Challenges to implementing the national programme for information tech
http://www.100md.com
《英国医生杂志》
1 Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT
Correspondence to: J Hendy jane.hendy@lshtm.ac.uk
Objectives To describe the context for implementing the national programme for information technology (NPfIT) in England, actual and perceived barriers, and opportunities to facilitate implementation.
Design Case studies and in depth interviews, with themes identified using a framework developed from grounded theory.
Setting Four acute NHS trusts in England.
Participants Senior trust managers and clinicians, including chief executives, directors of information technology, medical directors, and directors of nursing.
Results The trusts varied in their circumstances, which may affect their ability to implement the NPfIT. The process of implementation has been suboptimal, leading to reports of low morale by the NHS staff responsible for implementation. The overall timetable is unrealistic, and trusts are uncertain about their implementation schedules. Short term benefits alone are unlikely to persuade NHS staff to adopt the national programme enthusiastically, and some may experience a loss of electronic functionality in the short term.
Conclusions: The sociocultural challenges to implementing the NPfIT are as daunting as the technical and logistical ones. Senior NHS staff feel these have been neglected. We recommend that national programme managers prioritise strategies to improve communication with, and to gain the cooperation of, front line staff.
In 1998 the NHS Executive set a target for all NHS trusts to have electronic patient records in place by 2005.1 By the spring of 2002, just 3% of trusts were set to meet this target.2 The Treasury's Wanless report suggested two main reasons for this: budgets for information technology (IT), allocated locally, being used to relieve financial pressures elsewhere, and the inadequate setting of central IT standards.3 The report recommended ring fencing and doubling the IT budget. The government responded with ￡2.3bn ($4.4bn; 3.3bn) for a new national programme for information technology (NPfIT) in the NHS in England.4 The aim is for electronic patient records to be implemented in all acute trusts by the end of 2007.
The size, complexity, and innovation of this national programme (also now called Connecting for Health) makes it the biggest outsourced IT project from the public sector ever untaken.5 Implementing large scale health service IT projects, in the United Kingdom and other countries, has proved difficult.6 7 Problems of achieving effective information flow between users, the cornerstone of any integrated record system, and resolving issues of confidentiality and security have led to reported failure rates of around 30%.8 9 The recent IT implementation failure experienced by the Wessex Regional Health Authority ended in losses to the taxpayer of ￡43m.5 The NPfIT has been described as "ambitious" and "inherently risky."10 The National Audit Office is currently evaluating whether the programme is likely to deliver good value for money and reviewing implementation progress.11 A report is due in the summer.
The programme's key features are new stringent national data and IT standards, procured and paid for nationally. Implementation in acute trusts will be through one of five geographic partnerships with industry, called "clusters." A ministerial taskforce and a NHS IT director general oversee progress. The main national features are a new national networking service providing broadband, called "N3"; electronic booking, called "choose and book"; electronic transfer of prescriptions; and a nationally accessible, "cradle to grave" summary patient record called "the spine" (figure). The provision of electronic functions at acute trust level form part of the NHS care record service, a collective term for all aspects of clinical IT support applications, from clinical decision making tools to digital x rays. The output of these applications is intended to be a health record that can be shared. The NHS care record service replaces the earlier twin concepts of lifelong electronic health records and local electronic patient records.1
Outline of national programme for information technology (NPfIT)
We are studying the processes and outcomes of implementing the NHS care record service in four acute hospital trusts in England. This involves assessing the local context in each trust, in depth interviews of staff and patients over a two year period, and a quantitative analysis of the effects of implementing three electronic functions of the record service. In this paper, we report findings from each trust's baseline assessment and information gathered from the first round of interviews.
Methods
We collected baseline information by meeting key IT, finance, and clinical directorate staff and reviewing documents and routinely published data. Interviews are taking place in three stages, with stage 1 interviews (the focus of this paper) taking place twice, at the start of the project and 18 months later. These interviews concern the development of NHS electronic patient records. (Stage 2 and 3 interviews investigate how electronic functions are experienced by staff and affect working practices and how they affect patient care.) The data reported here are from the first round of stage 1 interviews, with 23 senior managers and clinicians from the four trusts.
To enhance the generalisability of our findings, we selected the four trusts to reflect a range of characteristics (differences in size, number of sites, performance indicators, and financial situation) and various stages of implementing electronic health records. Participants included all local senior management staff involved in implementing the NPfIT, including the chief executive, director of information technology, medical director, and director of nursing.
