V1 01FINAL Local Ownership Opportunity and RiskDiagnosis180608.doc6th June 2008

Local Ownership Opportunity and Risk Diagnosis

(LOORD)

“supporting the NHS to deliver better quality and safer services using IT”

Local Ownership Opportunity and Risk Diagnosis

Final Report

Product: NLOP

Version: 1.01

Amendment History:

Version / Date / Amendment History
V.0.01 / First Draft for Review with Linda Lloyd and John Willshere
V0.02 / Second Draft for Review to Linda Lloyd, John Willshere, Carol Clarke, Peter Magee and Paul Mansell
V0.03 / 5 May 2008 / Third Draft incorporating Linda Lloyd material for Review to Linda Lloyd, John Willshere, Carol Clarke, Peter Magee and Paul Mansell
V0.04 / 6 May 2008 / Updated Graphs and added table of figures
V0.05 / 6 May 2008 / Updated Graphs and table of figures
V0.06 / 6 May 2008 / Updated Graphs and added table of figures
V0.07 / 7 May 2008 / Revised document following review 6 May
V0.08 / 7 May 2008 / Main Report and Annexes separated into two documents, recommendations restructured
V0.09 / 10 May 2008 / Text modified and Executive Summary written Linda Lloyd & Jana Dale
V0.10 / 13 May 2008 / Slides Typing Errors Modified
V0.11 / 14 May 2008 / Altered to incorporate modifications requested by Linda Lloyd
V0.12 / 20 May 2008 / Incorporates Linda Lloyd and Jana Dale inputs
V0.13 / 23 May 2008 / Presentation changes following a discussion with Bob Alexander
V1.00 / 2 June 2008 / Final Report incorporating comments from Carol Clarke
V1.01 / 6 June 2008 / Case studies added by Linda Lloyd to Final Released Version

Reviewers:

This document must be reviewed by the following;

Name / Signature / Title / Responsibility / Date / Version
Carol Clarke / Director of Stakeholder Engagement & CRS / June 2nd, 2008 / V 1.00
Paul Mansell / Director, Moorhouse Consulting / June 6th, 2008 / V 1.01

Approvals:

This document must be approved by the following:

Name / Signature / Title / Responsibility / Date / Version
Carol Clarke / Director of Stakeholder Engagement & CRS / June 2nd, 2008 / V1.00

Distribution:

Approvers, reviewers

Document Status:

This is a controlled document. Whilst this document may be printed, the electronic version maintained in FileCM is the controlled copy. Any printed copies of the document are not controlled.

Table of Contents:

1Executive Summary

1.1Key Messages

1.2Background

1.3Purpose

1.4Principles of NLOP Transition Impacting Local Ownership

1.5Method

1.6Report Structure

1.7Summary Findings from the Trusts

1.8Progress on Risks Identified within TAR

1.9Correlation with Health Informatics Findings and Summary Care Record Early Adopters Evaluation

1.10Conclusions

1.11Main Recommendations

2Method and Approach

2.1Methodology

3Context

3.1Current Deployment Status by Local PfIT

3.2London Programme for IT Update

3.2 Southern Programme for IT update

3.3North Midland and East Programme for IT Update

4Scores and Analysis

4.1Discussion summary - principal observations and analysis

4.2Overall Confidence Ratings

4.3Confidence Ratings By Trust Category

5Dimension Analysis

5.1Governance

5.2Planning

5.3Capacity and Capability

5.4Performance Management

5.5Finance

5.6Deployment

5.7Service Implementation

5.8Service Management

5.9Commercial

5.10Clinical

5.11Benefits

6Conclusion and Recommendations

6.1The Local Level

6.2The SHA Level

6.3Recommendations and Observations: Local Programme Level

6.4The National Level

© Crown Copyright 2018Page 1 of 49

V1 01FINAL Local Ownership Opportunity and RiskDiagnosis180608.doc2nd June 2008

1Executive Summary

1.1Key Messages

There were a number of common themes running through all the project dimensions as well as the types of organisations that participated in the project:

