Fundamental deficiencies in the NHS out-of-hours recording and reporting system in West Yorkshire are putting patient safety at risk, according to an independent report commissioned by the service providers.
The problems outlined in the report highlight the difficulties in specifiying, commissioning and installing complex IT systems used by a number of public sector agencies.
West Yorkshire Urgent Care Services (UCS), the region’s out-of-hours service provider, has been using the SystmOne mobile communications system from clinical systems supplier TPP since April 2009.
NHS Kirklees, one of the five West Yorkshire primary care trusts (PCTs) that provides the out-of-hours service, commissioned an external review of the service after "concerns had been raised about its safety and usability."
Dr David Carson, director of the Primary Care Foundation, which reviews and develops best practice in primary and urgent care, carried out the independent investigation that revealed the system failings.
He reported his finding in the confidential 'Mobile Data Solution and Related Issues' report in December 2009, which was leaked to Pulse magazine earlier this month.
Prior to its deployment by West Yorkshire UCS, SystmOne was used by around 70 percent of GPs in the region, but not in an out-of-hours setting.
Carson's evaluation of the system has concluded that the system may not always pass on information and update records promptly when patients contacted their GP out of hours.
As a result, the report said the out-of-hours service as a whole did not "functionally appear compliant" with the Primary Medical Services (Out of Hours Services) Directions 2006 that were issued following the death of journalist Penny Campbell.
A major systems failure in a London out-of-hours service, over passing on information, was the contributory factor in the death of Campbell. She consulted eight doctors over the Easter weekend but each time her calls were treated as individual episodes.
The 2006 Directions therefore required out-of-hours systems that would alert doctors to a patient’s multiple phone calls and consultations.
However, one of the reasons SystmOne was described as non-compliant was because it did not make it clear to users looking at a call that there may be previous episodes within the last 72 hours.
Furthermore, during a live demonstration, Carson found that SystmOne had the potential to fail to transfer calls from the NHS Direct doctor to the person who would be providing the face-to-face consultation.
Yet, there was no alerting device in SystmOne to indicate this failure.
There was also not a function in SystmOne to log if patients called again with changed symptoms if they had an existing open call. This could happen while the patient was waiting for a doctor to call back or for a home visit.
"The sum total of these system issues makes the information system non-compliant with the regulations. If information about previous consultations is not available to clinicians that see the patient later, there are serious risks that should be addressed," Carson said in the report.
Despite having an IT-based system, the investigation also revealed a significant amount of a manual record keeping taking place as a back-up, by everyone from GPs to service providers.
"The information system should not only capture patient information but also pass safety critical information to the next step in the care process in a way that can be relied upon absolutely," said Carson.
"Any system which requires so many parallel manual safety procedures and work-arounds to ensure patients' calls do not get lost must be classified as unfit for the purpose for which it is being used."
The report also highlights the problems of definition and responsibility that can arise between organisations, commissioners, software suppliers, and other providers or stakeholders,when a new systems is specified and built.
A spokesperson for TPP said the problems raised in the report were not software-related: "Having reviewed in detail the comments made, it transpired that all the problems were to do with either misunderstandings of how the SystmOne software is designed to work, or were not software issues.
"Therefore, no changes were required to the software."
A statement from NHS Kirklees said that the Urgent Care Service was specified collectively by the five West Yorkshire PCTS, and the Urgent Care system was developed and implemented by TPP.
"The system was installed by TPP and training was provided by TPP, NHS and service provider trainers," it said.
However, TPP insisted: "As with all IT deployments, training is the NHS’s responsibility."
The West Yorkshire UCS chose to adopt TPP’s system over a patient management system from Adastra, which is specially designed for urgent and unplanned care.
This is despite Adastra’s system being in use to support the delivery of urgent care in West Yorkshire since the mid-1990s.
In March 2008, Adastra received notice that its contract in the region would end on 31 March 2009. This was due the planned consolidation of the urgent care services in West Yorkshire.
However, Adastra said that the urgent care service providers selected by commissioner NHS Kirklees, expressed a desire to work with Adastra and discussions continued between the parties through to January 2009.
Adastra was even told on 17 December 2008 that the commissioners would be supportive of the use of Adastra by the service providers.
Yet just over a month later on 23 January 2009, Adastra was told that its services would not be taken up because a hosting platform was not available.
"This was despite the fact that such options were being prepared and were known to the commissioners,” a spokesperson for Adastra said.
The spokesperson added: “We were extremely concerned that there were a number of clear risks to patient care inherent in the proposed change to a new and unproven system and in such short timescales.
“For that reason, we provided NHS Kirklees with a detailed operational risk log outlining 16 risks, including nine relating to the deployment of the proposed IT system.”
Adastra said that the system issues highlighted in Carson’s report do not apply to its system, “which is fully conformant with the 2006 national quality requirements in the delivery of out-of-hours services.”
As well as the software issues, the report noted problems with the hardware the system is delivered on – a laptop with an eight-inch screen.
Users connect the laptop, on a Windows platform, to the NHS network via an N3 connection to the central server holding the SystmOne records. Doctors access the system by connecting onto a mobile network and using an individual smartcard.
Although the system is supposed to retain information for 30 minutes if connection to the server is lost, the laptop tends to freeze, resulting in users restarting the laptop and losing the data entered after the drop in connection.
Other difficulties were identified with using the laptop in a dark and moving vehicle. The font size on the laptop screen is just six-point, and the keyboard is not backlit, which could lead to errors in data entry.
The report stated: "The unsuitable nature of the mobile equipment makes it almost impossible to use in the environment in which it is being deployed."
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