Semi-structured interviews were conducted on a one to one basis at each trust by a qualitative researcher. We developed the interview framework by drawing on literature concerned with installing electronic patient records to identify key constructs.12-14 Topics discussed included the processes and outcomes of implementing electronic healthcare systems and the impact of the NPfIT policies. Interviews were recorded and transcribed.
Data analysis
We analysed the interview transcripts in three stages based on grounded theory principles of coding and theme ion15 rather than strict adherence to the theory of Glaser and Strauss.16 Literature on organisational change suggests the context and processes of change will be multilayered and complex.17 We explored this complexity by examining variations within and between the four trusts, taking account of organisational changes relating to NHS policy. We then grouped emerging themes according to the context (each trust's characteristics) because "analysis of change needs to attend to the interplay between processes, people, and events both internal and external to the organisation."18 We explored the relations between each trust site and the wider organisation, between the organisation and the individuals within, and between individuals and the technology. Two members of the project team (JH and NF) independently read the interview transcripts to agree on emerging themes.
Results
The table shows the baseline characteristics of each trust, including level of implementation of existing electronic patient records and the expected date for replacing the patient administration system, the first step in implementing the NHS care record service. Data from the first round of interviews show the potential impact of these factors on implementing the care record service.
Table 1 Characteristics of the participating trusts
Multiple sites within trusts
Two of the trusts have multiple sites, resulting from recent mergers, and problems of poor communication and coordination between sites remain. Differences in working practices and organisational culture seem to have created tensions that may make the job of getting ready for the NHS care record service especially challenging (see box 1). Major changes resulting from the recent mergers seem to have affected staff morale, increasing the likelihood that staff will become resistant to the changes required during implementation.
Box 1: Issues of multiple trust sites and change overload
"There's the difference in cultures between the two ends of the same trust, the culture where the whole senior management team transported themselves over. And so I think at one end within the trust, the end, the clinicians and the nurses and others are all used to a different way of working, which the people here are not. So I think there is a big difference actually between—if you ask people at that end I think you'll find a very different philosophy there."—Clinical director, trust 2
"One of the things that definitely makes life much easier is that we're a single site organisation, so there is a single culture around this place; we're not a difficult political being with eight or nine hospital sites spread around. From an IT point of view that's very difficult to support and manage."—IT manager, trust 4
"So, like I said, I think the organisation, leaving aside the IT, has quite a few issues still in terms of the changes it's gone through. Then add in the national programme and that's just, just another thing on top, and that's going to affect working practices across the whole organisation... It is yet another change, and I think certainly people are fed up of change and people do identify the national programme as being yet another IT project that is probably not going to work, that's going to cost a great deal of money, and why should they really cooperate with it?"—Clinician involved in development of electronic patient records, trust 1
Box 2: Issues of communication with NPfIT headquarters and lack of clinical engagement
"So I think we've not had, you know, we had some of the interaction, and I think what we've been asking for is clarity about, um, getting things done, what isn't coming, things like. There was really something last week about... the radiology systems, about the radiology information system and PACs, and in the application there's no radiology information system, there's just PACs."—Executive director, trust 2
"The communication has been appalling, absolutely appalling. They've done some wonderful events, and I've met some people who are great, NPfIT, who are very facilitative and very enabling, and the next week you're told you're not allowed to talk to them. I've been to some meetings where I've met people who are very very good, and we've been ordered not, instructed, they've been ordered and we've been instructed that it's inappropriate to talk to them."—IT manager, trust 4
"Despite what people say there's a lack of, there's a lack of engagement and, you know, even as chief executives, I think we've been involved and been asked to promote something they, we're promoting—we say it's a bit like trying to go and sell, probably in IT terms, vapourware and that's really what it felt like."—Chief executive, trust 3
"I would say that the clinicians are sort of waiting to see what's going to happen before they commit themselves."—Assistant director of nursing, trust 4
Communication between the national programme for information technology and the NHS
The lack of clarity from the NPfIT about future developments—with poor communication between NPfIT headquarters, the local service provider, and trust managers—was reported to be a major concern in all four trusts. Managers felt that local needs and advice have been ignored and expressed sentiments in interviews of feeling ignored, being "done unto," and disempowered (box 2). Participants' views suggest a divide between the central NPfIT office and trusts, with the latter perceiving the former as failing to understand local issues. This lack of communication seems to have filtered down, with managers reporting a reluctance to communicate the benefits of the NPfIT to front line staff without having answers to questions about what IT services will be supplied and when (box 2).
