some of its rivals is focused on healthcare, claims to have 10,000 users of its technology. UK trusts are serviced from two offices, in Leeds and London.

In March 2010 G2 was nominated in three categories at the Philips Partner Awards Ceremony for its marketing, partner and technical prowess. The firm won the former category award. Since then the company has aligned its technology with the Dragon voice recognition platform and most recently with Microsoft Windows 7.

The firm's flagship trusts include Scottish health board NHS Borders and Southampton University Hospital foundation trust, where its MediSpeech platform was installed earlier this year.

Nuance Communications (site)

Massachusetts-based Nuance supplies both speech and imaging software to a variety of sector including healthcare, where its Speech Magic and newly-introduced Dragon Medical packages are in widespread use.

The firm's technology is based on the old Dragon Naturally Speaking speech recognition platform, which dates back to the early 1990s and has been updated to support medical terminology in 75 specialities and sub-specialities.

The firm claims that Dragon Medical is up to 99% accurate when used out-of-the-box, allowing staff to 'drive' their own speech-text sessions, with the resulting files then stored in EPRs.

Nuance's software is sold as a shrink-wrapped package for trusts to install themselves, as well as through DD partner firms.

Softech Global (site)

Formed in 1990, Softech has its headquarters near Brighton, with a sales and marketing operation in North Yorkshire and research and development operations at two sites in India. Over the last eight years the firm has invested more than £2 million in R&D.

Its Nomad DD system is used by a number of trusts, including Leeds Teaching Hospitals, Oxford Radcliffe Hospitals and The Rotherham foundation trust.

Earlier this year, Softech announced an expansion of its software's use at University Hospital Birmingham foundation trust where, after a year of usage, around 400 users in 29 departments across two sites are using Nomad.

In April 2010, The Rotherham started a complete implementation of Nomad, following a series of trials lasting four years, during which it was integrated into the trust's McKesson PAS. The system is already live in orthopaedics and rheumatology.

SRC (site)

SRC sells and services DD systems from Grundig, Nuance, Olympus, Philips and Winscribe. The London headquartered firm has systems installed at more than 2,500 sites in different sectors worldwide.

NHS clients include Chesterfield Royal Hospital, Dartford and Gravesham trust, Ealing Hospital, Royal Wolverhampton Hospitals, Taunton and Somerset Hospitals, Trafford Healthcare and more than 40 others.

In February 2010, SRC secured a 2,000-user contract with University Hospitals of Leicester. Spanning three sites, the Winscribe system supports the DD needs of 50 specialities in nine clinical directorates, making it the largest acute hospital implementation in the UK.

This summer (2010), the firm deployed a trust-wide electronic discharge summary system for the Hillingdon Hospital trust in west London, catering for 800 patient discharges a week.

In August the firm launched a web-based clinical correspondence platform in conjunction with Bluewire Technologies, following trials with two NHS trusts. As with many DD systems, this integrates closely with PASs as well as with SRC's Winscribe system.

Voice Technologies (site)

Voice Technologies, with offices in Glasgow and Sheffield, claims to be the largest supplier of DD technologies to the NHS, with its systems in use by more than 350,000 clinical staff worldwide. Covering the health and legal sectors, the firm is a Philips and Winscribe senior partner.

In July 2010, the firm won a contract to supply its WinVoicePro platform to NHS Tayside, NHS Highland and NHS Dumfries & Galloway boards in Scotland. The system is being used for inter-department electronic documents, as well as workflow with GP practices.

WinVoicePro, the firm's flagship software, was launched in March 2010 and is in active use by six trusts in England and Wales, interfacing with PASs from several vendors, notably Cerner Millennium, iSoft, Philips and SCI Store.

Winscribe (site)

Founded in 1995 by Amtel Communications in New Zealand, Winscribe is in active use across sectors including healthcare, with more than 350,000 users worldwide. The firm's technology extends beyond DD into workflow management.

The company has offices in the US, New Zealand, Australia, Switzerland and in Reading, and has more than 100 service partners around the world.

As well as offering a server-based DD platform, the firm supports BlackBerry, iPhone and Windows Mobile smartphones using a mobility suite that relates data, once transcribed, to the server, allowing 'dial-in' access to DD services.

In July 2010 the firm linked with Nuance Communications to allow close integration between the firm companies' products. The move effectively embedded speech recognition into Winscribe's software-based DD, transcription management and workflow routing system.

Steve Gold

Scotland measures up its NHS for cuts

Wed, 25 Aug 2010 08:00:00 GMT

A report suggesting that Scotland should reconsider ring-fencing the NHS budget has triggered a debate over the service's efficiency

The NHS in Scotland is not used to talk of "cuts". Since power was devolved in 1999, government spending on health has risen year on year, while even in the supposedly dark days of the Thatcherite 1980s and 90s the health section of the old Scottish Office budget continued to increase, albeit modestly. All that, however, is about to change – or is it?

It is according to the report of the Independent Budget Review (IBR) panel, which was published last month. This panel of "three wise men" was given the unenviable task of reviewing the SNP Scottish government's spending options in light of UK government plans for 25% cuts in spending. "We think", said the panel's chairman Crawford Beveridge with considerable understatement, "it's going to be very difficult."

The figures concur. Total government spending in Scotland is expected to fall by 12.5% in real terms by 2015 (£4.3bn). With health constituting more than a third of the Scottish government's budget, the IBR suggested a two-year pay freeze for all nurses – as an "essential first step" – reconsidering the bonus scheme for senior doctors, freezing the phased withdrawal of prescription charges and, perhaps most importantly, thinking "very carefully" about the policy of "ring-fencing" health spending.

John Swinney, the finance secretary, refused to comment on the detail of the panel's report – which was generally acknowledged as a thorough piece of work – while a Scottish government spokesperson points to the recent UK Budget, which committed the coalition government to "providing the National Health Service with real increases throughout the Parliament".

"We will pass on any Barnett consequentials from an increase to the health budget in England to the health service in Scotland," says the spokesperson. "We don't yet know what those consequentials will be. We do know that any increase to next year's health budget will be significantly smaller than the health service has been used to in recent years. The health service, like the rest of the public sector, faces serious financial challenges."

Ring-fenced thinking

Despite that caveat, continuing talk of "increasing" health spending concerns the former Scottish health minister Susan Deacon, now an honorary professor at Edinburgh University's School of Social and Political Science. "My view is that we need to be asking every political party, not just the SNP, for a different kind of debate," she says. "This ring-fencing mentality doesn't just ring-fence budgets, it ring-fences thinking and ring-fences discussion.

"We need some real political leadership in Scotland around this," she adds. "It takes us right back to inputs versus outputs. At the moment it's all about how much you spend, but when you're thinking about improving the health of the nation there's not a simple correlation between how much you spend and how much you improve that. What's important is that we think about what kind of society we want to live in, and that's not just about public purse, it's about the role of the private and voluntary sectors too."

Tom Miers, author of a recent Policy Exchange report, Devolution Distraction, agrees, citing a series of independent studies that have concluded that the Scottish NHS is performing more poorly than in other parts of the UK. "Yet these outcomes are barely recognised in Scottish political debate," he says. "Instead, discussion in political circles and the media focuses on lifestyle problems.

"It is almost as if the problems of the NHS were the fault of the Scottish people," Miers adds. "For there is very little discussion about how to run an effective health service – a service which has barely changed in the last 10 years."

The IBR panel also hinted that cuts provided an opportunity for creativity, recommending that if the Scottish government decides to ring-fence the health budget, then it should "consider alternatives… that allow for a broader interpretation of health spending", including "non-NHS services that support the health and well-being of the community, for example, early intervention programmes across the public sector".

