Stick with the programme?

Six months ago, trusts were understandably cautious when they were asked where they stood in relation to implementing the long awaited Lorenzo electronic patient record system under the National Programme for IT in the NHS.

Now, something has changed. Trusts in the North Midlands and East that traditionally said they remained committed to the programme are openly saying they are fed up of waiting and will follow their own destiny.

And who can blame them. Last year, Christine Connelly, the Department of Health’s director general for informatics, said that if local service provider CSC failed to get Lorenzo working smoothly across an acute care setting by the end of March 2010 the DH would look for a “new plan for delivering informatics in healthcare.”

Following University Hospitals of Morecambe Bay NHS Trust’s failure to go live with the latest version of the system on schedule, the ‘new plan’ announced by health minister Simon Burns seemed to amount to more local ownership.

In a ministerial statement, Burns said there would be more locally-led procurement and more modular implementations. However, trusts that go outside the programme will not get central funding. And the DH is being very clear that existing LSP contracts will be honoured.

A case of “rebranding”

One IT director, whose trust has recently invested heavily in clinical functionality, tells E-Health Insider: “When the release came out, we really thought that we were two years ahead of everyone else.

“But then there was more information revealing that the LSP deals would be honoured. So it seems more like a rebranding exercise and that nothing has really changed.

“It isn’t clear what’s going on in the South, there will be no money outside of the programme, but at the same time there will be no penalties for going outside NPfIT – did anyone really think there would be anyway?”

John Thornbury, director of ICT for Worcestershire Health, also finds it difficult to see how both a national and local programme can work in sync.

“The principle of interoperability and local ownership is very laudable, but the announcement that the LSP contracts will be guaranteed makes me struggle to see how there can realistically be any real choice in moving forward,” he says.

In or out?

However, it appears that many trusts have already come to terms with the fact that they may need to go it alone and are already building on what they have already implemented.

The majority of trusts that EHI spoke to said that their future was mapped out by the letters sent out by their strategic health authorities back in March.

These asked them if they would like to proceed with their plans to implement Lorenzo following significant cut backs to the functionality made to cut £600m from the programme by Labour in its last Budget.

One foundation trust IT director from the North of England who attended a meeting held by his SHA said he was shocked at the number of people choosing to opt out of Lorenzo.

“At first I thought it would just be the big acutes and the ones that had good, solid IT in place to build on with an obvious roadmap – but even some of the smaller ones were saying no,” he says.

Stephen Parsons, IM&T project manager at Trafford Healthcare NHS Trust, adds: “We were part of that circulation. Given the proposals to reduce functionality, and given that we have good functionality here, we couldn’t see any value in going ahead with the change – and therefore couldn’t say we wanted it.

“We cannot keep waiting on something not knowing what it’s going to be. For us the investments we’ve made we’ll continue to work on and enhance what we already have. We have a stable EPR, the pressure on us is not so much on clinical records but more on cost reduction in business and improving quality.”

Moving on

Similarly, Thornbury says that although the primary care trusts in the area remain committed to Lorenzo for now, the trust has opted out and will extend its original strategy.

“Because of the delays to NPfIT, like most trusts our key thing is to keep clinicians engaged. So we have had a dual approach, with the programme being our long term approach and our clinical portal being our interim.

“Now our clinical portal has become our long term strategy, which fits more with interoperability rather than rip and replace like before,” he says.

Similarly, Mark Thomas, director of IM&T at North Cumbria University Hospitals NHS Trust, said: "We already had a programme around interoperability which neither ruled in or ruled out Lorenzo.

"We have bundled this into a transformational programme (rather than a change programme), which will not only support the acute trust’s needs and aspirations but also work with locality based services too. All of this was on the cards before the white paper."

Cambridge University Hospitals NHS Foundation Trust has gone further. Indeed, it recently made the local news when it said that its IT system is so old that it is causing risk within the trust. It also said that steering clear of NPfIT is the right thing to do.

Frances Cousins, director of information systems at the trust, added: “It’s not risk free-there are many risks but the risk of not doing anything is much bigger. Our systems are becoming very old and we have to plan for a new future.”

Sticking with it

Still, according to Connelly, there are trusts out there willing to wait for Lorenzo despite its problems and now it appears that the scale of CSC’s renegotiated contract will be based on them.

But even some of those trusts seem a touch sceptical about whether they will ever receive Lorenzo, given that CSC’s contract finishes in 2016.

Christine Walters, associate director of IM&T at Pennine Acute Hospitals NHS Trust who has opted in for Lorenzo, told EHI: “We will not take Lorenzo until it is fit for purpose, and we could not even consider starting a project for the next 12-15 months. But then again, our plan has never been about moving quickly to Lorenzo.”

Royal Liverpool and Broadgreen University Hospitals NHS Foundation Trust, which has also opted in to Lorenzo, says that while it will “continue to consider all options open to the trust with regards to national contracts and once further details regarding the ongoing support are known, we will identify the direction of travel we will be taking.”

James Norman, director of IM&T at the trust adds: “The change to the programme doesn’t really change the way my trust views investment in IT. If anything, the financial downside has strengthened our resolved to ensure IT helps to support continued delivery of service to patients.”

Surprisingly, even one of the trusts that went outside the programme still opted in to Lorenzo when its SHA gave it the option. “Despite doing our own thing, we have continued to put our cards on the table. Our logic is ‘what if they really do crack this Lorenzo nut’? If there is at some point this wonderful piece of software that is free then we can’t rule it out.”

Ahead of the game

However, that same trust is one of many feeling that going outside the programme has put it ahead of the game. EHI’s contact says: “Before, we had to put the word interim in front of our strategy. Now, maybe, that has fallen off. But realistically, was it really there in the first place?”

Wrightington, Wigan and Leigh NHS Foundation Trust recently announced that it has chosen Swedish company Cambio to implement a health information system.

Stephen Dobson, director of IM&T tells EHI: “By pushing ahead with procurement last November, we believe we are ahead of where we would have been if we’d stayed with Lorenzo.

“We prefer the open market. It should increase competition and innovation between vendors and in the long term we believe this to be the fastest route to highly capable systems at a lower cost.”

Andy Jardine, IT director at Newcastle upon Tyne Hospitals NHS Foundation Trust, which went live with a Cerner Millennium implementation by UPMC: “For those trusts who chose to wait, regardless of whether they now opt for a LSP solution or look elsewhere in the market place, funding any solution in the current economic climate will undoubtedly be seen as a much bigger challenge than that same decision may have done two or three years ago.”

EPR versus clinical portal

So what now for trusts who have little money but a clear need to modernise the way they care for patients?

Jardine says: “If the Lorenzo programme is unlikely to deliver, then with the current economy I suspect there will be an increase in the development of cheap best of breed solutions that can rapidly deliver EHR – like portals using pre-existing applications.”

Walters agrees, saying: “I think a lot of the big trusts will continue to opt out of Lorenzo, with many of them building on what they have got.

“They don’t want to bring in a new patient administration system unnecessarily when they can just upgrade. It’s more about bringing in systems to support the clinician, such as electronic document management and portals.

“There isn’t the money out there to go and spend on new EPR systems; only a few brave souls will do that. However, building on existing systems will be positive and encourage much more collaborative working.”

Thornbury agrees: “The financial position of the NHS means that there is not a lot of spare cash, so I can’t see many trusts going for the large monolithic systems anymore.”