Financial circumstances of trusts
Two of the trusts have substantial financial deficits, which were reported as contributing to slow progress on local IT projects (box 3). Central funding does not cover all of the costs of implementing the care record service, and local IT spending must be sustained or increased to provide the infrastructure necessary to support it.19 For participants, funding for the change management associated with the care record service was a key concern. Up to March 2004, instead of increasing spending, participants in "cash strapped" trusts reported that scheduled IT implementation had been halted to await details of the NPfIT to be made public (box 3). Understandably, trusts may be reluctant to spend on IT if some of the cost will be covered centrally. This lack of certainty seems to have created "planning blight," with participants reporting that few IT initiatives have been championed (box 3), thus potentially widening the IT gap between "cash rich" and "cash poor" trusts.
Performance ratings
For trusts with a low performance rating (0 or 1 star), improving this rating was reported as a pressing concern (box 4). (Although the future of performance ratings is under review, performance indicators are likely to continue to be a key focus for trust managers.) Benefits of the NPfIT (which has a 10 year roll out), such as financial savings and improved patient care, will not be realised until after money has been spent on implementation. This will probably require investment in staff training as well as the IT infrastructure, perhaps temporarily reducing staff time available for clinical care. Trusts are likely to avoid any activity that decreases rather than increases productivity unless sufficient extra financial and human resources are provided (box 4).
Box 3: Issues of financial deficits
"I mean our first, our number one priority in this trust been stated by the , and is quite clear to anybody, is money. We have to claw back our deficit, a huge deficit; has an ever bigger one, and we are a very, um, broke strategic health authority, actually, but particularly this local health community. We're very strapped for cash, and we have to find millions and millions of pounds worth of saving this year alone and indeed over the next three years."—IT and NPfIT project manager, trust 3
"And we have a senior management that have too much on their plate to cope with at the moment, and EPR and IT, as well as between million pound underlying deficit. We're certainly not a trust that can invest from our own resources."—Medical director, trust 1
"We've made real progress, um, in the development of our EPR programme, and those who've done so much work in that particular programme are naturally quite distressed if our particular EPR programme is simply going to go on hold for two, three, or four years, while we wait for a national programme to be implemented."—Medical director, trust 1
"You know, the abandonment, the abandonment of the EPR has had an affect on people's desire to get involved too much in that way—let's wait until a bit later... I think there's a `Let's just not invest too much time' attitude at the moment and see how it goes from here."—Assistant director of nursing, trust 4
Supporting "legacy" IT systems
The NHS has traditionally devolved IT procurement, resulting in a proliferation of IT architecture. This approach contrasts with centralised standard setting and procurement under the NPfIT. Potential legacy problems reported by participants are the loss of existing electronic functionality and concerns over support for existing systems during any transition period.
All trusts in our study reported having highly effective customised pockets of IT. If these systems cannot be integrated with national "standards" some functionality may be lost (box 5). Loss of existing IT function may stall progress and is likely to beresisted. IT literate clinicians in our sample reported working hard to develop systems that best support their needs and the needs of their patients (box 5).
Box 4: Issues of performance ratings
"At the moment, you know, a lot of chief , a lot of your short term focus is on star ratings and performance management because that's where, you know, the carrot, that's why you're driven down that route. So, you know, we're paid to do that and keep the strategic vision going, but it depends how much pressure you get about where your focus could be."—Chief executive, trust 2
"So if that national programme wants this to happen they, the government, whoever, must make sure any moneys that come down through whatever route are ring fenced, and they're ring fenced right down to trust level, so that creative finance directors and others cannot divert them for other purposes."—IT and NPfIT project manager, trust 3
Replacing existing systems will require contracts with existing suppliers to be redrawn. Maintaining goodwill and continued support for such systems may be difficult. Trusts that actively pursued the original plan for electronic patient records1 may be particularly disadvantaged if they are bound into long term contracts with suppliers not awarded contracts under the national procurement process.
Timetable for replacement of patient administration systems
To implement the care records service software, most trusts will need to replace their existing patient administration systems. The new administration system will act as a foundation on which additional "bundles" of clinical functions can be added. However, patient administration systems cannot be replaced immediately in all trusts. For example, in London this activity alone is projected to take up to five years. The timing of this replacement is causing concern, and participants reported that their trusts have been jostling for a slot that meets their particular needs (box 6).