Spending cuts are, of course, political decisions, and with elections to the Scottish Parliament taking place next May, those bidding for power are naturally anxious to avoid being seen to wield the axe. But, as Susan Deacon warns, "if they all go into the election having a bidding war over who can protect the most things, then we're never going to have an informed discussion and the likelihood is we'll end up in a worst place as a result".

Commissioning a bridge for GPs' information gap

Michael Cross — Wed, 18 Aug 2010 08:00:00 GMT

The government's white paper does not recognise how important IT and data will be to GP commissioning

When the Department of Health asked the leaders of GP practice-based commissioning pilots carried out under the former government what they thought of the experience, information emerged high on the list of wants. Only 51% of leads rated as good the format and quality of information and data they received from primary care trusts (PCTs); 42% said the same of its timeliness.

Yet the government's white paper setting out plans to move the English NHS entirely to GP commissioning makes scarcely any mention of the need for information technology to plan health needs, measure outcomes and to manage the contracting process.

To judge by the white paper, there is little sign that senior policy makers have given any thought to filling the information hole left by the abolition of PCTs, let alone to the demands of new GP-led innovations. Yet as a recent Department of Health report Sustaining innovation in telehealth and telecare makes plain, information is vital if commissioning is going to lead to innovation. "Commissioners need a certain level of evidence to adopt a new approach to care, particularly when they may have to decommission or redesign an existing activity to accommodate it," it says. "This requires sophisticated systems for assessing population needs and making appropriate commissioning and decommissioning decisions."

For firm signs of how the government intends to fill the information gap, we must await the new information strategy to be published in the autumn. Some indication of what the strategy will need to tackle appears in a document published in July by the IT trade association Intellect.

The paper, Care commissioning in England – an Intellect perspective on the challenges ahead, warns that commissioning as a discipline is still a relatively new process, with PCTs still in the early stages of developing strategic capability. If GP consortia are to take on the role, they will access to information about the health of their populations and performance of their healthcare providers in a much more seamless way than today. It proposes that systems to support GP commissioning will:

- Provide access to data residing in provider organisations' system, directly or indirectly, in anonymised form.
- Set standards for data, based on existing initiatives such as the Secondary Uses Service and the proposed NHS Interoperability Toolkit.
- Enable business intelligence and data mining. Administrative and clinical data currently locked up in isolated data stores could be made available as a web service to commissioners and be put to use detecting patterns and trends "to enable funding for prospective care instead of the current situation of contracts being funded by retrospective episodes of care".

Commissioners will also need support for assessing the risks of different decisions and modelling the outcomes. The Intellect paper stresses the need for support in contract negotiation and managing performance.

With an eye to the political wind, the Intellect paper stresses that these functions can be achieved largely with existing systems: "These are not 'big ticket' new investments," it says.

From gap to gateway

In one sign of IT suppliers anticipating the new world, the two firms responsible for systems in 75% of GP practices, Emis and INPS, have announced a joint venture known as Healthcare Gateway, through which their systems will interoperate. The Medical Interoperability Gateway would exchange electronic discharge summaries and other documents.

One commissioning decision that will frequently come to the fore in the new climate is when and how to embrace telemedicine and telecare. Over the past few years, the vast majority of such initiatives have been led by PCTs. A new Department of Health study of these schemes casts doubt on whether the costs and benefits of different breeds of telecare are well enough understood for GPs to go it alone. The DoH briefing paper on the topic warns that for telehealth and telecare to survive and thrive in a cold financial climate, the use of such technologies "needs to be integrated into commissioning plans and local area agreements rather than being stand-alone programmes or pilots".

But it adds: "The process of scaling telehealth service remains a barrier to innovation, technology adoption and service transformation. New procurement models and risk-sharing will be needed to support local business cases unless there is significant take-up through the consumer market."

All this amounts to a major challenge for the debutantes of the GP commissioning world. While the findings from the practice-led commissioning leads may suggest that almost any innovation will be an improvement on the service they feel they get from PCTs, it is quite likely that perceptions of the usefulness of PCTs will rise when the new regime is in place - especially among the sceptical mainstream of general practitioners.

Michael Cross

Kirklees replaces offices with laptops

Steve Gold — Wed, 11 Aug 2010 08:00:00 GMT

Health visitors in one Yorkshire PCT are improving patient care and saving money by handling patients' data on the move

Remote working in patient care, with staff 'hot-desking' using mobile broadband-enabled laptops, is a proven cost-saver for the NHS. But the idea has been met with caution by some trusts owing to the limitations of 3G mobile reception.

However, one primary care trust, NHS Kirklees, has embraced the technology by deploying around 600 Panasonic Toughbooks, supplied and serviced by BT Health. The staff are, in the words of Robert Flack, managing director of Kirklees Community Healthcare Services (CHS), "loving it".

Flack's NHS organisation is the provider arm of NHS Kirklees, which employs more than 1,200 staff to meet the healthcare needs of more than 400,000 people across Dewsbury, Batley, Spenborough, and central and southern Huddersfield.

The area's topology is quite diverse, ranging from the university town of Huddersfield to open areas of countryside – and owing to the proximity of major towns and cities, almost all of the Kirklees trust area gets good 3G cellular reception.

But, says Flack, the technical aspects of laptop-toting members of clinical, nursing and administrative support staff is only part of the equation. Improvements in patient care in the field are what is driving the project forward.

The last 12 months have seen Kirklees CHS steadily introducing 600 laptops to staff in a variety of healthcare environments, including health visitor services, to patients in their own homes.

"The fact that it involves the patient working with NHS professionals to determine how their healthcare will progress is the really great thing. We've had 25 (in-depth) interviews with patients about the new system and they all love it," says Flack.

The use of laptops at the clinical coalface - in the patient's home - has been especially successful, says Flack, particularly on family partnership work. "This is where the NHS works with teenage mothers to ensure that mother and baby get the best start in life, and the system allows staff to fill in the health record with the mother," he says.

As well as tangible cost savings - NHS Kirklees is saving around £600,000 year in travel costs, as staff no longer need to return to base or the GP surgery to pick up notes - the use of remote working laptops has changed the way people work. Staff spend less time at base and increase their productivity when out and about.

Vision for faster healthcare

And, Flack says, it also increases the speed at which patients can receive their treatment. "We had one patient, a mother whose a baby had crossed vision. The treatment usually involves a visit to the GP who then registers an appointment with the local hospital, a process than can take a few months.

"With the laptop in the patient's home, the health visitor looked online and saw that the GP was also online - and was able to interact directly with him from the patient's home. The GP realised that it was in the patient's best interest to refer, and immediately made an appointment with the local hospital," he adds.

As a result of this immediacy of response, Flack says that the baby was given a hospital appointment to start treatment within three weeks, which is a much faster response than would have been possible under the old manual regime.

"The message here is simple - the technology is simple to deploy and use. It saves money and just works," he says.

BT Health provides the laptops to Kirklees CHS, as well as supporting staff in the field with remote access technical support or, where required, providing replacements on a next-day basis. Jon Moggridge, a BT spokesperson, says that the scheme has been well received, with the Toughbooks being kitted with integrated high-speed mobile broadband facilities and an integral NHS smart card reader.

The laptops are pre-configured and supplied by BT against an agreed standard build that includes the SystmOne clinical records application, as well as mobile Internet and email, using a secure mobile virtual private network connection to guard patient confidentiality.

Back at Kirklees CHS, Flack says that the plan is to deploy a further 50 Toughbooks to those staff that need them, with more in due course. With this further deployment, he says that his team are looking at a leasing arrangement to allow the trust to pay for the laptops out of operating expenses, rather than minor capital fund allocations.

