OSCHA 2001 NHS stream: Mark Richards

Mark Richards, is the IT director of the Nuffield Orthopaedic Centre in Oxford. He presented his slides on the INFOSTAT recovery story and argues that in house maintenance of a patient administration system in an NHS Trust is not only practical but cost effective.

Chair: When we were first looking at open source in healthcare we had a bit of a surprise. If you search the net using the usual tools, up pops a story about the Walton Hospital, a neurological hospital near Liverpool, and what happened to them when their IT supplier went bust. There was a recession, the high tech market was contracting a bit, the company that was the parent supplier for their supplier was American, and just dropped operations in the UK and contracted into the US. What goes around comes around; we are now in a small high tech recession... anyway they weren't the only people using the system: you were using the system and... carry on.

Mark Richards: Thanks for the introduction. I'm glad to see that Neil's here from the Walton centre: I'm actually from the Nuffield Centre: I've been there for eight years, and I've seen the project through from the start to where we are at the moment. We had a story this morning about Muffin, and this is another story, going I think from chapter 1: disaster, chapter 2: recovery, getting a better deal: chapter 3: getting a better system. There's a few lessons we learnt along the way, and there is an epilogue. It's not as good as Muffin because we didn't get a million dollars.

OK, like all systems and all projects, you intend to make it a great success and it's always a surprise when it doesn't work out to be a great success. We went by the rules, and we're currently going through another procurement using almost exactly the same rules. Rules in the NHS are no guarantee of success: they just make sure you tick the boxes and satisfy the auditors and keep the finance director happy. We were the second UK site to use this American system that had been installed in 50 US hospitals; a brilliant track record; we switched it on.

First of all the waiting list and the out patient module that had written specially for us just didn't work. The contracting module--if you can remember going back to the internal market in 1993--essential for our survival as a 1st wave trust because we were losing 200 000 ukp a year through lost ECR income--had never been tested. I was glad to hear someone earlier talk about actually being to look at the source code. I did that, to look at the logic and I told the supplier where the bugs were and how to fix them, without even switching it on. A lot of bugs in the system. The supplier sold us the system and then went off after some larger trusts because they wanted to make even more money out of the UK market. We were left with a situation within a few months whereby we had to do something pretty drastic: after a bit of coercion of users, the volume mounted using the system (after a bit of grumbling) and also, manna from heaven, the best programmer from that company came to join us.

[audience laughs knowingly]

So after a bit of argy-bargy including legal threats--the usual sort of thing--we made them give us an offer we couldn't refuse and they sold us a development license and we stopped paying them license fees. So immmediately we started saving money. Two other trusts, in addition to the Walton and ourselves had gone live with the system. Just after we took on the development license the supplier went out of business. We were OK, we were happy with that, because we hadn't relied on them for six months or so, but two other trusts had just gone live with the system, one of them within days of going live. They came to us. We had by that time started growing our own software developers and we had a ready made support network in place for them. One was in Swindon, the other was in London and that meant that meant that we could charge them for the time our guys worked in support of their systems and grow our team. At one stage we had five or six programmers and were probably the biggest software development team in the NHS. Because we used our own staff we paid them... well we'll come onto pay in a moment...

[audience laughs]

well-paid by NHS standards, but very low paid by commercial standards which meant we could develop out software at the fraction of the price we would have had to pay for it. As an example, we had a maternity system for about 20000 ukp and an A&E system for about 15,000 ukp fully-spec'd fully integrated with core PAS. You can't get that anywhere else--all fully integrated. Basic PAS, patient demographics, inpatients, outpatients, waiting times, coding, seven years later we were almost there with EPR 3. Along the way we picked up a few awards at Healthcare computing: if you were at Harrogate you would have seen that and one of the main parts of EPR3--electronic prescribing and discharge summaries we've had for six years or so. We can train junior doctors on the day they are induced: it's part of their induction training they have to do it.