Some trusts have reported an urgent need to replace existing IT systems for radiology or pathology. According to participants, the previously scheduled implementation of such replacement systems has been put on hold until details of the NPfIT have been made public (box 6). Such delay may mean a risk of system failure, but buying a temporary solution is seen as costly. Being first in the queue for implementing the care records service may increase the risk of delays and teething problems, with details of forthcoming support from the local service provider for change management still unclear. However, being at the end of the queue may lead to "planning blight," with no new local IT development until the new administration system is provided (box 6).20
Box 5: Issues of loss of functionality and resistance from clinicians
"There's a feeling of loss of autonomy, um, and possibly lack of or loss of functionality, because some of the systems that we've got are, have been developed over a period of time, and they're pretty well customised and people get used to that level of customisation."—Chief executive, trust 4
"Where it needs tailoring to local trusts—I don't think that's being listened to at all, and that's where they're going to find the biggest amount of resistance, which is where local systems will always be better than the national solution."—Electronic patient records and NPfIT programme manager, trust 2
"Our ITU consultant writes programs: he wrote the ITU one here, and he's writing us a little program for duty doctor handover. It's like swimming in treacle to get it integrated into our system. You can't get it if you're in a, you know, in a regimented system that is becoming increasingly."—Medical director, trust 1
"If we're saying to people, `You have to drop what you've got to a lower function,' well that's going to be very hard to sell."—IT director, trust 4
"Until we can get that level of functionality built into the national solution nobody is going to use it, well not from our trust anyway."—Electronic patient records and NPfIT programme manager, trust 2
"So, yeah, they may have been working overtime developing their own system and now are being told, `No, you can't use it.' And you have something which isn't as good or doesn't allow as much functionality or flexibility perhaps as something else."—Research and development business manager, trust 2
"As a taxpayer, I'm furious, as a clinician who's dedicated time speaking on behalf of other professionals who've spent hours of unpaid time trying to make this work, they feel devalued, marginalised, and ignored. So there's enormous anger in this organisation, particularly at , with the way in which we've been dismissively treated."—Medical director, trust 1
Discussion
NHS Executive. Information for health. An information strategy for the modern NHS 1998-2005. Leeds: NHS Executive, 1998.
Hoeksma J. IT strategy lies in ruins as only five trusts hit April EPR targets. Health Services Journal 2002;5797: 4-5.
Wanless D. Securing our future health: taking a long-term view. Final report. London: HM Treasury, 2002. www.hm-treasury.gov.uk./Consultations_and_Legislation/wanless/consult_wanless_final.cfm (accessed 12 Jul 2005).
Department of Health. Delivering 21st century IT support for the NHS. National strategic programme. London: DoH, 2002.
Dyke P. Healthy connections? Public Finance 2003;Sept: 24-6.
Herbert M. Professional and organizational impact of using patient care information systems. Medinfo 1998;9: 849-53.
Herbst K, Littlejohns P, Rawlinson J, Collinson M, Wyatt JC. Evaluating computerized health information systems: hardware, software and human ware: experiences from the Northern Province, South Africa. J Public Health Med 1999;21: 305-10.
Heathfield H, Pitty D, Hanka R. Evaluating information technology in health care: barriers and challenges. BMJ 1998;316: 1959-61.
Southon G, Sauer C, Dampney K. Lessons from a failed information systems initiative: Issues for complex organisations. Int J Med Inform 1999;55: 33-46.
e-Health Insider. 2003 Nov: Issue 99. www.e-health-insider.com (accessed 16 Nov 2003).
UK National Audit Office Publications. Work in progress: Department of Health: national programme for IT in the National Health Service. www.nao.org.uk/publications/workinprogress/nhs_it.htm (accessed 12 Jul 2005).
Jones AJ, Hart A, Henwood F, Gerhardt C. The use of electronic patient records (EPRs) in the maternity services: professional and public acceptability. Brighton: University of Brighton, 2003: 1-14.
Ash JS, Stavri PZ, Kuperman, GJ. A consensus statement on considerations for a successful CPOE implementation. J Am Med Inform Assoc 2003;10: 229-34.
Berg M. Implementing information systems in health care organizations: myths and challenges. Int J Med Inform 2001;64: 143-56.
Miles MB. Qualitative data as an attractive nuisance—the problem of analysis. Adm Sci Q 1979;24: 590-601.
Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. New York: Aldine de Gruyter, 1967.
Pettigrew A. The management of strategic change. Oxford: Blackwell, 1987.
McNulty T, Ferlie E. Re-engineering health care: The complexities of organisational transformation. Oxford: Oxford University Press, 2002.
