Sponsorship This Strategic Framework has been developed and endorsed by the following organisations: Welsh Assembly Government General Practitioners Committee (Wales) Informing Healthcare Local Health Boards and the Business Services Centre Royal College of General Practitioners (Wales) Welsh Association of Managers in Primary Care
Contents Summary 2 Introduction 2 The need for a strategic framework 2 Why change? 2 Conclusions 3 First steps 4 Context 5 GP practices in Wales 5 ICT Foundation Programme 5 Primary Care IM&T Programme 6 NHS Scotland 7 Connecting for Health in England 8 The Case for Change 9 The new GMS contract 9 Changes to related support systems 9 Standards for GP clinical systems 10 Designed for Life and the Individual Health Record 10 Efficiency 11 Strategic Objectives 12 Implementing the Objectives 13 Programme actions 13 Implementation strategy 13 Organisational structure to support the strategy 17 Short term objectives 18 Timing of change 18 Coordination with England, Scotland and Northern Ireland 19 Investment appraisal 19 Risk of change 20 Conclusions 21 Appendix A: Objectives and Actions 22 Appendix B: Glossary of Terms 23 1
Summary Introduction This document sets out a strategic framework to enable future development, integration and deployment of GP clinical systems in Wales in response to the IM&T requirements of the General Medical Services (GMS) Contract and the strategic direction of Informing Healthcare (IHC). The need for a strategic framework GP clinical systems are one of the medical informatics success stories. They have evolved from administrative systems providing repeat prescriptions and claims for payments into sophisticated Care Management Systems providing comprehensive clinical information on a patient s contact with a GP. This strategy sets out a framework for the future specification of GP clinical systems, and management structures that will enable the development and delivery of effective and efficient systems and services as the inter-related initiatives of IHC and the Primary Care IM&T Programme develop over the next five years. This strategy has been developed via consultation with key stakeholders including IHC, and has been strategically aligned with the Care Management Information Services Design & Implementation Strategy. Why change? There are significant external factors that mean that systems must change: The GMS contract now places an obligation on Local Health Boards (LHBs) to procure, manage and maintain all GP clinical systems, including assets necessary for their operation. The strategic framework needs to address and support these new responsibilities. GP clinical systems must now capture and report clinical information to specifically support GMS payments. GP clinical systems must be able to interface with and support the wider primary care professions, e.g. community nurses, out-of-hours services and screening services. The technical architecture and national systems which GP clinical systems currently interface with are being re-developed. Following devolution, Welsh health strategy is separate from other home countries, and systems may therefore have specific and unique requirements placed on them. 2
There are also many opportunities to evolve clinical systems further. Firstly, all GP practices should receive modern fit-for-purpose systems, and secondly, clinical information should be made available in a standard form by GPs and all sectors of the health service. A shared health record will deliver enormous benefits to patients and carers but requires consistent and high quality information from all GPs. The recent ICT Foundation Programme ensured a level of equity in terms of systems, services and support provided to GP Practices. Since the end of the Programme, and the lack of a corporate approach, inequities have started to emerge again. One of the aims of the strategic framework will be to re-establish the equity basis of IM&T provision across GP Practices within NHS Wales. Lastly, technology has developed significantly, and with the advent of relatively cheap, reliable data communications, there now exists choice in terms of clinical systems deployment, i.e. clinical systems can be hosted centrally in secure data centres and accessed by many GPs, without the need for individual practice installations and associated maintenance. Conclusions There are a number of drivers for change, many of which are known future requirements rather than fully formed requirements at this stage. For instance, the Individual Health Record (IHR) is scheduled to play a major role in providing information across all healthcare sectors, including primary care, but detailed plans for messages will emerge over time. Successor systems to the likes of NHAIS Exeter System will emerge over the coming years. This requirement for flexible change to GP systems is set against a context of new LHB responsibilities, where each LHB has inherited control over clinically critical systems. LHBs require support to discharge these responsibilities in line with statutory requirements and at best value. There is no coherent structure to coordinate, govern and deliver these changes at present. This strategy therefore concludes that such a structure is required urgently: NHS Wales will develop a set of mandatory standards for GP clinical systems to ensure that Welsh needs are met equally across Wales: the mandatory standards will be referred to as the Welsh Minimum System Specification 1 (MSS). NHS Wales will review the MSS regularly to facilitate the introduction of new services and functional requirements across Wales. Competition and choice in GP systems are central to their success to date. NHS Wales will therefore maintain a choice of systems, intended to cover all major suppliers and new entrants to the market. National framework contracts will be let for systems that comply with the MSS, thus enabling more efficient and effective local procurement. In conjunction with clinical colleagues, NHS Wales will continue to evaluate the potential for hosting GP clinical systems remotely, removing the need for local servers and management (where appropriate), examining synergies between hosting/managed services and the IHC Strategic Partner proposals. A GP clinical systems Purchase Consortium should be formed, with business decision-making powers, to provide a corporate steer on the future investment and development priorities of GP clinical systems. 1 All system suppliers will have to commit to mandatory standards. 3
