Challenges & Opportunities for Distributed ICT in the NHS in England

1

Dr Mark FerrarDirector of Infrastructure, NHS

Challenges & Opportunities for Distributed ICT in the NHS in England

And in the next half hour...

• Scale

• Consistency

• Connectivity

• Collaboration

• Identity

Scale

In a typical week...

• 6 million people visit their GP• Over 800,000 outpatients are treated• Over 10,000 babies are delivered by the NHS • Over 50,000 emergency journeys in NHS ambulances• District nurses make over 600,000 home visits • Pharmacists dispense ~8.5 million items• NHS surgeons performing ~1,200 hip operations, 3,000

heart operations and 1,050 kidney operations• Labs & associated services process millions of tests• That’s over 3 million critical transactions per day!

And in ICT...

• 700,000 PCs and 850,000 computer users in the NHS (in England)

• NHSmail has over 400,000 users• Amongst the world’s largest private, fully-featured, secure, single-domain e-mail

services

• NHSmail Relay Service processes 4,000,000 messages/day and activity bursts of 100 messages a second.

• N3 network transacts almost 100 terabytes of data each month• Equivalent to the 32 volume set of Encyclopaedia Britannica every 40 seconds

• The processing power of the NHS “Spine” (& its test environments) are equal to one of the top 100 supercomputers ever built

• Over 300 terabytes of storage – like the contents of a book shelf 3000km long

And remember the people...

Modern, integrated IT systems and services, connecting:

• 122,345 doctors

• 404,161 nurses

• 152,651 other health professionals

• Balance of 800,000+ computer system users are in administration functions across the NHS

• Most are degree educated or professionally qualified

• Most are also highly mobile throughout their work day

• Perhaps the largest “mobile knowledge worker” enterprise in the world!

Key delivery systems• NHS Care Records Service - Over 500,000 registered users

• Choose and Book - Over 10,000,000 bookings made

• Electronic Transmission of Prescriptions (ETP)

- Over 70,000,000 prescription messages issued

• N3 Network for the NHS - Almost 27,000 connections

• NHSmail - Almost 400,000 registered users

• Picture Archiving and Communications Systems

- Over 25,000,000 patient studies

- Over 600,000,000 images

• GP IT -

Quality Management and Analysis System

- 100% GP site deployment

GP to GP record transfer - Over 100,000 record transfers

What are "Secondary Uses"?

A considerable amount of information is collected during the provision of care and supporting services

The primary purpose of this information is to support and improve individual patient care

However, this information is of value for many other purposes to support healthcare and providing appropriate steps are taken to meet confidentiality obligations, this information can legitimately be used to support these other purposes.

These are called “secondary uses”

Identifiable Pseudonymised or Anonymised

•Individual records•Selected “lists” of

•records•Immediate access

•Dynamic, up to date•Workflow, rules based

•alerts

• Frequent abstracts•Focus on classes

of persons •Time series

•Short time intervals•Prospective indicators

•Focus on classesof persons

•Actual compared withexpected

(inputs, outcomes)• Ongoing

• Indicators

•Focus on classes or •cohorts

of persons• Disease, Service and

populationbased

• Forecasting•Periodic

OperationalDirect Care

Commissioning Analysis / Service Planning

BusinessOperations

Strategic /Policy / Research

Examples of characteristics of requirements

Primary and Secondary Uses

Objectives of SUS

To improve access to data to support the business requirements of the NHS and its stakeholders

To provide a range of software tools and functionality which enable users to analyse report and present this data

To be the single, authoritative and comprehensive source of high quality data

To enable linkage of data across all care settings

To ensure the consistent derivation of data items and construction of indicators for analysis

To improve the timeliness of data for analysis purposes

To provide a secure environment which enables patient confidentiality to be maintained according to national standards

SUS Information Flows

Presentation

Publication

Added-valueservice

providers

LocalSystems

NationalSpine

Manual Collection /Submission

ALB Use

LocalUse

DH Use

Local Data

DataManagement

DerivationsCalculations

DataCollection

Standards

Data Collection

Source systems

Data Management

Presentation Users

Some SUS statistics

16+ Terabytes of data in SUS

> £30 billion of PbR transactions processed

700+ million Activity records submitted to SUS

Over 1 million records entering SUS each day

Over 90,000 managed service extract reports produced from SUS

Over 12,000 user-defined extracts produced

Over 1500 users registered

Currently over 320 organisations submitting data

Consistency

We Can Only Influence Change

Remember how the NHS has historically dealt with data...