NHS Confederation. National programme for IT: an interview with Richard Granger and Peter Hutton. Tyneside: NHS Confederation Publications, 2003. (Briefing paper 89.)
Parliamentary Office of Science and Technology. New NHS IT. Post note No 214. 2004. www.parliament.uk/post (accessed 2 Mar 2004).
NHS National Programme for Information Technology. Making IT happen: Information about the national programme for IT. Birmingham: NHS Information Authority, 2004.
Department of Health. Improvement, expansion and reform—the next three years. Priorities and planning framework 2003-2006. London: DoH, 2002.
National Programme for Information Technology. NHS care record service: indicative deployment plan—Jan 2005. www.connectingforhealth.nhs.uk/all_images_and_docs/imp_plan_0105.pdf (accessed 12 Jul 2005).
Cross M. IT gurus attempt to win doctors' hearts and minds. BMJ 2005;330: 276.
Commission for Health Improvement. Performance ratings: overall summary of results 2002-3. www.chi.nhs.uk/Ratings (accessed 27 Feb 2004).
Comptroller and Auditor General. NHS (England) Summarised Accounts 2002-2003. London: Stationery Office, 2004.
Fulop N, Protopsaltis G, Hutchings A, King A, Allen P, Normand C, et al. Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis. BMJ 2002;325: 246.
Moorman PW, van der Lei J. An inventory of publications on electronic patient records. Methods Inf Med 1999;38: 294-7.
Gosling P. Here comes the enforcer. Public Finance 2004;Jul: 22-3.
Ash JS, Lyman J, Carpenter J, Fournier L. A diffusion of innovations model of physician order entry. Proc AMIA Symp 2001: 22-6.
Dykstra R. Computerized physician order entry and communication: reciprocal impacts. Proc AMIA Symp 2002: 230-4.
National Audit Office. Department of Health: patient choice at the point of GP referral. London: Stationery Office, 2005.
Darbyshire P. The practice politics of computerised information systems: a focus group study. Nurse Researcher 2001;8(2): 4-17.
Timmons S. Resistance to computerized care planning systems by qualified nurses working in the UK NHS. Methods Inf Med 2003;42: 471-6.
Harper RHR, O'Hara KPA, Sellen AJ, Duthie DJR. Toward the paperless hospital? Br J Anaesth 1997;78: 762-7.
Wyatt JC. Four barriers to realising the information revolution in health care. In: Lenaghan J, ed. Rethinking IT & Health. London: Institute for Public Policy Research, 1998: 100-22.(Jane Hendy, research fellow1, Barnaby C )
Correspondence to: J Hendy jane.hendy@lshtm.ac.uk
Objectives To describe the context for implementing the national programme for information technology (NPfIT) in England, actual and perceived barriers, and opportunities to facilitate implementation.
Design Case studies and in depth interviews, with themes identified using a framework developed from grounded theory.
Setting Four acute NHS trusts in England.
Participants Senior trust managers and clinicians, including chief executives, directors of information technology, medical directors, and directors of nursing.
Results The trusts varied in their circumstances, which may affect their ability to implement the NPfIT. The process of implementation has been suboptimal, leading to reports of low morale by the NHS staff responsible for implementation. The overall timetable is unrealistic, and trusts are uncertain about their implementation schedules. Short term benefits alone are unlikely to persuade NHS staff to adopt the national programme enthusiastically, and some may experience a loss of electronic functionality in the short term.
Conclusions: The sociocultural challenges to implementing the NPfIT are as daunting as the technical and logistical ones. Senior NHS staff feel these have been neglected. We recommend that national programme managers prioritise strategies to improve communication with, and to gain the cooperation of, front line staff.
In 1998 the NHS Executive set a target for all NHS trusts to have electronic patient records in place by 2005.1 By the spring of 2002, just 3% of trusts were set to meet this target.2 The Treasury's Wanless report suggested two main reasons for this: budgets for information technology (IT), allocated locally, being used to relieve financial pressures elsewhere, and the inadequate setting of central IT standards.3 The report recommended ring fencing and doubling the IT budget. The government responded with ￡2.3bn ($4.4bn; 3.3bn) for a new national programme for information technology (NPfIT) in the NHS in England.4 The aim is for electronic patient records to be implemented in all acute trusts by the end of 2007.