Kirklees CHS has been working with BT Health to calculate the true cost benefits of the Toughbooks and has developed a 'benefit output tool' that can quantify how much money the mobile health worker solution can save in both direct and indirect terms. BT Health says the likely cost savings for Kirklees CHS is likely to be around £10m a year.

NHS Kirklees says that the next stage in the project is to carry out a study into whether the trust can reduce its property estate, as there are fewer staff to house in their offices.

The Toughbooks are provided under a centralised agreement for mobile health workers administered by the Yorkshire and The Humber strategic health authority. According to Trevor Wright, its deputy chief information officer, it is recognised that mobile health working gives clinicians the ability to make more informed diagnoses, more able to recommend the most appropriate courses of action and therefore deliver higher quality of care.

"However, as you would expect in the current financial climate, the key driver for mobilising our clinicians is centred on increasing productivity and reducing costs," he says. "The business case for mobile health working has been proven with a number of deployments across the region that have demonstrated an increase in clinician productivity and significant cost savings, including reduced travel costs and a reduction in unnecessary hospital admissions."

Steve Gold

How Lansley's NHS can keep sharing in place

Sade Laja — Wed, 04 Aug 2010 08:00:00 GMT

The abolition of primary care trusts could affect the NHS's ability to share services and co-operate with other organisations through Total Place

The plans outlined in the Equity and Excellence: Liberating the NHS white paper have given NHS organisations a lot to think about. Among other things, abolishing primary care trusts (PCTs) and strategic health authorities and handing commissioning to GP consortia means that shared programmes of work are particularly vulnerable to change.

Health secretary Andrew Lansley's changes will take place pretty quickly: GP commissioning consortia will appear into shadow form in 2011-12 and will hold contracts with providers by April 2013. SmartHealthcare.com examines the specific impact on two key areas: back office shared services and local co-operation under the Total Place programme.

Back office services

NHS Shared Business Service (SBS), a 50/50 partnership between the Department of Health and Steria, currently provides shared services including finance, payroll and other technology to more than 50 primary care trusts – organisations that will be abolished in a few years' time.

But despite its large PCT clientele John Neilson, managing director of SBS at Steria, sees the changes as a great opportunity – while admitting that it is hard to judge the exact impact.

"I think it's difficult to say precisely what it means, but we're very much looking at this as a glass half full sort of perspective at the moment. They (PCTs) still need to save a lot of money and there are still two and half years to go until they're abolished so there's money that has to be saved in that period. Clearly if they don't start soon they're going to run out of runway to actually save in that time period," he says.

Neilson says that since the first round of government cuts were announced and the NHS reforms were outlined, interest in SBS has "jumped up quite dramatically". "We expect that to continue and I'm hoping that with prospective PCTs it will accelerate," he adds.

"I actually think that there is quite a short window. If they haven't done something within in a year, clearly the benefits of cost saving are going to be much less and actually it might be much harder for the (GP consortia) clusters to make any decisions when it comes to that point when it is time for service."

Much is being made of the power that will be given to GP consortia and whether the transition will go smoothly, which will be dependent on the number of clusters that emerge. Neilson isn't too concerned about the numbers and believes that the SBS model can be applied to individual GPs and consortia. He says that it will be in their interest to use the service.

"The GP consortia may or may not have access to the different supplier arrangements that PCTs have, so whether they're ordering anything from pencils to syringes to bandages to whatever, if they can take advantage of existing or in fact new regional or national supply contracts, then that has got to be in their advantage to do that," he points out.

Victor Almeida, healthcare analyst at Kable, agrees with Neilson that the reforms could provide substantial opportunities. "Procurement services will provide a growing market, as GPs with limited experience in the field turn to external suppliers with strong credentials," he says.

But he warns that technology suppliers should note that performance and procurement are becoming intrinsically linked, adding that many procurement frameworks will now be supported by various quality standards.

Total Place

Giving more power to local authorities and scrapping PCTs will undoubtedly affect the Total Place efficiency initiative, set up under the former Labour government but still in its early stages. Launched in July 2009, it promotes shared working between local organisations such as councils, PCTs and police forces, with 13 areas participating in pilots.

John Tizard, director of the Centre for Public Service Partnerships, an independent researcher that has advised Worcestershire on its Total Place pilot, thinks the government's reforms could present some challenges.

"Every local authority has a partnership relationship with its PCT or PCTs. That relationship has obviously been built up over a period of time. It will be based on maybe institutional and personal relationships and any move to fragment one of those partners is going to put a strain on collaboration and partnership working," he says.

Tizard believes that the proposed GP consortia should be obliged to work in partnership with other agencies. He says that consortia may focus too much on health, rather than relationships with other local organisations.

"The GPs are all set to be small businesses that are looking to maximise their business outcome and may not therefore have the wider, and I stress may not, have the wider public interest the PCTs have," Tizard adds. He also acknowledges that there are some "extremely good" GP practices working in the community sector, but says the government must take note of the risks.

Critics of the new government have said that it has not paid close enough attention to Total Place. Tizard agrees that "it is not what you hear Eric Pickles and members of the current government talk about".

Leicestershire is hosting one of the Total Place pilots. Andy Robinson, assistant chief executive of Leicestershire County Council and local leader of the project, believes the increase in the local authority role outlined in the white paper "helps in a Total Place context".

"It'll certainly change the way we do things, but we don't see any of that as being dramatic as such. On the GP sides of things we'll be working with one or more GP clusters rather than the PCTs so there will be more people to work with in that sense, but we don't think the focus of that activity will change," he says.

Robinson disagrees with John Tizard on the potential behaviour of GP consortia. "There are no indications that GPs will have a less positive attitude to that than the PCTs have, so then of course the local authority has this role to co-ordinate health social care and well being activity," he says. "That's a role I think that Leicestershire would see itself playing in terms of democratic accountability and ensuring that we can join things up across the place."

Tizard believes that some form of collaborative working "is inevitable" once the NHS reforms are in place. "We hope that the coalition government facilitate that rather than just allowing it to happen circumstantially area to area," he concludes.

Sade Laja

NHS's got talent: will the white paper lose it?

Cath Everett — Wed, 28 Jul 2010 08:00:00 GMT

The English NHS needs to think about how to retain good staff as many of its constituent organisations are abolished

One of the key challenges that the NHS faces in the wake of the coalition government's proposed radical reorganisation is a major drain of the talented staff it needs to ensure a smooth transition from one commissioning model to another.

The proposals laid out in the white paper, Equity and Excellence: Liberating the NHS, include abolishing today's 152 primary care trusts (PCTs) and 10 strategic health authorities (SHAs) within three years. Meanwhile, the government will hand 80% of the NHS budget currently handled by PCTs to an unspecified number of newly-created GP commissioning consortia.

At the same time, the NHS will be expected to find £20bn in efficiency savings and cut management costs by 45%.

Press coverage has also indicated very heavy cuts to management costs. According to HealthInvestor magazine, PCT and SHA management expenditure currently stands at £1.85bn annually. But an email to NHS managers from health secretary Andrew Lansley seen by that publication said that the figure could be reduced to £850m by financial year 2013-14 following the commissioning changes.

The Sunday Telegraph reported that the reorganisation would likely result in an estimated 30,000 back room managers and staff, which includes IT, being axed.

And senior NHS sources have told Health Service Journal that the government may give the new GP consortia an annual management allowance of £9 to £12 for each patient they cover. This would equate to a total budget of £450m and £600m across England.