  • Awareness of NLOP– all the organisations were aware of the National Programme for IT (NPfIT) Local Ownership Project (NLOP), but the extent of understanding of what it meant in practice varied. The penetration of NLOP principles below the SHA level remains subject to local variations and interpretation. The majority of risks identified in the TAR report remain.
  • Concerns about credibility and low confidence – currently acute secondary care CRS products are seen as very weak, and the LSPs’ ability to deliver to timescales on these has not been credible. Similarly there are serious doubts about the deployment approach with many parallel or only slightly staggered projects. Trusts want to see clear, successful demonstrators before committing to the Programme. Conversely some MH and community products have been implemented very successfully, with much benefit gained and more to come as some organisations belatedly redesign care and exploit benefits across Trust boundaries.
  • Insufficient Communication is a common theme running through all aspects and dimensions of this review. This issue may have been expressed in a number of different ways, e.g. lack of transparency, lack of clarity, being secretive and similar. The comments often referred to areas where there appeared to be no commercial or other internal reasons for not making information available to the Trusts.
  • Commitment to the vision – all Trusts interviewed expressed their continued commitment to the vision of patient-centred life long electronic health record shared across local health communities (LHCs). This commitment was re-stated despite local frustrations with lack of progress with systems implementation, business change and benefits delivery to date.
  • Lead Role of PCTs – the leadership role PCTs perform in local health communities in terms of the development of IM&T strategy and planning appears to be directly related to the maturity and stability of the NHS organisations and their working relationships. Although all the PCTs were still consolidating following the last re-organisation, the CEOs were consciously developing their SRO roles and integrating IM&T into the business planning cycle. Relationships with local foundations trusts were not presenting any specific problems. The positive developments to date indicate that local health communities offer the best chance of success for the implementation and exploitation of IM&T.
  • Capability and capacity – the majority of the Trusts have made some progress in developing their capability to use IM&T successfully. The largest gaps are in the area of mainstreaming, business change and benefits management. These are also identified as areas where support would be most useful. The Trusts also feel that more advantage should be taken of pooling resource and creating resource mobility.

1.2Background

The National Programme for IT (NPfIT) Local Ownership Projectwas implemented in the middle of 2007. It was primarily focused on transferring accountability and responsibility for the planning and delivery of NPfIT products and solutions from NHS CFH and as such had the following objectives:

  • strengthen local governance and ownership, so that the SHAs and PCTs are enabled to drive the LPfIT in an appropriate direction that achieves the right balance between national imperatives and local needs
  • reinforce the value and benefits that can be derived from NPfIT
  • implement the recommendations of the NAO Report in 2006
  • follow the direction provided by Sir Ian Carruthers’ letter (‘NPfIT – Responsibilities and Information Governance’ dated 21 Aug 2006)
  • implement the recommendations of the NHS Management Board.

NLOP Transition Assurance Review (TAR) was carried out in 2007and considered the transfer of ownership from NHS Connecting for Health to the ten SHAs. The review reported ten risks. These were based on self assessed scoresobtained from the ten SHAs and follow-up interviews. The review did not seek to go below the SHA level.

The LOORD project was commissioned in February 2008 bythe Director of Finance, Performance and Operations on behalf of the NHS Management Board to obtain an evidenced base view of the extent to which NLOP has penetrated down from the SHA level into the wider NHS at the local level and how risks are perceived by NHS organisations (Trusts)[1].

1.3Purpose

The objectives of the LOORD project have been to:

  • measure the degree to which the principles of Local Ownership of the Local Programmes for IT have penetrated beyond the SHA level to individual NHS organisations
  • establish an evidenced based understanding of the degree of confidence Trusts have in the current arrangements
  • identify areas of good practice that could potentially be replicated more widely
  • identify areas where central support might be provided at the national, SHA or local level to help resolve the issues identified through the project.

1.4Principles of NLOP Transition Impacting Local Ownership

Amongst the objectives that NLOP transition was seeking to achieve, the following are relevant at local level:

Relevant NLOP Principle / LOORD Team Commentary
Safe transition:
to 'pressure-test' NLOP transition against the then current risk profile of the NPfIT implementation programme / NLOP transition does not seem to have worked fully. However it is necessary to identify the extent of real, substantive risk to the programme and to differentiate risks from issues. The identified risks are:
Financial – costs are duplicated and prolonged as roll-outs slip behind published schedules and Trust have to bear programme costs
Resource consumption – An increased demand for resources in excess of initial estimates which diverts important and scare resources away from other important initiatives.
Clinical – weak products and governance arrangements could combine to create clinical risk and loss of commitment leading to impaired benefits realisation
Core Functions:
to focus on the core functions of Deployment and Design, Build and Test (DBT) / The majority of Trusts are not satisfied in this area – they do not feel that they design the solution but merely configure it. The first engagement event is to talk about deployment not design and they dislike the “one size fits all” approach.
Ownership:to shift ownership to the SHAs with the expectation that they then establish clear ownership and accountabilities at the local level / Results are uneven but there are pockets of good practice that are worth investigating to see if they can be replicated more widely.
Senior Stakeholders:
to provide assurance to the senior stakeholders: SHA CEOs, NLOP Regional SROs, NHS CEO, NHS CFH / This list does not include Local SROs and this is consistent with the Trusts’ issue that LSPs and NHS CfH do not see them as the customer
Risk Mitigation:
to identify, quantify, and qualify the risks to successful programme delivery caused as a result of the NLOP transition / Risks remain substantially unresolved - see section 1.8 below