Raising the bar...

• “Patchy” NHS IT infrastructure maturity and performance

• “Infrastructure Themes” seen in 2005 still exist and some evidence best/worst gap widening

• TCO not lowest (or even competitive), despite being the 800lb Gorilla in IT purchasing in EU

• A consistent, well-managed desktop is vital for the success of Local & National IT programmes

• Premature use of high value technology prohibits lowest TCO and/or maximum benefit being realised soonest

Infrastructure Challenges...

• Significant cost - according to analysts, 70% of typical IT spend goes on IT Infrastructure! (run the organisation) – (70% of £2.2bn = £1.54bn)

• NHS IM&T Managers should not just rely on gut feel when setting investment priorities

• Inconsistent terminology makes it difficult to benchmark (TCO)• Organisational changes in the NHS means that many IT

infrastructures are in silos and not optimally managed• Some suppliers don’t create infrastructure solutions that NHS Trusts

request, actually need or are ready for• Many NHS Trusts need help to build coordinated infrastructure

improvement plans• Some key tasks often get overlooked because their impact on

infrastructure is not obvious

Enabing Consistency...

Enable consistency across the NHS in England by:

• Providing software through Enterprise Agreements

• Latest products at lowest cost

• Close relationships with suppliers

• Establish “yard stick” against which organisations can measure themselves (and compare with others)

• NHS Infrastructure Maturity Model (NIMM)

• Common User Interface programme (CUI)

• Collaboration Architecture & Solution Enablers (CASE)

• Harvest & Share good (best) practice

NIMM Summary

How should you use the NIMM?

• Perform a self assessment using the NIMM

• Prioritise and invest to improve lowest scoring areas

• Aim for a balanced score, rather than excellence in isolation

• Higher value MS EA technologies only available to those with CAPABILITY to exploit them

• Leverage capabilities of Core EA products that are licensed for all and don’t default to Enterprise products that aren’t – especially if your organisation isn’t ready to exploit them

Collaboration

Common Themes – Integrated Projects

Manage Risk

Responsiveness

Innovation

Competency

Efficiency

ROI/Business Value

Standards

Re-use

Agility

Consistency

What is NHS CASE?

Collaboration Architecture Solution Enablers

An end to end model to support the development of

collaboration solutions

A set of tools which can be used at various stages in developing collaboration

solutions

A set of candidate solutions described in business terms

to help the NHS envision their collaboration

capabilities

A mechanism to share via the PSPG good practices

and collaboration solutions

What was the driver for NHS CASE?

Technologies Architectures& Methodologies

CUIGood Practice

SSADM

Prince 2

What was the driver for NHS CASE?

Technologies Architectures& Methodologies

CUIGood Practice

SSADM

Prince 2

Business DriveTo Collaborate & Share




solutions



capabilities



What’s in NHS CASE?



BusinessImperatives

CollaborationCapabilities

Solution Design

Technology Architectures

Service Delivery

Governance

People & Change + Programme Management



solutions

Collaboration DNA Ruler

OtherBusiness TasksPeople, Personal & SocialBusiness KnowledgeKnowledgeLists & InformationDocumentsAccess