As a result of such cost cutting proposals, Jon Restell, chief executive of union Managers in Partnership (MiP), said that the current planning assumption, particularly on the commissioning side of the equation, was that between a third to a half of management members would either lose their jobs or be redeployed.

His concern is that such a radical revamp will simply distract attention away from running existing services effectively during the financially straitened times to come. "It's a hugely challenging thing to deliver in a short period of time if you're trying to cut managers by between 20% and 30% but are asking them to introduce huge change and keep staff motivated in their posts."

Restell adds that the white paper said "very little" on the workforce and management implications of the proposed changes, dedicating only two lines to the issue. But if such uncertainty continues, the worry is that the "best people will start looking for opportunities elsewhere", which could lead to a "very big drain" if the transition is not handled well, he believes.

"The question is what's in it for them to stay? They'll stay if they see light at the end of the tunnel, but they'll be asking 'will I get a job?' and 'will the NHS support me in getting a job in three years time?'" Restell says. "If not, they'll start looking out for 'me' and take their skills elsewhere. There'll be a lot of talk about incentive payments, but it's more about job futures."

Talent spotting

Andy Lowe, practice leader at career consultancy Right Management, agrees. He believes that the hiatus period between "telling people what is going away (in job terms) but not what they're replacing it with is a very risky time for the NHS," because of the uncertainty that such a situation engenders.

While Lowe is not yet seeing CVs landing on his desk, he is nonetheless already "hearing stories and anecdotes of people starting to move".

He says that the theory of managing change suggests that it is crucial to know "who your talented people are, to start painting a picture for them of the future and ensure you keep nurturing them".

There is a tendency to try and stabilise the entire organisation, but in practice this is likely to be too much of a challenge. "So it's about identifying the crucial few key roles and skills that you'd be in real trouble if you lost. It's also inevitable, however, that the very people you want to retain are probably the ones that are the first to be snapped up when their CVs appear on the market," Lowe says.

The situation is generating other concerns. One, according to MiP's Restell, is that backroom administrative staff and managers will be given large sums in redundancy and pension pay-outs before being hired again by GP consortia, either directly or in a consultancy role, and possibly even at higher rates.

"So you need a strategy to get staff from one part of the NHS to another and you need to know what skills you need. Not something based on wishful thinking that you don't need managers or proper IT, but a strategy based on a much more resourced, evidence-based approach," he says.

As a first step in attempting to clarify a muddy situation, Gill Bellord, director of workforce advisory body NHS Employers, said that NHS chief executive Sir David Nicholson requested in a letter sent to all trust chief executives that staff affected by the proposed changes be given the opportunity to speak to their line managers by the end of September.

"We welcome this support and encourage all organisations to ensure that measures are in place to provide support and advice for all staff," she added.

Another good sign is that Sir Neil McKay, who is currently chief executive of NHS East of England, has been appointed to work alongside the Department of Health's director general of the NHS workforce Clare Chapman. His new role will be to oversee the lead coordinators for transition who are due to be appointed to each SHA.

Right Management's Lowe explains: "He's been tasked with coordinating the people transition response so we may see some coordination of downsizing activity, although it's not clear yet."

But he believes that such coordination would nonetheless be vital to ensure that the 2% of their budgets – £2bn in total – that PCTs have been required to put aside to manage the transition is not wasted on staff simply being paid to leave before being rehired.

"We recommend that they have some central redeployment processes and tools, where displaced people can go and see where the jobs are elsewhere, that is managed centrally," although it might also be possible to build on the existing NHS Jobs service, he adds.

As for the likelihood of industrial action as a result of the proposals, which include the possible dismantling of national pay bargaining, MiP's Restell believes it is too early to say, not least because the white paper is "so huge" in terms of its implications.

"Many member organisations are having to spend a lot of time working out just what it might mean. It's so big that they can't quite see around the edges so no one's in a position to say 'we're going to fight'. What we do know, however, is that it's very radical and the timescales proposed make it a very risky venture," he concludes.

Cath Everett

Join our live online careers forum

Steve Gold — Mon, 19 Jul 2010 15:00:18 GMT

Taking place on Wednesday 21 July, 1pm-4pm, in association with Guardian Careers

The coalition may have said the NHS budget will grow in real terms, unlike other parts of the state sector, but informatics and health IT look set to be affected by the major reorganisation of the health service recently announced by minister Andrew Lansley.

Primary care trusts and strategic health authorities will be closed, although new GP commissioning groups will be formed in their place, and changes are expected to the National Programme for IT. However, the government is also planning to increase the amounts of data published online, for transparency and to help patients choose services.

You can discuss what the changes to informatics and health IT might mean for those working in these areas, as well as find out how to start or advance your career, through SmartHealthcare.com's first online careers forum, on Wednesday 21 July from 1pm to 4pm, held in association with Guardian Careers. Questions can be posted in advance, or asked live during the session.

To join the forum, either to post a question in advance or on the day, click here.

Panellists

Steve Gold is an expert writer on IT, security and health. He worked for the NHS for 11 years as both a nurse and as an accountant before leaving to pursue a career in journalism. As well as writing regularly for SmartHealthcare.com, he acts as technical editor for Infosecurity magazine.

Mik Horswell initially trained as a healthcare general manager and followed this career path mainly in acute hospitals before changing course after 10 years into the emerging specialism of information management and managed information and IT functions at hospitals and health authorities for a further 10 years. Leaving the NHS at director level, he moved into management consultancy and for 14 years has worked with suppliers and NHS organisations at all levels on strategy and project management of information and communications technology, information governance. He is very interested in professional development and is chairman of his local Institute of Healthcare Management region, is currently director of marketing & communications of the UK Council for Health Informatics Professions (UK Chip), a member of Assist's National Council and a chartered member of the British Computer Society.

Jenny Jackson is an informatics graduate management trainee within the NHS's Yorkshire and Humber region, nearing the end of the final year of the scheme. Prior to the scheme, she undertook a 12 month placement within health informatics as part of a four year BA Hons Business Studies degree. She has been in health informatics for about four years, working in various roles and organisations. Following the scheme, she has just been successful in securing a project manager job working with the Yorkshire and Humber's Long Term Conditions Programme and Stroke Telehealth.

Ben Needham is a systems integration manager for iSoft, a health software firm with major software development and systems integration operations in the UK which claims to be the largest supplier of IT to the NHS. A version of its Lorenzo suite of software has been developed specifically for use by NHS trusts, as part of the National Programme for IT.

Alan Simmons is careers consultant for the NHS Careers information service in England. He's been with NHS Careers for 10 years, and has a prior background in providing careers advice to people of all ages and backgrounds, but with a particular focus on school and college students. Alan is a frequent contributor to the Guardian Careers' health forum.

To join the forum, click here.

Steve Gold

Lansley analysis: From phoney war to white paper liberation?

Michael Cross — Wed, 14 Jul 2010 08:00:00 GMT

Andrew Lansley's health white paper shows the government starting to act on its criticisms of NHS IT

Nearly 20 years ago, a Conservative government's health reform designed to put GPs in the driving seat left as its legacy the biggest success story in NHS computing. It was the near-universal move to computerised practice management - for many a first step to electronic patient records - made necessary by GP fundholding.

It is far to early to tell whether the "Nothing about me without me" reform announced in health secretary Andrew Lansley's white paper on 12 July 2010 will have the same effect. What is clear is that the paper marks the end of the strange phoney war between the coalition government coming to power and it going on the offensive against what, in opposition, ministers had claimed was wasteful IT spending. That battle seems set to commence, in the run-up to an information strategy to be published in the autumn.