1.5Method

The project team collected information and interviewed senior executives, very often including the CEO, from a representative sample of 37 NHS Trusts. Trusts scored themselves againsta set of confidence statements covering the following dimensions:

  • Governance
  • Planning
  • Capability and Capacity
  • Performance Management
  • Deployment
  • Service Implementation
  • Service Management
  • Commercial
  • Clinical
  • Benefits

Based on these scores, the team facilitated peer challenge sessions of comparable Trusts or where this was not possible interviewed the NHS organisations individually.

The project field work was carried out between 12 March and 1 May 2008

1.6Report Structure

The report presents findings from the self assessments and subsequent interviews. The report then draws conclusions and makes high level recommendations to be considered by the Project sponsor and, if appropriate, by the NHS Management Board. It will be shared with SHA CEOs in their SRO capacity under NLOP.

SHA CIOs have committed to disseminating and supplementing these recommendations with their own early action plans, developed for local dialogue. In addition, mapping with the recommendations from the Health Informatics Review is to be carried out.

1.7Summary Findings from the Trusts

The primary focus of the project was on the effects of NLOP transition. The Trusts’ focus, however, has moved on to the longer term and they are concerned about how they implement and transition to ‘business as usual’. The findings reflect this position and are summarised here against the four project objectives.

Objective 1

Measure the degree to which the principles of Local Ownership of the Local PIT programmes have penetrated beyond the SHA level to individual NHS organisations

  • Perceptions as to the effectiveness of NLOP transition vary both within and between the Local Programmes for IT. There is still a need for greater clarity as there is not yet a consistent understanding amongst Trusts about how arrangements have changed post-NLOP and how these changes affect them.
  • Some Trusts are unaware of any resource shift from the centre to the front line.
  • The Trusts feel that neither the LSPs nor NHS CFH consider or treat them as the customer.

Objective 2

Establish an evidenced based understanding of the degree of confidence Trusts have in the current arrangements

  • The Trusts feel that weaknesses of acute CRS products combined with confusion about governance could combine into a substantial clinical risk.
  • The Trusts feel very strongly that they lack a role in the contract and any levers to control the delivery of the contract both during deployment and in live running; local influence and control over deployment and service management is lacking).
  • Many Trusts did not treat the National Programme deployments as part of their mainstream project portfolio leading to unclear investment objectives and weak benefits management.
  • The adoption of a mass roll-out approachis seen as deeply flawedas the products need a large degree of development. Trusts believe that this approach should be abandoned until such time when the solutions are stable and can be rolled out across multiple parallel sites.
  • The delays occurring as a result of remedial work and fixes to the products are resulting in ever shifting timescales and a lack of credibility of the DIP and the Development Plan.
  • Trusts challenge the timetable for rollouts as the capacity and capability of both the LSPs and the LHCs to support the proposed rhythm of delivery appear questionable, even if the CRS products were fit for purpose and ready for use.

Objective 3

Identify areas of good practice that could potentially be replicated more widely

  • Some NHS organisations show markedly greater confidence in local arrangements and ownership than the average, particularly those where there was a cohesive local health community covering more than one PCT, the local Acute Trusts, Mental Health Trust and local authority, even independent contractors and the charitable sector.