OK, we had some staff turnover. It's very good to retain good programmers. We get them in as trainees, after a few years they'll start looking elsewhere. We can't match the salaries, an example we lost one programmer at Christmas, she was on about 22k, she joined a company paying 30k and they would increment her money by 5k/year after that. The NHS cannot do that. From the bottom, programmers are better paid than nurses which causes quite a lot of jealousy and envy and we certainly can't fit into NHS career path and structure. We can't retain staff.

In addition IT is always a soft target when times are hard, so savings targets, you cut staff particularly when you are relying on your own staff to make changes rather than purchasing contracts through normal procurement. Support from the top is essential in the early days and the chief executive threw his full weight behind the system and that's probably what made it the success it was. You need high level support and you need the board to be fully behind you. We had a change in chief executive recently, priorities change. The NHS has changed to; it's a different business model working at the moment.

And I suppose the other part of the risk is, yes, the technology is always dead simple by comparison to the organisational change and the effort there.

Advantages. One of the things I didn't put down here is that it's actually enterprise wide. In a lot of examples locally within the area where I work, hospitals have allowed doctors to develop their own systems using their own tools. You end up with 100 systems and then someone has to say, "well, how do we integrate all these? How do we get the data out?" And the simple answer is you can't do it; but we had an enterprise wide solution across all patients. We were able to develop software to keep up with the business. We are now actually turning the circle right back with the contract monitoring software that we wrote in 1994. We don't have an internal market any more, but the board recently required contract monitoring again. I said "We've got the software already, you switched it off three years ago. We can switch it back on.

As I said earlier, it's extremely cost effective. The full team of programmers costs about 150k ukp/year. We generate about two thirds of that in external income from the other trusts we support so we have a full PAS with all the support and all the development for a snip. The great thing about a single database is that when you want a theatre system, you just write a theatre system and it fully integrates with the waiting list. You can add a patient in, decision to admit, you can actually say, your operation date is going to be this date, is that OK with you? That's booked admissions for you. We'd done it six years ago. But we didn't call it that then.

The other good thing about doing your own thing is complex projects such the year 2000 which take about nine months of C programmer time, and we did it in 1996, and then the rest of the world woke up. More recently we got the software out to GPs over the NHSNet, and they're using it to make referrals. The consultants aren't yet allowing them to make appointments into their clinics, but that'll be dead simple. And we own it.

So, recently within the last few months we were relying on that little bit more funding out of the LIZ to get us to EPR3. LIZ was cut, our PAS was cut out of that. We're now in a situation where we can't actually take it any further under our own resources. The other trusts that we were supporting are now moving onto their own solutions through PFI deals so our opportunity to make money out of other organisations has dried up as well, so our only option if we want to move forward as an organisation and meet the targets is to collaborate with the large turst nearby.

The fourth line down about meeting the NHS targets is correct. It will be achieved but we won't stick to the principles because we'll achieve EPR 3 one way or another. If we'd done it our way we probably would have done it properly, but we may well up with a solution that takes us backwards several years but we'll hit the targets. So, sadly the systems only got about 4 years left, after which it will be consigned to history, unless

Audience member: things change?

MR: Things change.

I was hoping to come along here with a tape, and say, if you want it, here it is. Because in 1995 that's exactly what we said we would do. Any NHS organisation that wants it: here's the source. We didn't realise it, but it was open source, we didn't call it that. I don't have a tape, but if you want a copy, please contact me. You're more than welcome.

Thank you.

I don't know if you want me to answer questions.

Chair: If there's a burning question hanging in the air, let's have it now.


AM1: Can we ask what the core system was?

MR: yes, the language was called Forthright, it's basically a set of compiled C routines, if you receive the program you can basically go into it and redo them. It's a very limited subset, Forthright was designed in healthcare in the US for rapid application development.

Copyright Mark Richards 2001. You may reproduce this table in any medium provided this copyright notice is also maintained. Transcription by Douglas Carnall: dougie@carnall.org
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