The size, complexity, and innovation of this national programme (also now called Connecting for Health) makes it the biggest outsourced IT project from the public sector ever untaken.5 Implementing large scale health service IT projects, in the United Kingdom and other countries, has proved difficult.6 7 Problems of achieving effective information flow between users, the cornerstone of any integrated record system, and resolving issues of confidentiality and security have led to reported failure rates of around 30%.8 9 The recent IT implementation failure experienced by the Wessex Regional Health Authority ended in losses to the taxpayer of ￡43m.5 The NPfIT has been described as "ambitious" and "inherently risky."10 The National Audit Office is currently evaluating whether the programme is likely to deliver good value for money and reviewing implementation progress.11 A report is due in the summer.
The programme's key features are new stringent national data and IT standards, procured and paid for nationally. Implementation in acute trusts will be through one of five geographic partnerships with industry, called "clusters." A ministerial taskforce and a NHS IT director general oversee progress. The main national features are a new national networking service providing broadband, called "N3"; electronic booking, called "choose and book"; electronic transfer of prescriptions; and a nationally accessible, "cradle to grave" summary patient record called "the spine" (figure). The provision of electronic functions at acute trust level form part of the NHS care record service, a collective term for all aspects of clinical IT support applications, from clinical decision making tools to digital x rays. The output of these applications is intended to be a health record that can be shared. The NHS care record service replaces the earlier twin concepts of lifelong electronic health records and local electronic patient records.1
Outline of national programme for information technology (NPfIT)
We are studying the processes and outcomes of implementing the NHS care record service in four acute hospital trusts in England. This involves assessing the local context in each trust, in depth interviews of staff and patients over a two year period, and a quantitative analysis of the effects of implementing three electronic functions of the record service. In this paper, we report findings from each trust's baseline assessment and information gathered from the first round of interviews.
Methods
We collected baseline information by meeting key IT, finance, and clinical directorate staff and reviewing documents and routinely published data. Interviews are taking place in three stages, with stage 1 interviews (the focus of this paper) taking place twice, at the start of the project and 18 months later. These interviews concern the development of NHS electronic patient records. (Stage 2 and 3 interviews investigate how electronic functions are experienced by staff and affect working practices and how they affect patient care.) The data reported here are from the first round of stage 1 interviews, with 23 senior managers and clinicians from the four trusts.
To enhance the generalisability of our findings, we selected the four trusts to reflect a range of characteristics (differences in size, number of sites, performance indicators, and financial situation) and various stages of implementing electronic health records. Participants included all local senior management staff involved in implementing the NPfIT, including the chief executive, director of information technology, medical director, and director of nursing.
Semi-structured interviews were conducted on a one to one basis at each trust by a qualitative researcher. We developed the interview framework by drawing on literature concerned with installing electronic patient records to identify key constructs.12-14 Topics discussed included the processes and outcomes of implementing electronic healthcare systems and the impact of the NPfIT policies. Interviews were recorded and transcribed.
Data analysis
We analysed the interview transcripts in three stages based on grounded theory principles of coding and theme ion15 rather than strict adherence to the theory of Glaser and Strauss.16 Literature on organisational change suggests the context and processes of change will be multilayered and complex.17 We explored this complexity by examining variations within and between the four trusts, taking account of organisational changes relating to NHS policy. We then grouped emerging themes according to the context (each trust's characteristics) because "analysis of change needs to attend to the interplay between processes, people, and events both internal and external to the organisation."18 We explored the relations between each trust site and the wider organisation, between the organisation and the individuals within, and between individuals and the technology. Two members of the project team (JH and NF) independently read the interview transcripts to agree on emerging themes.
Results
The table shows the baseline characteristics of each trust, including level of implementation of existing electronic patient records and the expected date for replacing the patient administration system, the first step in implementing the NHS care record service. Data from the first round of interviews show the potential impact of these factors on implementing the care record service.
Table 1 Characteristics of the participating trusts
Multiple sites within trusts
Two of the trusts have multiple sites, resulting from recent mergers, and problems of poor communication and coordination between sites remain. Differences in working practices and organisational culture seem to have created tensions that may make the job of getting ready for the NHS care record service especially challenging (see box 1). Major changes resulting from the recent mergers seem to have affected staff morale, increasing the likelihood that staff will become resistant to the changes required during implementation.