The Liberating the NHS white paper admits that the government's vision of an NHS led by GPs and patients will depend on an information revolution. However, the white paper gives little clue how this will be achieved.

For example, if local authorities are to replace primary care trusts (PCTs) in joining up the commissioning of local NHS services, social care and health improvement, they will need to take over many of the IT functions of PCTs, including full interconnection with NHS organisations.

The goal of giving patients the ability "to download their record and pass it on, in a standard format, to any organisation of their choice" is highly optimistic in the near future, especially if electronic records contain social care data.

As expected, the white paper says that control and choice in procurement will devolve to frontline organisations. "NHS services will increasingly be empowered to be the customers of a more plural system of IT and other suppliers."

However in throwing out the PCT bathwater, the government may also be throwing out some bonny babies: some PCTs are showing leadership in local IT implementations. One example is the recently announced link between urgent care services at Aintree Hospital on Merseyside and 100 local GP practices.

Merseyside's natural community

The project, claimed to be the largest such scheme in England, is reminiscent of the electronic integration of "natural communities" envisaged in the NHS Information Management & Technology strategy of the 1990s. The scheme relies on the ability to view information from Aintree's Medway hospital information system, supplied by System C, on the GPs' Emis Web software.

Opening GP-held information to hospital clinicians will give them a fuller picture of a patient's care, reducing the margin for error and speeding treatment and waiting times as well as reducing repeat testing and other duplications of effort. The hospital estimates that access to information will allow the medical assessment unit to handle an extra patient every hour.

The white paper implies that patient and GP-led initiatives will achieve the same end result, with less bureaucracy. Although there is no mention of privately held health record systems, the presumption is that they will be part of this future. It is significant that Microsoft took the opportunity of the phoney war for the long-awaited launch of its HealthVault system in the UK (article).

Meanwhile, we are still waiting for official news on the future of the Summary Care Record and Healthspace. The publication of the Greenhalgh evaluation of the project was the most significant step by NHS Connecting for Health during the phoney war. It produced an interesting government response: Simon Burns, the minister of state for health, told the BMA that the government "broadly" sees a need for patients and clinicians "to be able to access patient records in electronic form".

The minister also showed sympathy with the BMA's concerns about confidentiality and consent, stressing that the effective use of summary care records "depends on patients and doctors feeling comfortable with those records rather than them being seen as... imposed as a central part of government."

Where this leaves the organisations responsible for this supposed imposition remains to be seen. To the surprise of some, the white paper supports the strengthening of the Health and Social Care Information Centre, as part of the agenda to increase choice based on accurate information. The white paper also assumes the continuation of a centrally run electronic choose and book service.

But it also promises the imminent publication of a review of arms' length bodies: "Subject to Parliamentary approval, we will abolish organisations that do not need to exist." At the launch of the white paper, NHS chief executive David Nicholson said that there would be news on the National Programme for IT "in the next four weeks or so". But the assumption must be that NHS Connecting for Health will not be part of Mr Lansley's information revolution.

Michael Cross

Translation and a 'home hub'

Cath Everett — Wed, 07 Jul 2010 08:00:00 GMT

SmartHealthcare.com looks at two technologies with the potential to offer new dimensions to healthcare

Communication is key in a people business like healthcare. At the very least, clinicians need to be able to communicate effectively with their patients it gather and record information to provide the best care possible.

Technology is now bringing down many former barriers to such communication, and two developments that could take the trend further are the development of Multilingual Interpreting Communications System (MICS) and PassivSystem's telecare product.

MICS is a PC based translation system to facilitate short structured conversations such as in helping patients to fill out forms.

The technology comprises a software module installed on the user's desktop and an online database of useful phrases at the back end. Both Kurdish and Arabic are supported at the moment, with Portuguese and Polish to follow.

When clinicians (or even receptionists) wish to initiate a conversation, they simply log on to the system and are authenticated against the online database. They then select from a range of subject options on the screen, before choosing a suitable phrase, which is both written down and spoken in the relevant language. Patients then select the correct answer from a multiple choice menu, which is highlighted on the screen as it is verbalised.

The idea came from Dr Cort Williamson, a GP and public health specialist at the Suffolk Refugee team, who spotted a need for such a tool during the course of his work with people of many nationalities.

He subsequently approached Health Enterprise East (HEE) with the concept in late 2007. It set up a project within its NHS Innovations East hub to develop a proof-of-concept, and has since spent £50,000 on development work, filing patents and the like.

HEE also received a grant of £20,000 from the Regional Development Agency last year for market research into the offering's commercial potential. It was completed this February and the plan is now to either find a commercial partner to licence the technology or spin it out as a commercial venture. The latter could involve a partnership arrangement or housing the product in a start-up vehicle.

Dr Chandu Patil, senior innovation manager at NHS Innovations East, says he believes that one of the key benefits is its cost-saving potential. A study will begin in the next three months to generate concrete figures, but initial estimates indicate that the system could save hospital departments as much as 30% of their existing bills on interpreting services.

"The assumption is that a busy department makes an average of 10 calls per day to telephone language lines, which cost on average about £1 per minute," Patil said. "Some trusts put on a limit of 15 minutes per phone call, so that's £15 each time. But we estimate that trusts may no longer have to make up to a third of those calls, which would save them significant amounts of money."

The aim is to secure a commercial arrangement between six and nine months after the costing study has been completed, with the first target markets likely to be A&E and GP practices in that order.

A longer term goal is to port the system onto mobile devices such as smartphones, while incorporating telephone helpline support so that users can access such services seamlessly - hopefully at discounted levels - if required.

Another organisation that is facilitating communication in a slightly different way is PassivSystems. It was incorporated in September 2008 and started selling its first product, PassivEnergy, a wireless energy management system for home use, in May of this year.

The supplier is also developing "early stage elective" telecare applications to run on the same back end, internet based platform that is now installed at the firm's headquarters in Newbury, Berkshire. The aim of the system is to monitor the daily routine of elderly people and flag up any exceptions, such as a poor night's sleep, to either clinicians or carers, depending on the severity of the problem.

The objective, said development director Fraser Harding, is to help people stay in their homes for longer by undertaking "non-invasive monitoring of their daily routine".

"So what this platform will provide is a level of remote monitoring by picking up signals from sensors and funnelling them, maybe via a text message or interactive voice response call, to carers for low priority issues or to a monitoring centre that is able to respond medically for high priority ones," he explained.

The idea is that customers would receive a 'home hub' similar to the routers supplied by broadband providers today in order to manage the wireless network. Specialised trained resellers would install a series of sensors to detect "occupancy movement", and the anonymised, encrypted information would be sent over the internet to PassivSystems' back end, Java based applications for monitoring. The packages are expected to run on standard Linux based hardware under an Oracle database.

The vendor has also received a grant from the South East Health Technology Alliance to test the suitability of new Electric Potential (EP) sensors developed by the University of Sussex.

Unlike the dry or wet gel sensors that are currently used in telecare, the EP devices neither require skin preparation to be worn nor are they affected by changes in skin resistance. This makes them comfortable to wear and suitable for use over long time periods.

The firm began a year long test of the sensors in its laboratories in mid-May, and so far the results appear positive. But it also expects to begin asking staff to employ them in their home environments from the fourth quarter of this year for field testing.

"We want to make sure that the potential they show is realisable for a product that can be delivered at a mass market price point and that has to be absolutely reliable. If they give false positives and people get messages or calls to say that someone is unwell because the sensors have triggered, they become desensitised," Harding said.

But the organisation is also working with the University of Portsmouth's telemedicine practice to make sure that the interface as easy to use as possible for a non-clinical consumer audience.