First steps There are some steps towards the strategy that are already in train or planned in the short-term: The Primary Care IM&T Programme and its partners will establish projects to take forward the implementation of the strategic framework under the direction of the GMS IM&T Programme Board. The Primary Care IM&T Programme will develop a communication plan to communicate this strategic framework more widely. The Primary Care IM&T Programme will recommend the formation of a GP clinical systems Purchase Consortium to provide a corporate steer on the future investment and development priorities of GP clinical systems. The Primary Care IM&T Programme, in collaboration with IHC (and the National Architecture Design Board), will establish a MSS Design & Compliance Group to develop and maintain the MSS for GP clinical systems in Wales, ensuring appropriate alignment with similar initiatives in other Home Countries. The Primary Care IM&T Programme, in collaboration with IHC will commission a testing provider to ensure systems comply to the MSS under the direction of the MSS Design & Compliance Group. The Primary Care IM&T Programme will assess the practical benefits, implications and limitations of current GP clinical systems deployment methods to ensure that informed choices can be made. 4
Context GP practices in Wales GP practices are independent partnerships, contracted by the health service to provide General Medical Services through the GMS contract. Wales has 22 LHBs aligned with local authorities boundaries. LHBs manage healthcare strategies and commission health care services on behalf of their populations. LHBs have responsibility for managing the GMS contract and now have direct responsibility for all GP computer expenditure. The Business Service Centre (BSC) operates across Wales and provides shared business support services for all LHBs where this achieves economies of scale. Services include contractor services, Human Resources, Finance and IM&T (including Primary Care ICT). The BSC currently provide hosting services for GP clinical systems on behalf of some LHBs, covering 12% of Welsh practices. Practices use a variety of systems, with most users concentrated on three suppliers systems: In Practice Systems, isoft and EMIS: InPS isoft EMIS Other Total Totals 211 124 146 20 501 ICT Foundation Programme The ICT Foundation Programme for General Medical Practices has provided a valuable basis from which to develop this strategy. The Programme invested 37.5m over four years to 2005 to deliver a consistent ICT foundation across practices in Wales. The Programme updated clinical systems, provided broadband to all practices, and invested in developing ICT skills in practices to enable staff to benefit from the IT investment. Key lessons learned and factored into this strategy are: The need to maintain a corporate 2, standard, equitable approach to GMS IM&T systems and services for all GP Practices in Wales. The need to include clinicians in the development and implementation of policy. Corporate developments such as the e-mail service provided by Health Solutions Wales provide better value and greater flexibility to deal with change. Framework contracts for GP clinical systems offered significant benefits through delivering better value and control of GP systems suppliers. IT investment must be accompanied by investment in developing skills to use the technology to maximum benefit. 2 A corporate approach to GMS IM&T will help to protect GP practices from any future organisational changes that may occur. 5
Primary Care IM&T Programme The Welsh Assembly Government s Information Services Division (ISD) has recently established a Primary Care IM&T Programme to set corporate IM&T policy and strategic direction for all Primary Care contractor professions in Wales. The Primary Care IM&T Programme is part of the Welsh Assembly Government's Programme Management Unit (PMU) for NHS Wales. Working collaboratively with all key stakeholders, the Programme s principal objectives are to: Set corporate IM&T policy and strategic direction for all Primary Care contractor professions in Wales. Support the new/existing contractual IM&T requirements (both clinical and administrative) for General Medical Practices, Community Pharmacists and General Dental Practices. Ensure the delivery of a corporate, consistent and equitable approach to ICT facilities and services to Primary Care contractor professions in Wales. Ensure compliance with the strategic direction of IHC with specific focus on the future integration requirements of the Individual Health Record. The GMS IM&T Sub-Programme was initiated during April 2006. The principal objectives of the GMS IM&T Programme are to: i. Set strategic direction for GMS IM&T in Wales. ii. Support LHBs in their contractual GMS IM&T obligations whilst maintaining corporate consistent standard approach to service delivery. iii. Enable all GP practices across Wales to benefit from high quality GP clinical systems and associated support to a consistent standard. iv. Ensure GP clinical systems are updated regularly in line with evolving business need. v. Provide best value in GP clinical systems and associated services across Wales. vi. Maintain clinician choice in the selection of new GP clinical systems. vii. Enable innovation in GP clinical systems through new market entrants. viii. Support the emerging IHR provided by IHC. ix. Ensure that LHBs and practices receive coordinated support for changes. x. Provide IM&T support in relation to the payment of GPs. xi. Improve data quality in GP clinical systems in support of the GMS contract and national 3 initiatives. xii. Enable interoperability between GP systems and other national systems. xiii. Ensure telecommunications infrastructure is appropriate and can respond to change. 6 3 The word national refers to Wales only.