Box 1: Issues of multiple trust sites and change overload
"There's the difference in cultures between the two ends of the same trust, the culture where the whole senior management team transported themselves over. And so I think at one end within the trust, the end, the clinicians and the nurses and others are all used to a different way of working, which the people here are not. So I think there is a big difference actually between—if you ask people at that end I think you'll find a very different philosophy there."—Clinical director, trust 2
"One of the things that definitely makes life much easier is that we're a single site organisation, so there is a single culture around this place; we're not a difficult political being with eight or nine hospital sites spread around. From an IT point of view that's very difficult to support and manage."—IT manager, trust 4
"So, like I said, I think the organisation, leaving aside the IT, has quite a few issues still in terms of the changes it's gone through. Then add in the national programme and that's just, just another thing on top, and that's going to affect working practices across the whole organisation... It is yet another change, and I think certainly people are fed up of change and people do identify the national programme as being yet another IT project that is probably not going to work, that's going to cost a great deal of money, and why should they really cooperate with it?"—Clinician involved in development of electronic patient records, trust 1
Box 2: Issues of communication with NPfIT headquarters and lack of clinical engagement
"So I think we've not had, you know, we had some of the interaction, and I think what we've been asking for is clarity about, um, getting things done, what isn't coming, things like. There was really something last week about... the radiology systems, about the radiology information system and PACs, and in the application there's no radiology information system, there's just PACs."—Executive director, trust 2
"The communication has been appalling, absolutely appalling. They've done some wonderful events, and I've met some people who are great, NPfIT, who are very facilitative and very enabling, and the next week you're told you're not allowed to talk to them. I've been to some meetings where I've met people who are very very good, and we've been ordered not, instructed, they've been ordered and we've been instructed that it's inappropriate to talk to them."—IT manager, trust 4
"Despite what people say there's a lack of, there's a lack of engagement and, you know, even as chief executives, I think we've been involved and been asked to promote something they, we're promoting—we say it's a bit like trying to go and sell, probably in IT terms, vapourware and that's really what it felt like."—Chief executive, trust 3
"I would say that the clinicians are sort of waiting to see what's going to happen before they commit themselves."—Assistant director of nursing, trust 4
Communication between the national programme for information technology and the NHS
The lack of clarity from the NPfIT about future developments—with poor communication between NPfIT headquarters, the local service provider, and trust managers—was reported to be a major concern in all four trusts. Managers felt that local needs and advice have been ignored and expressed sentiments in interviews of feeling ignored, being "done unto," and disempowered (box 2). Participants' views suggest a divide between the central NPfIT office and trusts, with the latter perceiving the former as failing to understand local issues. This lack of communication seems to have filtered down, with managers reporting a reluctance to communicate the benefits of the NPfIT to front line staff without having answers to questions about what IT services will be supplied and when (box 2).
Financial circumstances of trusts
Two of the trusts have substantial financial deficits, which were reported as contributing to slow progress on local IT projects (box 3). Central funding does not cover all of the costs of implementing the care record service, and local IT spending must be sustained or increased to provide the infrastructure necessary to support it.19 For participants, funding for the change management associated with the care record service was a key concern. Up to March 2004, instead of increasing spending, participants in "cash strapped" trusts reported that scheduled IT implementation had been halted to await details of the NPfIT to be made public (box 3). Understandably, trusts may be reluctant to spend on IT if some of the cost will be covered centrally. This lack of certainty seems to have created "planning blight," with participants reporting that few IT initiatives have been championed (box 3), thus potentially widening the IT gap between "cash rich" and "cash poor" trusts.
Performance ratings
For trusts with a low performance rating (0 or 1 star), improving this rating was reported as a pressing concern (box 4). (Although the future of performance ratings is under review, performance indicators are likely to continue to be a key focus for trust managers.) Benefits of the NPfIT (which has a 10 year roll out), such as financial savings and improved patient care, will not be realised until after money has been spent on implementation. This will probably require investment in staff training as well as the IT infrastructure, perhaps temporarily reducing staff time available for clinical care. Trusts are likely to avoid any activity that decreases rather than increases productivity unless sufficient extra financial and human resources are provided (box 4).