To protect personal privacy, for example, activity such as going to the toilet x number of times during the night will not be recorded, but rather highlighted as a 'disrupted night' using a traffic light system to indicate the severity of the problem.

Although PassivSystem's telecare offering will not appear on the market until 2011 at the earliest, the expectation is that it will cost customers no more than a couple of hundred pounds. A potential future aim over time, however, would be to broaden out the use of the system to monitor vital signs such as blood pressure and insulin levels.

Cath Everett

NHS Confederation: Doing more with what feels like less

SA Mathieson — Wed, 30 Jun 2010 08:00:00 GMT

Innovation looks set to become an essential activity for the NHS, according to speakers at the NHS Confederation conference

During David Cameron's televised question and answer session last week, a public sector employee asked the prime minister to admit that the two year pay freeze announced in the budget was, in fact, a pay cut. He conceded that this was the case.

The health service could reasonably ask the coalition government a similar question, and it could reasonably get the same confirmation. The government has promised to protect NHS spending, rather than subject it to the major cuts faced by other departments. But as several speakers at the NHS Confederation conference in Liverpool on 23 to 25 June 2010 said, this will feel like a cut.

The reason is the end of the last decade's large increases in NHS funding, along with 'healthcare inflation' caused by an ageing population, rising public expectations and expensive new treatments. Matthew Swindells, now of Tribal Group and the British Computing Society but formerly an adviser to Labour health ministers, told one session that such inflation typically runs at 4% a year. Nicolaus Henke, a director at consultancy McKinsey, said it has consistently outrun gross domestic product by 2% a year across the developed world for the last 70 years.

Henke made the obvious point that this is unsustainable: if it continues to grow at this rate, by 2100 the US will be spending 98% of its money on healthcare. All rich countries will have to work out how to make healthcare more efficient over the next few years – Britain may just find itself going first.

"The real terms increase, we know, will not be of the order of recent years," health secretary Andrew Lansley said in his speech to the conference. "'Protection' for the NHS is not protection from the need for efficiency – it is protection for patients," he added of the health service's funding.

Coping with increasing demand for healthcare on lower unit costs will require new thinking, which Lansley said he is keen to promote. "We have to set the NHS free to innovate. We should constantly be thinking about how we can do things better – encouraging the adoption of successful ideas throughout the health service. We don't capitalise on innovation and ideas today because the system is too rigid – because we do 'one thing at a time' – what the centre dictates, when it dictates it."

Developing new ideas

Even with ministerial encouragement, making major changes to the health service will be a big challenge. McKinsey presented examples, largely from the developing world, of new services that are making healthcare more widely available (article). These included Mexico's Medicall telephone-a-doctor service and highly specialised 'factory' hospital chains in India, which maintain quality while dramatically cutting costs. The UK has similar services, such as NHS Direct and specialist hospitals.

But as Brian James, the chief executive of Rotherham foundation trust, noted in a question to the McKinsey session, lower costs are not going to encourage British patients as they do not directly pay for treatment. In fact, moving complex operations from many hospitals to a few specialist centres usually runs into opposition, even though such centres tend to cure more of their patients.

Another questioner noted that air travel saw new companies challenging and disrupting incumbents, but the NHS was going to have to disrupt itself. However, it is possible that individual NHS organisations could disrupt others, although they are very unlikely to put it that way.

NHS Direct's chair Joanne Shaw told one session that its online decision aids alone could save the health service £150m a year (article). She also commented that the organisation has not done a good job of publicising itself – something she and her chief executive Nick Chapman, who gave an on-stage interview at Smart Healthcare Live last month (article), seem to be going out of their way to change.

How could the health service use the ideas floated at the NHS Confederation conference to become more efficient? They mostly involve doing less healthcare in the most expensive places, hospitals, and more in the cheapest places, patients' homes. That could mean NHS Direct growing much faster, perhaps trying the virtual GP surgery idea championed by the Commission on 2020 Public Services Trust, with other trusts making more use of telehealth and staff working in the community with mobile equipment. It could also see bigger, fewer, specialist hospital departments reducing unit costs while increasing quality, adapting the techniques used in India.

The logical outcome of all this, however, would be to close or reduce the size of many hospitals. Matthew Swindells said that more than a quarter of hospital patients would rather be treated elsewhere – and technology means this is increasingly possible – and better productivity could allow another similar reduction. That could halve the amount of hospital capacity needed.

Nick Seddon, deputy director of think tank Reform, replied that as health secretary, Patricia Hewitt had found that proposing hospital closures meant you got lobbied by your own ministerial colleagues. Ideas and technologies that have worked for other industries and in other countries could almost certainly make the NHS significantly more efficient. Whether the public and the NHS workforce would accept the institutional closures that are likely to follow is another matter.

SA Mathieson

King's picks cows for its wards

Sade Laja — Wed, 23 Jun 2010 08:00:00 GMT

A south London hospital has concluded that computers on wheels (cows) and laptop trolleys suit e-prescribing better than handheld devices

Electronic prescribing is becoming more prevalent within the NHS and is generally viewed as a more convenient way to dispense prescriptions to hospital patients. But finding the right technology to facilitate it on wards is not always easy.

Mobile clinical assistants (MCAs) have been chosen by a number of NHS organisations due to their lightness and compact nature, but not by King's College Hospital in south London.

"They were lightweight, they were handheld, and you'd think that they were ideal, but they weren't for us," said Ben Fidler, team leader of the electronic prescribing and medication administration (EPMA) team at the hospital.

"Unfortunately for us the screens were a little bit too small. Our application has a lot of data, you have to display lots of information about drug charts and prescribing and our users felt that that they were just a little bit too small," he told the Smart Healthcare Live conference on 16 June 2010. Fidler added that there were also issues around reliability.

With hospitals increasingly looking for smaller and more mobile technology, shirking devices like MCAs in favour of something larger and less portable sounds like a counter-intuitive move by King's. Staff at the hospital are temporarily using computers on wheels (cows) until a decision on what technology to use is made.

Cows for courses

Fidler said that the cows are "ideal" for wards which use patient lockers, but are problematic for staff that use drug trolleys. "Obviously they don't fit on the drug trolley. For wards that do use drug trolleys, you're pushing it around and you're pulling a cow, which our users do not like," he added.

Choosing the right e-prescribing technology is proving to be quite problematic for King's College, which has trialled more than five different products in two years. The hospital originally started a wireless technology pilot to replace paper drug charts in November 2008.

"Our standard was to have two or three desktop PCs per ward, but essentially what was happening was that on a ward round doctors were going backwards and forwards between the nurses' station and wherever the PCs were located to find information," director of ICT Colin Sweeney told Smart Healthcare Live.

Wireless requirements at King's vary from ward to ward depending on whether the staff administer medication using a wheeled trolley with all the drugs inside it or keep all the medication in a locker for each patient. There are 10 wards at the hospital which now actively use e-prescribing, with 30 to go.

After the failure of MCAs, King's tried small ruggedised laptops, on the basis that they were portable. However, staff flagged up the same problems they had with MCAs – small screens and lack of integration with the trolleys. "You had to tie them on a tray on the side and you had to tie them to the top of the drug trolley. They (staff) weren't overly keen on them," Fidler said.

The hospital had one final stab at using laptops, testing an XT2 touchscreen model which could be folded into a tablet shape. But there were problems with wireless connectivity and some staff were having trouble documenting everything with only a touchscreen.

"Laptops weren't really working, so we went back to the drawing board," said Fidler. As a result the hospital is now testing a small drug trolley with a built-in computer from Parity. The lighter design eliminates the problem of staff having to pull around a cow. The hospital will also test a similar recently released model from RDP Health and decide which one it prefers. Using laptop trolleys rather than cows will save around £1,000 for each unit.