Recent Developments Welsh Health Circular (2005) 044 'Extended' Interim IM&T Guidance recommended LHB/BSC consolidation of GP System Support contracts for 2005/06 onwards. A recent development which received unanimous support from LHBs was the establishment of an 'All-Wales Support Agreement' for existing GP clinical systems. The Agreement, sponsored by the Primary Care IM&T Programme (on behalf of LHBs and constituent GP Practices) and endorsed by key stakeholders (namely the GMS IM&T Programme Board, LHB Chief Executives, LHB Directors of Finance and GPC(Wales)) provides: a corporate, standard and equitable support service for all LHBs constituent practices across Wales. a common service description that has been agreed with the three main suppliers (EMIS, isoft and InPS) that have systems deployed in 95% of practices within Wales. specific detail of the support services that will be provided for both core systems and peripheral equipment along with the day to day management arrangements and the cost and payment terms. The Agreement, has been developed based on existing support contracts between clinical system suppliers and individual practices, and has resulted in an emphasis for a standardised service and LHB-centric payment mechanism to produce efficiency and cost savings. NHS Scotland NHS Scotland has 1,050 GP Practices. Of these, 880 currently use the GPASS product, a Crown Copyright development available free of charge to practices in Scotland. The remainder use broadly the same systems as practices in Wales. The Information Systems Division of NHS Scotland is implementing a number of measures to modernise GP clinical systems under a GMS Primary Care IM&T Programme. The Programme launched in January 2004 a set of mandatory standards for Scottish GP clinical systems: the Scottish Enhanced Functionality (SEF). The Programme received resistance from GP clinical systems suppliers to amend systems to meet the SEF, but all have now completed conformance testing. The Scottish Executive requested that the Programme establish a hosting environment to enable all GP clinical systems to move to remote hosted operation. This is now underway, with 22 practices currently live on hosted operation. Atos Origin provide the hosting and associated service management under a broader outsource contract with NHS Scotland. NHS Scotland has implemented a number of impressive initiatives to communicate primary care information with secondary care: SCI Gateway - electronic hospital discharge/referral communications, with a web interface. elinks - to enable secure and reliable communications between systems. Emergency Care Service - access from A&E clinicians to summary information on all Scottish patients. NHS Scotland has demonstrated that the key aspects recommended in this strategy are feasible, and provides a useful source of lessons learned for Wales. 7
Connecting for Health in England The NHS in England has 8,800 practices. The National Programme for IT (NPfIT) has let contracts to five Local Service Providers (LSPs) to provide and integrate clinical systems across all sectors of the NHS in five geographically defined 'clusters'. The LSPs provide a choice of systems to GP practices (based on certain criteria). LSPs are putting in place facilities to 'test' GP Systems end-to-end against the specification laid out in their contracts with NPfIT. The LSPs are responsible for integrating GP systems with a national 'Spine' which provides a range of national services, such as patient demographic information, summary clinical information and secure sign-on for staff. The predecessor to NHS Connecting for Health (NHS CFH), the NHS Information Authority, maintained (until 2001) Requirements for Accreditation (RFA), i.e. the minimum standards for GP clinical systems. NHS CFH has now introduced a successor to RFA to cater for the requirements of the National Programme for IT. The new accreditation scheme will be relevant for Wales since the majority of the testing will relate to core general practice functionality. It will therefore provide a strong basis for the development of any Welsh minimum system standards, enabling Welsh resources to be focused on Wales-specific requirements rather than generic GP system functionality. The new initiative known as 'GP Systems of Choice' (GPSoC) 4 aims to ensure progressive improvement of the functionality available to GPs until transition to a LSP supplier fully integrated solution. GPs now have the option of using systems provided by either their LSP, or from an approved set of existing GP Systems providers. Approval will be based on standards that will ensure that systems will properly inter-work with new NHS Systems as they become widely installed by NHS CFH. There are six Compliance Levels within the GPSoC Solution Maturity Model, the achievement of each level will be dependent on achieving compliance with the requirements:- Level 0 Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 RFA 99, QMAS/QoF and Information Governance (IG) Level 0 plus Choose and Book, Personal Demographic Service (PDS) access/update capability Level 1 plus Electronic Transmission of Prescriptions (ETP) Level 2 plus GP records transfer capability (GP2GP) Level 3 plus system provided as a data centre hosted solution to NHS CFH standards Level 4, plus access/update capability to the summary patient record held within the Personal Spine Information Service (PSIS) on the NHS CRS Spine Level 5, plus fully integrated with the LSP Care Record Fully integrated Service System across all care settings NHS CFH also provides a number of systems which are used directly or indirectly by Wales: the NHAIS Exeter System, National Strategic Tracing Service, NHS Central Register and the Data Transfer Service (DTS). NHS CFH is migrating these systems to alternatives which may or may not be shared with Wales. IHC is planning appropriate interfaces and/or successors for each for Wales. 8 4 See http://www.connectingforhealth.nhs.uk/gpsoc