Intr

anet

Inte

rnet

Fac

ing

Ext

rane

t – In

side

N3

Ext

rane

t – O

utsi

de N

3

Mob

ile A

cces

s

Offl

ine

Acc

ess

Doc

umen

t Man

agem

ent

Cen

tral

Lib

rary

& R

epos

itory

Doc

umen

t Arc

hivi

ng

Doc

umen

t Con

trol

s

Doc

umen

t Rig

hts

Man

agem

ent

List

Man

agem

ent

Rec

ords

Man

agem

ent

Cen

tral

Rec

ord

Rep

osito

ry

Sha

red

Tas

ks

Sha

red

Cal

enda

rs

Kno

wle

dge

Rep

osito

ry

Kno

wle

dge

Dis

cove

ry

Ent

erpr

ise

Sea

rch

Bus

ines

s In

telli

genc

e

Bus

ines

s R

epor

ting

Bal

ance

d S

core

card

s

Man

agem

ent D

ashb

oard

s

Key

Per

form

ance

Indi

cato

rs

Per

sona

l Inf

orm

atio

n

Tea

m F

ocus

Org

anis

atio

nal F

ocus

Tar

gete

d F

ocus

Soc

ial N

etw

orki

ng, B

logs

& W

ikis

Com

mun

icat

ion

& P

rese

nce

Con

fere

ncin

g &

Mee

tings

Bus

ines

s F

orm

s

Wor

kflo

w

Pro

ject

Info

rmat

ion

& R

epos

itory

Bus

ines

s N

ews

Arc

hive

Pol

icy

Con

trol

Drivers

Needs, Problems & Concerns

Capabilities Required Potential Benefit Areas

Functional Shared Workspaces

Staff expected to know what's going

on in their areaProfessional Profile

Staff recruitmentis difficult

Professional ProfileGive value for

moneyCost Customer is King

Team Focused Mass Publishing Targeted Publishing

Document Management List Management Document Controls

Social Networking Blogs Shared Calendars / Tasks

Mobility Archive Capability News

People have too much to read; how do they know what 's

important?

Link to : D5

NPC 9

A wide geographic area and culture [make it difficult for people to stay connected]

Link to : D5, D6, D8

NPC 10

Using Contractors is difficult because standard working

[practices] is not easily available


NPC 13A

No Shared structures on file servers, etc.

Link to : D6

NPC 17

People don't know where to go to get information on a project

Link to : D2, D5, D6, D9

NPC 21A

Need to summarise what we're doing to avoid information

overload and drive consistency

Link to : D6

NPC 20

Need to make information easy to find

Link to : D6

NPC 23B

Policies and Procedures need to be easy to find

Link to : D5, D6, D7, D9

NPC 23A

Personal Development Cost Avoiding Efficiency & Productivity

Effectiveness Staff Morale Customer Satisfaction

Environment / Carbon Footprint

Value to the organisation?

Our

Abi

lity

to D

eliv

er?

1

High

High

Low

Low

2

3

4

5

6

7

8

91011

12

13

14

15

16

17

18

19

20

21

2223

Varying levels of understanding and interest of IT by our

customers


NPC 2

Information overload

Link to : D6

NPC 3

Can't get access to information on the move


NPC 6

Need to publish information and metrics internally, externally and

securely


NPC 7

Need Information to be available through both Push and Pull

Link to : D6

NPC 8

Need to track and ensure staff have attended key briefs and

training

Link to : D6

NPC 1

We don't know what [information] we've got

Link to : D6

NPC 11

Need to avoid duplication [Linked to NPC11]

Link to : D3, D6, D9 & NPC 11

NPC 12

Using Contractors is difficult because standard working

[practices] is not easily available


NPC 13A

Initiative

1

2

3

4

5

6

Extern

al –

Insid

e NHS

Extern

al –

Outsid

e NHS

Team

Foc

used

Mas

s Pub

lishin

g

Targe

ted

Publis

hing

Patien

t Ide

ntify

ing In

form

ation

Docum

ent M

anag

emen

t

List M

anag

emen

t

Docum

ent C

ontro

ls




capabilities

Single Points of Information

Team Workspaces

Central Document Repository

Information Centre Manager’s Workbench

My Workspace Projects & Programmes

Secure HR Library Corporate Calendar




Internal Audit(Computer Audit)

Draft Annual Audit Plan & Timetable

SMT

Host PCT Risk & Audit Committee

Feedback / Rejection / Approval

AuditLibrary

Annual Audit Plan &

Timetable

Approved Annual Audit Plan & Timetable

Draft Approved

HIS Staff

Read Access to all final docs.

Step 2

Draft Audit Plan Mandate

HISDirector

Corp. ServicesManager

AreaLeadMgrs.

Draft Audit Plan Mandate

Final Audit Plan Mandate

Step 1

Operational Managers & Key Personnel

Step 3Final Audit Plan Mandate

Audit Tracking

Tool

Actions & Alerts

Access and updates

Host PCT Risk & Audit Committee

SMT

Access and updates

Evidence

Evidence

Draft Audit Report

Ste

p 4

Feedback

Draft Audit Report

Final Audit Report

Final Audit Report

Feedback

FeedbackLoop

Any Manager

Read Access to all draft & final docs.