Case study: Worcestershire PCT and the single Worcester County ICT Services (WHICTS)
The PCT Chief Executive has been involved with the National Programme since its inception. He chairs the LHC Information and Communications Technology (ICT) Programme Board and is a member of the West Midlands Programme Board chaired by the SHA CEO. Creating and maintaining good governance both within ICT and between ICT and service organisations is seen as critical to achieving the Programme’s outcomes.
A structure now exists (Project Boards through Organisational Programme Board to County ICT Programme Board) that streamlines decisions and direction at the right level throughout the strategic, programme and project life cycles. This also supports and is guided by reference groups (Primary Care, Clinical Reference Group, and Information Governance Forum) in the county, providing a critical path for service leaders to ensure alignment and influence the strategic and operational direction of travel of ICT Services and Projects, reducing ‘silo’ planning.
Service Level Agreements (SLA) have been established between WHICTS and the three Trusts as well as between WHICTS and primary care general practitioners. The SLAs are formally agreed by the County ICT Programme Board.
The LHC is also developing a portfolio management approach and expanding its pool of project managers who can be used both in IT and non-IT projects. The overall emphasis is therefore on a benefits led approach to planning and implementation that covers the whole business and IM&T agenda, not solely the National Programme solutions.
Risk is managed at programme and project level. Risk logs are maintained at a project level using OGC evidence based risk tracking, allowing Project Board and assurance roles to have ready access to them. Significant risk is then taken through organisational risk registers, if appropriate.
  • There are notable examples of effective working within the National Programme, where Trusts have negotiated specific arrangements to the solution and/or variations to the original contract; some Trusts have brokered local implementations of additional products/solutions (‘top-ups’) to bring forward interim solutions and to fund new requirements within that interim product
  • Two Mental Health Trusts, Tees, Esk & Weare Valley and Leeds, are receiving PARIS as an interim solution ahead of Lorenzo through the National Programme:

Case Study: Tees, Esk and Weare Valley Mental Health Trust
The quest for a shared electronic patient record began in the Trust’s predecessor, with a MH services strategy which put electronic records at its heart, and generated an IT business case in 2003, as NPfIT started up. The Trust became an early CRS adopter for Mental Health.
November 2005 saw their CRS work cease, due to lack of development of the product, despite the project running for a year, with 500+ users trained and being under the national spotlight as one of the first in mental health.
As a result of good intelligence sharing, the North East Mental Health Forum made a convincing case and gained agreement with CFH to offer an alternative MH solution in Trusts with unsupported systems. Following lengthy multi party negotiations which survived a change in the main contractor from Accenture to CSC, and creation of a new, merged NHS Trust, contracts between CFH, CSC, In4tek and Digica, were signed in December 2007.
In terms of people, clinical leadership in the the trust fully supported the decisions and at times although frustrated by the delays, were focused on the real delivarbles and fully backed and support our work and stance with NHS CFH. It is hard to articulate how invaluable this was and how this gave us strength and confidence to continue down this route
The Trust is now just weeks away from the first 600 users going live on the PARIS system. Over the next 9 months, in excess of 200 change workshops will be undertaken to ensure that the real benefits the system can facilitate are delivered, through enhancing our processes and ways of working, over 3000 users will be trained and the system will be available at over 100 sites.
Only through aligning with the key business objectives, has the project stayed at the forefront of the organisations business. It has survived the test of time and change of organisations. Now the pressure is really on to make it deliver what it set out to - Improvements in care for patients and a modern work environment for staff’
  • An Acute Trust that has introduced both an additional gateway prior to go-live and a three part payment to replace the single DVC payment. The impacts of this on payments to the supplier have been handled by NHS CFH.

Case Study: Taunton & Somerset NHS Foundation Trust
In general, Trusts see the deployment process as too rigid and consequently perceive that they are placed under a lot of pressure to sign off milestones and stick to unachievable dates.
However, Taunton and Somerset NHS Foundation Trust took ownership and control of the project and introduced strong local project management discipline. This resulted in diligent scrutiny of project milestones and insistence on good quality deliverables before allowing the project to progress to a next stage.
Additional gateway reviews were introduced at key points e.g. a gateway review eight weeks before go-live meant that the Trust insisted on the testing phase being completed before proceeding to the final deployment phase. Although this sounds like common sense and simply adherence to good project management there are examples in different organisations were these disciplines were not adhered to, resulting in problems further down the line.
After the go-live, the Trust agreed a partial (three part) sign-off and introduced more meaningful local sign-off criteria, departing from the norm of either signing or rejecting completely at the end of 45 day deployment verification period. This was beneficial both to the Trust and the supplier. The impact of this on payments to the supplier were handled by NHS CfH.
  • An increasing number of Trusts see information as a key business resource and are incorporating IM&T planning into their business planning cycle
  • Some Trusts have a rigorous approach to benefits management that applies to all investments in that organisation, including IM&T projects
  • There is evidence of a developing programme and project management culture and an increasing recognition that project management is a professional skill that needs be used to manage both IM&T and other projects
  • There is some evidence of local pooling of specialist resources, e.g. trainers

Objective 4