The Case for Change The new GMS contract The GMS contract which forms the basis for payments to GPs for all general medical services was updated in April 2003. Under the new contract, the basis for payment is shifting from activity to quality based claims. The next generation of GP clinical systems must therefore provide the functionality to support the new GMS Contract, such as information to enable Quality and Outcomes Framework (QOF) payments. The GMS contract also places an obligation on LHBs to procure, manage and maintain all GP clinical computing systems, including assets necessary for their operation. LHBs are also now responsible for the procurement of replacement practice systems, where, in the past, GP practices (independent contractors) themselves purchased systems and were then reimbursed by LHBs. An LHB (a public sector body) purchasing a significant number of systems, will be subject to european procurement rules and regulations. This means that LHBs have inherited responsibility for GP systems as a 'managed service', a large amount of responsibility relative to their previous position. This introduces significant new requirements and risks around procurement, maintenance of systems and management of assets. Changes to related support systems Wales and England have traditionally procured and operated a number of services collaboratively. NHAIS manages GMS payments and provides a framework for screening and transplant initiatives within LHBs and English Strategic Health Authorities. NHS DTS provides a secure messaging infrastructure to enable information to be transferred between practices and hospitals/lhbs. NSTS provides common patient demographic information. NHSnet, through the Managed Network Services Agreement (MNSA) contract, has enabled Wales to implement its own virtual private network called the Digital All Wales Network (DAWN). Within England MNSA has recently been superseded by N3. All of these services are to be superseded in England, and may be provided by different organisations in Wales in the future. GP clinical systems will have to change to accommodate changes to related systems and services. A mechanism is required to align GP systems across Wales with successor systems and services. The definition of successor systems and services in Wales is managed by IHC and are in development. 9
Standards for GP clinical systems Requirements for Accreditation (RFA) provided a set of national standards for GP clinical systems maintained across the home countries, and amended from time to time. RFA comprised a published set of standards, and an independent testing regime to verify that systems which claimed compliance did actually comply. Testing included dummy electronic transactions to verify that messaging standards had been met correctly. The last version of RFA, RFA99, is mandated; in order for GPs to be able to seek central reimbursement for GP clinical systems, systems have to be RFA99 accredited. RFA99 is still the de facto standard, and there are no longer facilities to test systems to it. The RFA system is not currently maintained however it is soon to be superseded in England by successor accreditation standards being developed by NHS CFH, core elements of which may be used to support Welsh accreditation. New systems, such as isoft Lorenzo PC and the latest version of InPractice Systems Vision were created after the RFA testing ended, and so have not been accredited to date. This puts new systems in limbo - neither accredited nor with identified issues. Suppliers are therefore keen that testing should resume as soon as possible to enable new entrants to the market, not only in England but across the UK. Designed for Life and the Individual Health Record The nature of clinical information is changing. Historically, records have been siloed in organisations, with the same information gathered by several carers and stored separately. Too often, silos create inconsistency or errors, leading at best to inconvenience and at worst to inappropriate treatment. Designed for Life sets out a vision for Welsh Health Service to be achieved over the next 10 years to 2015. It places particular emphasis on designing services around patients with integrated pathways which function seamlessly across organisations working in partnership. Designed for Life recognises information and IM&T as a key enabler in allowing care to be integrated across settings. The key initiative resulting from this is the Individual Health Record within the IHC Programme. The IHR will be a record which will ultimately provide summary information about individual patients through all of their care settings. The IHR initiative is likely to place training, quality and data exchange requirements on primary care. Such requirements will emerge over time and will need to be coordinated with other requirements, such as QOF extracts. GP clinical systems will become pivotal in delivering the IHR; just as GPs are the gatekeepers to most care delivery, GP clinical systems form the foundation for most care information. It is therefore imperative that such information is based on quality standards and held in a format which lends itself to integration with other sectors of the health service through the IHR. The IHC Programme is establishing a Strategic Partner contract to provide capacity and capability to support investments in healthcare information technology in Wales. Given the pivotal role of primary care as a stakeholder in any information initiatives, it is clearly important that any future investment in primary care is consistent with the Strategic Partner approach. Specifically, the Strategic Partner is likely to provide a managed secure hosting environment, service management support, systems integration and integration testing support. These areas must be explored as they would all be relevant for primary care, subject to realistic timescales for their introduction. 10