Step 5

AuditActions

Ste

p 6

Draft Audit Report

Audit Collaboration

BCP & Emergency

Planning

Major Incident Plans

IT Recovery Plans

Public Paper Copy

Restricted Paper Copy (includes home phone numbers)

Sussex Emergency

Services

Updated Document

BC / MI Manager

Sussex HIS BCP Plan

BC / MI Manager

Contributors

HIS Staff

General Read Access

Business Unit Functional

Incident Plans

Action Cards

FEB

25

Annual Audit Plans

Internal Audit

Site Managers

FEB

25

Host PCT

Approval

Host PCT Board

Rehearsal Plans

Site Managers

Incident / Recovery Plans

Authorised Access

Review Team

Member

Plan Contributor

Business Continuity Planning

?

Performance Management

Enabling EWA...

• Microsoft

• NHS is Microsoft’s largest civilian customer and treated as a “segment of one” – i.e. Uniquely

• Most of Microsoft’s collaboration technologies are licensed to the NHS under this deal

• Novell

• NHS is Novell’s largest global customer

• Novell Identity Management and some collaboration technologies are licensed under this deal

• Oracle

• NHS is a “top 3” global customer for Oracle

• Most of the NHS’s centrally held data (e.g. SUS, PSIS) is stored in Oracle databases

Innovative solutions...

• Groove is a peer-to-peer collaboration environment which is part of Office 2007 Enterprise

• 100,000 Groove “seats” currently available for NHS use

• Many fewer than that deployed and in use – why?

• Groove needs thinking about!

• Groove is part of the offering of the Collaboration Environments & Solution Enablers (CASE) work done by Microsoft Enterprise Strategy Consultant working for CFH

• Groove is a great product... But...

• There are too few Groove solution partners in the UK

• NHS is experimenting with Groove, learning from it, learning a new way of working

• CFH looking to implement central Groove Relay for the NHS (directory)

Key platform updates...

• Moving NHSmail service to Microsoft Exchange 2007

• Largest Exchange 2007 implementation of its type in the world

• Moves 300,000 active accounts to new service whilst maintaining service continuity.

• Engaged end users throughout the design process, ensuring those who’ll use NHSmail have a service that meets their needs

• Over 500 servers installed two new secure Data Centres built by C&W

• New servers currently undergoing final build & commissioning

• Each mail server has 20TB storage and is part of a 3 node geographically diverse cluster (each has dedicated storage)

• Over 1300 separate Design Requirements documented in over 2,000 pages

Connectivity

Architecture Overview

Messaging/Integration Backbone (TMS)

LSP Data Centre

Local ApplicationInstance

EPR

Local Application Integration


EPR

Local DataWarehouse

MI

Terminology/Decision Support

Terms &Drug dB

LSP User Domain

Primary User Secondary User Tertiary User Community User

ICRS NASP Data Warehouse

SUS

SUS

SUS

CAB NASP Domain

CAB Data Store

E-Booking Application

Booking Management

Service

Telephone

ebX

ML

/ HL

7 V3

HL

7 V3

ICRS NASP Domain

SSB

PDSPSIS

SDS

ACF

Secondary Care Application

EPS

(Security & Access )

Enhanced Retained Legacy Systems

Primary User Secondary User

SecurityInfrastructure

Primary CareApplication

EPR

Secondary CareApplication

EPR

Event Engine/Integration Layer

Event Engine/Integration Layer

Integration Overview

LSP Data Centre


EPR



EPR

Local DataWarehouse

MI


Terms &Drug dB

LSP User Domain


LSP Data Centre


EPR



EPR

Local DataWarehouse

MI


Terms &Drug dB

LSP User Domain


BT MPLS(N3 IP VPN)

N3 PoPs

N3 Users

Private Circuit

DSLEthernet Access

Private Circuit

DSL

Ethernet Access

N3 Users

3rd Party Service Provider Local/National Service Provider

Data Centre(Primary)

Data Centre(Primary)

Data Centre(Secondary)

Other NHS organisations

Internet

NHS Direct

COINs

Data Centre(Secondary)