Fidler and Sweeney both emphasised the importance of hospitals thoroughly testing equipment before making decisions on what technology to implement. But Sweeney acknowledged that financial cuts may force hospitals to review their spending. "I think it's going to be very difficult in the current climate to to put a lot of investment in for the implementation of systems like these, so you do need to have a good case."

Technology implementation is "horses for courses", said Fidler, adding that different hospitals have different needs. He cited Salford Royal foundation trust's extensive use of MCAs as an example of organisations' different preferences.

Despite past problems with smaller devices, Fidler is not completely ruling out the use of touchscreens and PDAs in the future, but said it is not something the hospital is currently considering.

"For our use at the moment the keyboard and the mouse is the way forward," he added.

Sade Laja

Mobile clinical assistants: assisting your choice

Steve Gold — Wed, 09 Jun 2010 08:00:00 GMT

MCAs are now commonplace in the NHS, but what are the choices? We look at products from Advantech, Motion, Panasonic and Tabletkiosk

Mobile Clinical Assistants (MCAs) have been around in the NHS since the early 2000s, mainly as a result of devices such as Blackberry smartphones and modified laptops being customised by systems integrators. But the technology really started to develop when computer chip giant Intel unveiled a reference design in late 2006/early 2007.

The Intel MCA was developed in conjunction with NHS Connecting for Health, as well as vendors of electronic patient record systems such as Cerner and iSoft, to ensure software compatibility. After three years of development, including a pilot at Salford Royal NHS Foundation trust, the first MCA was unveiled by Motion Computing in February 2007. Since then, several vendors have developed their own versions, most of which are based on the Intel reference design.

Processors vary between various MCAs - and there numerous options from most vendors - but the primary features of an Intel-based MCA typically include an integral bar code reader for patient wristbands, pharmacy and other patient treatment products, plus Bluetooth wireless compatibility for other portable patient diagnostic devices. There is also normally an optional radio frequency ID (RFID) system for localised wireless scanning of suitably equipped staff badges and other authentication devices.

MCAs, like most pieces of clinical kit, are significantly pricier than even the more expensive equivalent consumer devices, such as Apple's iPad. The devices typically cost from £1,500 to £2,500, owing their required robustness and conformity to NHS Connecting for Health guidelines, as well as certifications such as UL60601-1, EN60601-1, and ISO 13485.

Advantech (site)

Like many MCA vendors, Advantech is a US-based supplier with UK partner distribution and support. The firm has two MCAs: the Mica-101, a fanless unit, and the MT-100, which is both fanless and lightweight. Both devices feature a 10.4 LCD display, with the Mica-101 certified as an IP54 dust and water-splash proof sealed system with Bluetooth plus WiFi connectivity. There is optional 3.5G mobile broadband connection.

Other features include an integrated camera/scanner and RFID reader, as well as an optional image-based (non-laser) barcode scanner, webcam and fingerprint reader. The MT-100 is a lighter version that is also IP54 dust and water-splash certified, and includes a WiFi connection for simple connectivity. Customised versions are available but it seems that the MT-100 is best viewed as one-size-fits-all MCA, rather than a unit that can be optionally upgraded.

Motion Computing (site)

This firm was first out of the gate back in early 2007 with an MCA, since when its range has been expanded to include two main models, the C5 and F5, with battery life claimed to be three hours on both units. It is another US vendor with UK distribution and support: its US pricing goes upward from $3,300 mark (£2,300, although hardware often costs more in the UK).

The C5 is a standard MCA with a choice of an 160GB magnetic hard drive or a 64GB solid-state drive. Motion has included 3.5G mobile broadband as standard plus WiFi connectivity. This makes the MCA useful for domiciliary visits, as well as other mobile usage. Weighing in at around three pounds, the sealed C5 is IP54 rated for moisture and dust resistance. It can also be dropped from a height of 36 inches (MIL-STD-810G certification). Options include an integrated digital camera, and barcode/RFID scanner.

The F5 is a semi-rugged slate and is best described as a more robust version of the C5. Both units have optional mobile docks and carry case systems and are Windows 7-based (XP and Vista also available) with native handwriting recognition and auto-fill for form filling.

Motion also produces a J3400 tablet PC with a 12.1-inch display and a higher-powered processor with optional 3.5G mobile broadband. Although not based on the Intel MCA design, the unit is an interesting alternative.

Panasonic (site)

The firm has UK offices but also supplies through partners. Its CF-H1 unit is based on the popular Toughbook design with a 10.4 inch screen with touchscreen features. Tipping the scales at 3.4 pounds, the $2,999 unit has hot-swappable twin batteries, for six hours life between charges, and a shock-resistant 80GB magnetic hard drive as standard.

Designed to military 810F rugged standards the MCA has a magnesium alloy chassis and is robust enough to be dropped from a height of 36 inches (MIL-STD-810F certification). Features include an integrated barcode scanner plus a fingerprint scanner. Unusually for an MCA, Panasonic offers a contactless smartcard reader on the unit, as well as GPS facilities, Bluetooth. 3.5G mobile broadband is an optional extra.

Other features include a 2 megapixel camera with what the firm calls the ability to scan most items. Because the item is sealed, like most MCAs it is fanless, but Panasonic claims the unit has a totally smooth surface with sealed buttons, a gapless LCD screen and no exposed ports. Its warranty is, again unusually for an MCA, three years, perhaps reflecting the robust nature of the CF-H1.

Tabletkiosk (site)

The firm is another US vendor with international distribution and support. Its main offering is the Medislate MCA i1040XT, which is billed as the only MCA with a sunlight readable 10.4-inch resistive touchscreen. Like most units, it is based on the Intel reference design and is designed to interface with most popular EPR systems.

Claimed to IP54 standard for spills and dustproofing, as well as 36 inch drop-protected (MIL-STD-810F standard), the unit features an integrated barcode scanner, 2.0 megapixel camera, fingerprint reader and an RFID reader built into its handle.

The firm is pitching the 3.25 pound MCA firmly into the clinical care environment, allowing professionals to enter data, verify patient identification, verify themselves as authorised care givers, and scan pre-printed labels from patient ID bracelets, medication packaging and blood vials and other sources.

Standard features also include an 80GB magnetic hard drive or 32GB solid-state drive – the firm has opted for 2GB of memory on the i1040XT, rather than 1GB as seems standard on most MCAs – as well as hot-swappable twin batteries giving a battery life of 4.5 hours. The MCA is Windows Vista-driven (Windows 7 soon) with an optional Windows XP downgrade if required.

Resellers

The most important aspect of the MCAs featured here is that specifications are constantly changing and, if your order is potentially for several units, most MCA vendors can customise the units as required. It may also be worth talking to resellers, such as the following selection:

- Aerohive Networks (site), which recently supplied a major wireless MCA deployment for NHS Mid-Essex.
- DevelopIQ (site), an Anoto digipen and BlackBerry smartphone specialist, which also supplies MCA systems.
- HD Clinical (site), which recently supplied wireless systems to Frimley Park Hospital.
- Kelvin Connect (site), a Scottish PDA/systems integrator.
- NDL-Metascrybe (site), a wireless healthcare integrator which has completed a flagship installation at NHS Rotherham.

Finally, it's also worth noting that the NHS has itself developed wireless tablet computing systems, such as Gateshead Queen Elizabeth Hospital, which has developed one for wireless pharmacy drug dispensing.