Efficiency National policy such as Making the Connections makes the case for achieving value for money through organisations working together to adopt common back office functions, sharing support functions and maximising leverage through collective procurement. Making the Connections is aimed primarily at collaboration across Government sectors, but a necessary precursor to inter-departmental collaboration is collaboration within each sector. GP clinical systems are currently purchased and implemented in a piecemeal way, often practice based servers requiring local management and support. There is a compelling case for collaboration between LHBs and practices to procure systems and services, realising economies of scale. Now that high quality data communications are available, there is also the potential for single installations of hosted GP clinical systems, held in secure data centres and accessed remotely by practices. Hosting has already been implemented as a service model in some parts of Wales: The BSC currently operates hosting for c. 60 practices using InPractice Systems and isoft Ganymede from its Pontypool data centre. This initiative along with other similar hosting arrangements (i.e. The Phoenix Partnership) has been well received by GPs and LHBs across Wales, and provides a valuable service and body of expertise in the interim while further guidance is developed for hosting services. Managed services in terms of hosted GP clinical systems are still relatively new and offer a number of potential benefits. There is some nervousness about this relatively new model of delivery, including concerns about security, confidentiality and resilience. These must be addressed before significant further expansion is considered. The fact that currently 12% of Welsh practices are already hosted by the BSC makes the case for further guidance to inform policy and strategic direction for hosting particularly important. 11
Strategic Objectives The GP clinical system marketplace has evolved over many years into a mature market, with complex and accomplished systems now providing clinical support in primary care. It is clearly important that any strategy ensures that this evolution is able to continue. Key factors which should be preserved include: Enabling new entrants to come into the market new blood drives innovation forward, in existing systems as well as the new systems. Clinically led selection of systems: GPs have invested significant time and effort into their chosen systems and do not accept forced migration, with its considerable risks (both actual and perceived). Preserving the ability to challenge suppliers so that if a product falls behind, it can be replaced or appropriate remedial action taken. The key objective for the strategy is to encompass the business drivers for change above, through the following more detailed objectives: O1 O2 O3 O4 O5 O6 O7 O8 Enable all GP practices across Wales to benefit from high quality GP clinical systems and associated support to a consistent standard across the health community Ensure GP clinical systems are updated regularly in line with evolving business and service development needs Provide best value in GP clinical systems and associated services across Wales Maintain a competitive and dynamic marketplace for GP clinical systems in Wales Support the emerging Individual Health Record provided by Informing Healthcare Ensure that practices receive coordinated equitable support for changes Provide GP clinical systems which maximise tangible benefits in patient care and patient safety Provide effective electronic communications in support of: care delivery: with hospitals, screening services, community carers and other practices patient care: with patients administration: with LHBs and BSC O9 Maximise benefits from installed technology 12
Implementing the Objectives Programme actions The previous sections set out the need for change and the strategic objectives over the next five years. The Primary Care IM&T Programme has initiated a work programme, namely the GMS IM&T Programme, to take forward these objectives, and will implement a number of changes over the forthcoming years. Experience shows that incremental implementation is the only safe way to introduce change. It is the Programme s intention, therefore, to phase implementation of change over a reasonable period, reviewing and changing tack, if necessary, to factor in practical experience. Implementation strategy There will be a number of key strands of work: 1. the formation of a GP clinical systems Purchase Consortium and associated work to enable collaborative investment and development of GP systems and services. 2. the formation of the MSS Design & Compliance Group and definition of the MSS. 3. migration of existing installed base to the MSS. 4. procurement via OJEU framework agreement and maintenance of a catalogue of new systems which can be purchased by LHBs/practices which conform with the MSS. 5. a structure to enable continuation of the training and organisational development work started by the Foundation Programme, developing to support new initiatives. 6. a structure to enable continuation of the data quality initiative started by the ICT Foundation Programme,developing to support new initiatives. The Programme will complete the steps outlined below. Appendix [A] shows the strategic objectives grouped according to the primary objective which each step contributes to. Minimum System Specification NHS Wales will develop a set of mandatory standards for GP clinical systems, known as the Minimum System Specification, to ensure that Welsh needs are met equally across Wales. A minimum system specification is not new to the NHS and to a large extent the MSS will build on the success of the joint English and Welsh Requirements for Accreditation (RFA) system, first introduced in 1993. RFA provided: common standards without which national system interconnectivity could not have been achieved (such as for the transfer of registration details, pathology request and results); availability of a core set of functionality to all Practices; and a sound basis for testing systems as being fit for purpose. 13