Box 3: Issues of financial deficits
"I mean our first, our number one priority in this trust been stated by the , and is quite clear to anybody, is money. We have to claw back our deficit, a huge deficit; has an ever bigger one, and we are a very, um, broke strategic health authority, actually, but particularly this local health community. We're very strapped for cash, and we have to find millions and millions of pounds worth of saving this year alone and indeed over the next three years."—IT and NPfIT project manager, trust 3
"And we have a senior management that have too much on their plate to cope with at the moment, and EPR and IT, as well as between million pound underlying deficit. We're certainly not a trust that can invest from our own resources."—Medical director, trust 1
"We've made real progress, um, in the development of our EPR programme, and those who've done so much work in that particular programme are naturally quite distressed if our particular EPR programme is simply going to go on hold for two, three, or four years, while we wait for a national programme to be implemented."—Medical director, trust 1
"You know, the abandonment, the abandonment of the EPR has had an affect on people's desire to get involved too much in that way—let's wait until a bit later... I think there's a `Let's just not invest too much time' attitude at the moment and see how it goes from here."—Assistant director of nursing, trust 4
Supporting "legacy" IT systems
The NHS has traditionally devolved IT procurement, resulting in a proliferation of IT architecture. This approach contrasts with centralised standard setting and procurement under the NPfIT. Potential legacy problems reported by participants are the loss of existing electronic functionality and concerns over support for existing systems during any transition period.
All trusts in our study reported having highly effective customised pockets of IT. If these systems cannot be integrated with national "standards" some functionality may be lost (box 5). Loss of existing IT function may stall progress and is likely to beresisted. IT literate clinicians in our sample reported working hard to develop systems that best support their needs and the needs of their patients (box 5).
Box 4: Issues of performance ratings
"At the moment, you know, a lot of chief , a lot of your short term focus is on star ratings and performance management because that's where, you know, the carrot, that's why you're driven down that route. So, you know, we're paid to do that and keep the strategic vision going, but it depends how much pressure you get about where your focus could be."—Chief executive, trust 2
"So if that national programme wants this to happen they, the government, whoever, must make sure any moneys that come down through whatever route are ring fenced, and they're ring fenced right down to trust level, so that creative finance directors and others cannot divert them for other purposes."—IT and NPfIT project manager, trust 3
Replacing existing systems will require contracts with existing suppliers to be redrawn. Maintaining goodwill and continued support for such systems may be difficult. Trusts that actively pursued the original plan for electronic patient records1 may be particularly disadvantaged if they are bound into long term contracts with suppliers not awarded contracts under the national procurement process.
Timetable for replacement of patient administration systems
To implement the care records service software, most trusts will need to replace their existing patient administration systems. The new administration system will act as a foundation on which additional "bundles" of clinical functions can be added. However, patient administration systems cannot be replaced immediately in all trusts. For example, in London this activity alone is projected to take up to five years. The timing of this replacement is causing concern, and participants reported that their trusts have been jostling for a slot that meets their particular needs (box 6).
Some trusts have reported an urgent need to replace existing IT systems for radiology or pathology. According to participants, the previously scheduled implementation of such replacement systems has been put on hold until details of the NPfIT have been made public (box 6). Such delay may mean a risk of system failure, but buying a temporary solution is seen as costly. Being first in the queue for implementing the care records service may increase the risk of delays and teething problems, with details of forthcoming support from the local service provider for change management still unclear. However, being at the end of the queue may lead to "planning blight," with no new local IT development until the new administration system is provided (box 6).20
Box 5: Issues of loss of functionality and resistance from clinicians
"There's a feeling of loss of autonomy, um, and possibly lack of or loss of functionality, because some of the systems that we've got are, have been developed over a period of time, and they're pretty well customised and people get used to that level of customisation."—Chief executive, trust 4
"Where it needs tailoring to local trusts—I don't think that's being listened to at all, and that's where they're going to find the biggest amount of resistance, which is where local systems will always be better than the national solution."—Electronic patient records and NPfIT programme manager, trust 2
"Our ITU consultant writes programs: he wrote the ITU one here, and he's writing us a little program for duty doctor handover. It's like swimming in treacle to get it integrated into our system. You can't get it if you're in a, you know, in a regimented system that is becoming increasingly."—Medical director, trust 1
"If we're saying to people, `You have to drop what you've got to a lower function,' well that's going to be very hard to sell."—IT director, trust 4
"Until we can get that level of functionality built into the national solution nobody is going to use it, well not from our trust anyway."—Electronic patient records and NPfIT programme manager, trust 2
"So, yeah, they may have been working overtime developing their own system and now are being told, `No, you can't use it.' And you have something which isn't as good or doesn't allow as much functionality or flexibility perhaps as something else."—Research and development business manager, trust 2
"As a taxpayer, I'm furious, as a clinician who's dedicated time speaking on behalf of other professionals who've spent hours of unpaid time trying to make this work, they feel devalued, marginalised, and ignored. So there's enormous anger in this organisation, particularly at , with the way in which we've been dismissively treated."—Medical director, trust 1
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