N3 Architecture Schema

N3 Physical TopologyDevice Naming

Colindale = n3-ld-c-01-colind-xxFaraday = n3-ld-c-03-farady-xxKingston IG = n3-ld-c-inetgw-xx

Where xx = router number

AS 64530(Kingston IG)

AS 64669(IPStream)

AS 64551 (Colindale PoP)

AS 65500(BTW)

R60 R67 6

BTW-NTE1

BTW-FER1

BTW-NTE2

BTW-FER2

R01

R51 R52

BTW-NTE1

BTW-FER1

BTW-NTE2

BTW-FER2

1110

AS 64552 (Faraday PoP)

R01

TSrv-96

R02

TSrv-96

R02IG-R01

400, 402

400, 402, 415

8R70 8

R55 0

R51 10 R52 11

. . . . .

.97 8R70 8

G1/1

G5/1-2

G5/1-2

G1/2

415 425

425415

G1/1

G1/2G1/2

G1/1

G1/1

G2/2G2/2G2/2G2/2 G1/7 G1/7

G1/2

R67 6R55 0 R60 5. . . . .

G5/1-2

G5/1-2

G2/1 G2/1G2/1G2/1

G0/0G0/1

G2/3G2/4 G2/3G2/4

G0/0G0/1

G0/0G0/1

410

411

410, 412

R71 9R71 9

G2/1 G2/1 G2/1 G2/1

G1/0/2 G1/0/2G1/0/2G1/0/2

420, 422 420

421423

421

G0/0

G0/1

G2/3 G2/4G2/4G2/3

G0/1G0/0 G0/1G0/0

5

400, 402, 425

Te3/3 Te3/3

Te3/4Te3/4

G1/0/12 G1/0/12

421423

411413

411413

G1/0/1 G1/0/1 G1/0/1 G1/0/1

G1/3 G1/4 G1/3 G1/4G3/1

G3/6

G3/7 G3/1

G3/6

G3/7

AS 2856 (MPLS Core)

IG-R02

VLAN ID VLAN Description400 DSL Internet Transit LAN

402 OSP F Transit LAN410, 411 Session Handoff LANs412, 413 DSL Transport LANs415 DSL Core Transit LAN420, 421 Session Handoff LANs422, 423 DSL Transport LANs425 DSL Core Transit LAN

Faraday

GigE Ring

Colindale

Terminal Sever Ports attached to Async 0/1/xx

Colindale Faraday xx xx

400, 402

400, 402

400, 402

F2/6

F0/0F0/0

F2/6

Colindale Faraday

Hospital 1

Hospital 2

NHSnet

NHSnet Router

Hospital

Hospital

Hospital

• N3 is not just one Wide Area Network, but many...

• Communnity of Interest Networks (CoINs) connect local infrastructures across some Health Communities

• CoINs connected by N3 to rest of N3 and other networks

CoINs

Identity

Who is an "NHS user"?

• Spine Directory uses Sun One• NHSmail uses Active Directory• 65% of 12,000 NOS use Microsoft AD (or NT4!)• 35% of 12,000 NOS use Novell eDirectory (or NDS!)• ESR is Oracle database for most (but not all) NHS workers

• An unknown number of application services holding their own username & password lists

• ID badges and building access “swipecards”• Telephone exchanges & mobile phones• And web sites and external applications (e.g. Academic systems)

• All with different administration and standards

Reduce identity chaos...

• Reduce user and administrator effort by integrating multiple identities belonging to the same person

• Synchronise some identity information

• Federate some directory services

• Deliver “self-administration” portals for users

• Establish provision/de-provision links and processes

• Leverage identity proof at the highest level (e-GIF L3)

• Make the NHS smart card the “key” to all other identities (if you can’t eliminate them)

Summary

• Scale• The scale of the NHS provides challenges to data consistency, connectivity,

effective collaboration all whilst being sure of a person’s identity (because of confidentiality)

• Consistency• Providing enablers and examples of good practice help drive towards consistent

infrastructure, systems and data

• Connectivity• The connectivity challenge of the NHS is significant – but it is not just about the

“wiring” – though that is a challenge in itself

• Collaboration• Knowledge workers collaborate – but we need consistent ways to enable that over

greater distances and with more people

• Identity• The NHS identity management challenge is considerable – organic growth of

services must be enabled by effective use of our most “sure” identity services