The aims and objectives of the MSS reflect those of RFA to a large extent, but will add emerging business, technical and clinical needs relevant to Wales. The MSS will: ensure equity of functionality across Wales, by setting out minimum standards. provide a vehicle for specifying systems development required to meet the GMS contract requirements and national strategies led by IHC. ensure increased functionality, security and reliability of GP systems. provide a level of functional commonality and interoperability with the national architecture, its systems and services (such as the IHR). provide information to suppliers regarding the current and future IM&T development programmes within NHS Wales. provide the basis for the procurement via OJEU framework agreement of a catalogue of new systems which can be purchased by LHBs in conjunction with practices; and ensure GP systems suppliers upgrade their systems by allowing only those systems that meet the MSS (and it subsequent releases) to be available to practices in Wales via the framework agreement. The MSS will be based on core elements of the English accreditation scheme, which is currently under development (scheduled for release in late summer 2006). It is intended that all existing contracts with GP systems suppliers should be migrated onto the new agreement and that the current installed base of RFA99 compliant systems be registered as MSS v1.0 during 2006/7. The MSS will be developed and maintained by a Design & Compliance Group led by members of the Primary Care IM&T Programme and IHC (via the National Architecture Design Board) seeking input from key stakeholder groups such as clinicians, LHBs and GP system users and vendors. Once in place the MSS will be regularly reviewed by the Design & Compliance Group to facilitate the introduction of new functionality services across Wales. All LHBs will offer GPs a choice of MSS compliant systems subject to appropriate business cases. NHS Wales will provide guidance and testing for suppliers in support of the MSS. GP clinical systems Purchase Consortium A GP clinical systems Purchase Consortium will be formed, with decision-making powers, to provide a corporate steer on the future investment and development priorities of GP clinical systems. It will be the role of the Consortium to identify and approve programmes of work compliant with MSS that should be funded corporately ensuring equity. The Consortium will act collectively in: Prioritising future developments, based on drivers not only of policy, of programmes such as IHC and the Primary Care IM&T Programme, but also through the representation of LHB and reference to systems user groups. 14
In collaboration with the Primary Care IM&T Programme the Consortium will run a procurement exercise to establish an All-Wales Framework Contract. The framework contract will facilitate the purchase of new GP Systems and Services by LHBs and Practices, and will ensure agreed terms for the purchase of GP clinical systems and an agreed basic price list. The Consortium will be responsible for the maintenance of the All-Wales Framework Contract to facilitate the purchase of new GP Systems and Services by LHBs and Practices. The Consortium will facilitate the interface of GP clinical systems between GP Practices and all other relevant parts of the NHS Wales through the development of the MSS and other services. The membership of the consortium will be drawn from LHBs, Welsh Assembly Government and IHC. Procurement of new GP clinical systems and services As previously mentioned LHBs are now responsible for the procurement of replacement practice systems and services in line with their obligations under the new GMS contract. LHBs will be potentially purchasing a significant number of systems and services, and therefore must comply with european procurement regulations. In practical terms, this means that an LHB should undertake formal OJEU procurement exercises. This would clearly be a substantial overhead european procurements are expensive and time consuming and require a degree of expert facilitation during the procurement life cycle. LHBs could elect to disregard european regulation, but this could leave them open to legal challenge. This Strategy therefore recommends that the GP clinical systems Purchase Consortium steer the development and maintenance of an All-Wales Framework Contract to aid local procurement of MSS compliant GP clinical systems. The diagram below displays the structure of the framework contract and shows how a practice and LHB may access the agreement. All Wales GP Clinical Systems Framework Contract GP Clinical System Supplier Standard Terms and Conditions Management MSS MSS Compliant System Practice LHB Access Agreement List of MSS Compliant Systems Additional Services The Primary Care IM&T Programme will be responsible for the administration of national framework contracts. 15
The Primary Care IM&T Programme will support the Purchase Consortium in the procurement of an all Wales Framework Contract. The Framework Contract will establish key common commercial terms which will apply to all purchases of GP clinical systems, such as conformance with MSS. The LHBs will then be able to purchase through the framework using an Access Agreement a side agreement between LHBs and the GP systems suppliers. The purchase order through the Access Agreement could allow supplementary terms, negotiated pricing and specific details such as implementation timescales. Through use of the Framework Contract, LHBs will comply with european procurement rules. It is recommended that all existing contracts between GP Practices and systems suppliers be novated onto the new Framework Contract over a reasonable period. Deployment of GP clinical systems Central hosting of GP clinical systems is a key strategic direction in both England and Scotland, with the English NHS offering enhanced services payments to Primary Care Trusts (PCTs) based on practice transition to hosted systems. There are still a number of issues which need to be resolved as previously mentioned, many of which should boil down to reassurance that hosting in a remote location does not compromise safety or operation in GP practices. To this end the Primary Care IM&T Programme will facilitate a review of GP clinical systems deployment options and associated services. The review will include: a GP/PCT/LHB-focused assessment of clinical systems currently centrally hosted across the UK it terms of: original GP practice/pct/lhb objectives of the implementation. documentation of the scope and approach taken. anticipated benefits including costs. actual benefits realised; and. lessons learnt. a qualitative assessment of the benefits of both hosting and practice-based deployment, with an assessment of the factors that must be in place for benefits realisation. an assessment of the key risks associated with both hosting and practice-based deployment, with an assessment of appropriate mitigation. an assessment of whether hosted and practice-based deployment fit with other national and local healthcare delivery strategies. An assessment of managed services to circumvent LHB obligation in terms of ownership of IT equipment. Confirmation of GP clinical system suppliers product development strategies. indications of GP practice/pct/lhb experience of the implementation effort & costs and the on-going management of hosted environments. Clinical colleagues will play a key role in this review. 16