Steve Gold

How simulation centres help healthcare rehearse

SA Mathieson — Wed, 02 Jun 2010 08:00:00 GMT

US healthcare provider Kaiser Permanente is one of the few organisations in the sector using simulation centres

Most industries carry out extensive testing and simulation of processes and products before releasing them to the public. Healthcare involves thorough tests of medicines, but in many cases less work has been done on processes and technology.

Progress is being made, however, through the use of simulation centres – mock wards, theatres and consulting rooms where medical staff can try out new equipment and working practices, then review what went wrong and right, often with the help of video recordings.

University College London Hospitals (UCLH) and Brighton and Sussex University Hospitals have a shared, camera equipped centre that has been used to improve team working for 1,500 staff. Professor Aidan Halligan, director of education for UCLH and chief of safety for Brighton and Sussex, told HC2010 in April that this has provided a significant boost for patient safety (article). Meanwhile, Cerner has established mocked-up wards and offices in a Paddington tower block to help NHS trusts work out how to implement the firm's Millennium software (article).

Similarly, Norway's University of Science and Technology in Trondheim has a usability lab, where medical staff are filmed using technology. Professor Dag Svanæs told the Mobile and Wireless Healthcare conference in February that the research showed that hospitals need a range of mobile devices, and cannot simply use standard computer equipment designed for offices (article).

Kaiser Permanente, the Californian based not for profit integrated healthcare provider, is also in on the act, using the Garfield Centre, a 37,000 square foot innovation facility in San Francisco, to test new ideas.

Its director, Dr Yan Chow, says its benefits became clear when it was used by nurses to test the addition of medication carts to workstations on wheels (also known as computers on wheels or Cows). "It didn't take more than 10 minutes to find it's not going to work," says Chow, citing problems including lack of security for drugs and doctors changing their minds about what to prescribe.

The centre also tests technologies through giving them the hospital equivalent of a test drive in its 'operating theatre of the future' unit. "If a vendor says something is interoperable, we get them to plug it into everything and see it's interoperable," says Chow. It makes it possible to evaluate how well equipment works with other technology, and to test it within actual processes. Kaiser has published consumer reports on the basis of such research, although it has not taken the further step of treating patients within an innovation centre (which has been done by the Mayo Clinic in Minnesota).

Game on

It is looking at how to train clinicians and test hi-tech equipment. Chow says there is potential in "clinical gaming" with computer game hardware, such as teaching staff how to deal with obstetrical haemorrhage, a rare but life threatening condition. Kaiser has already used a Nintendo Wii to encourage an eight year old girl to do physical therapy that she disliked.

Chow was in Britain having visited South Devon Healthcare trust, which is setting up the Horizons Centre to carry out similar work. Sasha Karakusevic, director of performance and development at the trust, is looking at how the NHS deals with a fractured neck of femur, a condition often affecting the elderly which he says can involve up to 30 professionals. "It's one of the most complicated pathways going," he says.

The innovation centre was opened to help test Kaiser's electronic health record system, provided by US vendor Epic, which it started installing in 2003. The organisation, which has 8.6m members, 6,000 staff and 450 locations, only recently completed the $4bn implementation project (£2.8bn at current rates). "With a very large technology project, there is only a certain pace at which you can push," says Chow.

He adds that the main benefit of the Epic system is that it provides for much better data, which can be used for high quality research. The system allows members to view their records online – although Chow is very wary of the idea that they should control these records.

"If you let the patient modify it, it's useless to any physician," he says. He adds that the new system's greater impact on patients has been through other features, including online appointment booking, fast communication of test results and particularly the ability to email doctors through a secure webmail system.

The latter requires staff to reply within 48 hours – less in some departments. Kaiser's research suggests that this reduces the number of physical appointments in some specialities, saving money as well as patients' time, and making them more likely to continue to subscribe to the organisation – a serious consideration for US providers. It now promotes the ability to email doctors in the organisation's surgeries, and in future the online service may be expanded to suggest services patients might take up on a personalised basis, such as types of screening.

Most US hospitals have thin profit margins and cannot afford work such as that done at the Garfield Centre. According to Chow: "It's too disruptive, too risky." As a relatively large not-for-profit provider, Kaiser is unusual in being able to afford this.

But he adds that even if it is pricey in the short term, simulation and innovation work pays off. "Other industries have done this for years. It's really expensive to roll out products that haven't been tested," he concludes.

SA Mathieson

How Cameron and Clegg plan to change NHS IT

Michael Cross — Wed, 12 May 2010 08:00:00 GMT

The new Conservative-Lib Dem government is set to treat England's National Programme for IT as a substantial source of savings

Conservative MP Andrew Lansley will become health secretary, as David Cameron's party goes into coalition government with Nick Clegg's Liberal Democrats. The former minister responsible for health IT, Mike O'Brien, lost his seat in the general election, and as this article was published his replacement had yet to be announced.

Whoever does get the job, traditionally passed to the most junior member of the department's ministerial team, is in for an interesting time. The next few years are likely to see an increasing divergence between the NHS IT infrastructures in England and those in Scotland and Wales – with the English programme continuing to falter.

The Conservative party will have found little difficulty aligning its ideas for NHS IT with those of the Liberal Democrats: both parties are keen to extricate the government from large contracts and national patient record systems. The Conservatives' election manifesto pledged to "decentralise power", "make the performance of the NHS totally transparent" and to put patients in charge of decisions about their care "including control of their own records".

There are three reasons to expect policy decisions within weeks, rather than months. The first is the emergency budget promised by the Conservatives. While the scope for immediate savings through the cancellation of local service provider and national infrastructure contracts is limited, the budget will be ruthless with what the Tory manifesto describes as "expensive layers of bureaucracy". Few institutions would make more politically palatable targets than those associated with IT.

One clue to policy is in the Conservative technology manifesto published earlier this year. As well as calling for an immediate moratorium on planned IT procurements it proposes to create a small IT development team under a strengthened chief information officer. This "skunk works" unit would ensure that systems developed in one part of the public sector are re-used in others and enforce compliance with open standards. It would also open the way to abolishing NHS Connecting for Health.

Critical care

The second development is the impending publication of the full evaluation report of the Summary Care Record (SCR) programme. This is likely to be critical of the SCR's clinical value as well as its implementation, and will attract high-profile commentary. A Conservative-run Department of Health can be expected to respond with a moratorium on the whole programme, devolving to a local level policies on sharing of health data.

How this will square with the manifesto commitment to give individual patients access to a single budget combining health and social care funding remains to be seen. One clue is in the third development, the UK launch of Microsoft's HealthVault personal health record system, expected in June. Microsoft is likely to be followed closely by Google. Although the Conservative manifesto was coy on the matter, such systems still seem to be what the Conservatives have in mind when they talk of patients having control of their own records.

The availability of commercial systems will give a budget-cutting government a good reason to kill off the HealthSpace project and greatly scale back the NHS Choices website. One clue to Conservative thinking here is the vision in the technology manifesto of government websites as "like public parks, where people can come together to discuss issues and solve problems".

In all but one of these polices – the involvement of commercial health records companies – the Lib Dems go at least as far as the Conservatives. The Liberal Democrat manifesto says outright that it would cut in half the Department of Health and abolish "unnecessary quangos" such as Connecting for Health. However it would also integrate health and social care into a seamless service, which would require some central IT coordination.

Such political uncertainty suggests difficulties for IT-based innovation. Although there are signs of renewed bullishness in the industry, the policies of the coalition's constituent parties means that the default position, even at trust level, is likely to be against any new procurement. That in turn will make it hard to realise the efficiency savings that all the contenders for government claim to be ready to make, but that is a lesson that will take several years to sink in.

Michael Cross