Data quality One of the key focuses of the ICT Foundation Programme was on data quality through the Data Quality Initiative. This was targeted at the Coronary Heart Disease (CHD) National Service Framework (NSF) and the Diabetes NSF. Due to this initiative progress on data quality is widely recognised. At this same time it is accepted that further improvement is required. Continued support to improve data quality remains a key objective of the GMS IM&T Programme. The Programme will work closely with IHC to ensure data quality initiatives and readiness activities are focused on both primary care and information sharing requirements. As part of this work, this strategy is recommending the adoption of data quality accreditation (or 'kite marking') of information, to defined data standards, that will be shared within the health community through the introduction of the IHR and associated initiatives such as GP2GP record transfer. It is recognised that GP clinical systems contain a significant level of information which would be a valuable source for various analyses, e.g. to inform future health services planning. By ensuring a good standard of data quality these opportunities can be explored further. Responsibility for defining data quality standards will rest with the Primary Care IM&T Programme in collaboration with IHC, guided by the GMS IM&T Programme Board. Education, training & development, including best practice As with the ICT Foundation Programme, data quality has close inter-relationships to an education, training and development (ETD) framework. The ETD Framework will be linked to a number of drivers:- - Continued promulgation of basic computing skills. - IHC Information Governance Initiatives. - Training to support data quality initiatives. - Training to support best use of clinical systems. Detailed documentation on each component of the implementation strategy will be developed and published in due course. Organisational structure to support the strategy The GP clinical systems Purchase Consortium will be responsible for prioritising future developments and investment, based on drivers not only of policy, of programmes such as IHC, but also through the representation of LHBs, GPs and the systems user groups. Management of the Contract Framework will be through the Purchase Consortium supported by the Primary Care IM&T Programme and its partners. GP Systems User Reference Groups (to be established) will also have a key role in helping to define and develop changes to the National Framework Contract and MSS and to disseminate to their members on the impact of various developments as they evolve. The diagram below displays the key organisational groups along with typical membership of each group. 17
Membership LHB Welsh Assembly Government Primary Care IM&T Programme IHC BSC Membership GPs other Practice staff LHB Purchase Consortium Membership IHC Primary Care IM&T Programme BSC Systems User Reference Group MSS Design & Compliance Group Short term objectives The Programme will start with a series of short term objectives: The Primary Care IM&T Programme and its partners will establish a project take forward the implementation of the strategy under the direction of the GMS IM&T Programme Board. The Primary Care IM&T Programme will develop a communication plan to communicate this strategy more widely for consultation. The MSS Design & Compliance Group, in collaboration with the Primary Care IM&T Programme, will develop the first MSS for GP clinical systems in Wales, working closely with colleagues in England, Scotland and Northern Ireland. The MSS Design & Compliance Group, in collaboration with the Primary Care IM&T Programme Team will appoint a testing provider to accredit systems to the MSS. The Primary Care IM&T Programme Team will assess the practical benefits, implications and limitations of GP clinical systems deployment methods to ensure that informed choices can be made, and that future options are identified and available as appropriate. The Purchase Consortium, in collaboration with the Primary Care IM&T Programme Team, will commence procurement of a framework contract for GP clinical systems. The Primary Care IM&T Programme Team will recommend that a GP clinical systems Purchase Consortium is established and will help seek members. Timing of change The milestones below show the key deliveries planned by the Primary Care IM&T Programme Team in support of this strategy. These are included as indicative timescales only at this stage more detailed plans will be published to stakeholders as specific products develop. 18
Milestone Target date Strategic framework published September 2006 GP Clinical System Framework Procurement OJEU Notice September/October 2006 MSS Design & Compliance Group nominations September 2006 GP Clinical Systems interim Purchase Consortium nominations September 2006 Deployment Options Review published September 2006 GP Clinical Systems interim Purchase Consortium active October/November 2006 Publish MSS V1.0 October/November 2006 First systems MSS V1.0 Compliant November/December 2006 GP Clinical System Framework Agreement Procurement complete March/April 2007 Begin to Develop MSS V2.0 November 2006 (etc.) Coordination with England, Scotland and Northern Ireland The Primary Care IM&T Programme Team has already established links with Home Countries, and will continue to explore possibilities of collaborative working to reduce costs for Wales. The working assumption is that the MSS will be based on the emergent English accreditation scheme, so that it does not diverge too far from GP clinical systems dominant market. Investment appraisal Investment in replacing GP practice systems is not included in the scope of this strategy, since this will be driven by specific initiatives or outputs. For instance, as the IHR begins to implement changes across general practice, such changes will require a route to improve data quality, develop training and implement system changes. Developments such as the IHR, NHAIS replacement etc. will require investment appraisal and funding through Welsh Assembly Government defined routes. The ICT Foundation Programme provided a considerable level of refresh in terms of both hardware and systems upgrades. The majority of equipment though is now three years old and older, it is therefore acknowledged that new investment will need to be identified in line with future deployment options of GP systems, such as managed services to circumvent LHB obligation in terms of ownership of IT equipment. The purpose of this strategy is to develop a framework into which new requirements can be placed. The investment directly related to this strategy includes the foundation of the structures, namely the: MSS and the appointment of a testing provider to accredit systems to the MSS. National Framework Contract. GP clinical systems Purchase Consortium. The establishment of such is considered to be below the 2m delegated threshold for investment set by Welsh Assembly Government. 19
Risk of change Any change has risk associated with it. Whilst the Programme aims to minimise risk through incremental implementation, some risks will remain for practices, for LHBs and for the Programme. 20 Risk GP suppliers in Wales do not comply with requirements through lack of clarity causing failure of initiatives Network failure causes hosted system problems Patient confidentiality breached GMS payments inaccurate or delayed GP clinical systems incompatible with replacement supporting systems (e.g. NHSCR) Level of change required to support Walesspecific requirements unaffordable or LHB budgets need to rise as a result of change One or more major suppliers do not conform to MSS Data loss in migration Change required faster than MSS can deliver Failure to integrate with IHR as it develops Failure of strategy leading to further fragmentation GP system choice leads to GPs selecting more expensive systems than LHBs can afford Divergence of English and Welsh strategies makes GP systems for Wales unaffordable Mitigation MSS established as a single route for systems changes across Wales to provide clarity for GP systems suppliers. Hosted solutions to be fully assessed, tested and proven prior to implementation. Options for minimising the impact of network failure to be assessed and will include holding copies of practice data locally. IHC producing information governance principles to ensure that MSS and other developments comply with best practice. The GP clinical systems Purchase Consortium has combined purchasing power to ensure compliance with mandatory standards. MSS to include standards related to ensuring accurate and prompt payment. IHC to incorporate requirements into MSS. Purchase Consortium provides feedback loop to enable policy initiatives leading to systems changes to be evaluated properly and assessed by LHBs with a single voice. Ensure new investment areas for MSS are evaluated through formal investment appraisal. MSS must be constrained to minimum standards, not a wish list for GP clinical computing. Where possible, in collaboration with GP Systems suppliers all migrations should be fully tested prior to implementation. MSS will be dependent on close collaboration with a number of key stakeholders including NHAIS, IHC, other Primary Care work streams. Introduction of MSS will ensure minimum level of common functionality. MSS Design & Compliance Group will have IHC member and links to IHC Design Groups. Ensure acceptance of strategy through wide communication prior to proceeding. Purchase Consortium to develop guidance on practical operation of systems choice. IHC to include consequential costs in IHC investment appraisals.
Conclusions There are a number of drivers for change, many of which are known future requirements rather than fully formed requirements at this stage. For instance, the IHR is scheduled to play a major role in providing information across all healthcare sectors, including primary care, but detailed plans for messages will emerge over time. Successor systems to the likes of NHAIS Exeter System will emerge over the coming years. This requirement for flexible change to GP systems is set against a context of new LHB responsibilities, where each LHB has inherited control over clinically critical systems. LHBs require support to discharge these responsibilities in line with statutory requirements and at best value. There is no coherent structure to coordinate, govern and deliver these changes at present. This strategy therefore concludes that such a structure is required urgently: NHS Wales will develop a set of mandatory standards for GP clinical systems to ensure that Welsh needs are met equally across Wales: the mandatory standards will be referred to as the Welsh MSS 5. NHS Wales will review the MSS regularly to facilitate the introduction of new services and functional requirements across Wales. Competition and choice in GP systems are central to their success to date. NHS Wales will therefore maintain a choice of systems, intended to cover all major suppliers and new entrants to the market. National framework contracts will be let for systems that comply with the MSS, thus enabling more efficient and effective local procurement. In conjunction with clinical colleagues, NHS Wales will continue to evaluate the potential for hosting GP clinical systems remotely, removing the need for local servers and management (where appropriate), examining synergies between hosting/managed services and the IHC Strategic Partner proposals. A GP clinical systems Purchase Consortium should be formed, with business decision-making powers, to provide a corporate steer on the future investment and development priorities of GP clinical systems. 5 All system suppliers will have to commit to mandatory standards. 21