Big changes are upon us in the provision of healthcare. They will succeed only if there is a root and branch change in the culture and NHS way of working. And this time, failure is not an option. When it's time to go live, how ready will Trusts be?

The vision of 'Connecting for Health' is one of treating more patients, better and quicker, with given resources. But the NHS's implementation deadlines for the IT that will make it possible are challenging - and they are to be attained without compromising the drive to gain and keep control of Trusts’ budgets. So the big question seems to be this: “When financial and resource constraints are so in evidence, is it better to proceed with the speediest and most comprehensive possible implementation of this vision, for the benefit of patients into the future, or to apply available resources to maintaining patient services now?” The answer lies in understanding where a Trust is, compared with where it needs to be when change is complete, and in establishing clear priorities that will take it there. WCI's Francesco Casi explains.

Present or future perfect?
The 'present versus future' question is not academic because, whatever the benefits, there's little public mileage in 'some new IT system' , especially given the lamentable record of big IT projects. Whereas there's a very great deal of mileage in the maintenance of excellent, comprehensive local healthcare provision - perceived by patients as 'something we've already paid for.'

It is hard to see how this circle can be squared so as to maintain current standards while going for earliest implementation nationwide. But that is the task that faces Trust CEOs and their Directors of IT, Finance and HR. And it is not a task in which it will be acceptable to fail. Government pressure to achieve full and timely implementation is intense. Partial implementation will not be acceptable; healthcare is either connected or it is not. A situation in which some Trusts are hooked up and others are not cannot be sustained - records would be compromised and medical decisions could be affected. So, can Trusts do it?

The answer has to be 'yes', and the way forward lies in the detailed 'how' of implementation. It is clear that not all the tasks that need to be completed have the same degree of urgency, difficulty or severity of consequence if they are not done, or not done well. It is a matter of assessing the current situation and in light of the constraints, identifying the key tasks, prioritising them and planning to tackle them. The art is to do more with less - learning from past implementations and best practice, for example - while focussing on the targets that matter.

Constraints and obstacles
Trusts are finding life harder all the time. But in IT, traditionally chronic problems are becoming acute. Why? First, there's the need for universal connectivity. 'Connecting for Health' is responsible for delivering the National Programme for Information Technology. Through the Programme, all the Trusts of the NHS will adopt the National IT standards, acquiring and deploying the same communication abilities. They will commission and install any relevant software, connections, hardware and support services - for people as well as for IT systems. That's already a big mountain to climb, and many Trusts that had hoped to be beacons, early adopters have had to abandon the heady heights of ambition and opt for slower, surer change. The new technology offers little scope for local control - that is in its nature - yet it is at the very core of operational success. That is a considerable challenge to both technical and clinical understanding, with huge penalties for failure. While ever-closer implementation deadlines pull one way, newly tightened limits on IT expenditure pull the other -at least as Trusts and other healthcare units see it.

At the same time, the Local Service Providers (LSP) have changed focus from aggressive deployment to achieving smoother, tactical wins in an environment where demand far outstrips technical capacity. But as deployment dates get pushed back, Trusts inevitably grow uncertain of whether they can adopt - or want to. There are other challenges in handling the expected demand for skills and the actual requirement on the ground. And if LSPs are already stretched to meet the timetable, imagine the situation inside the NHS's own IT departments. Given NHS pay constraints, they already have difficulty in attracting sufficient quality IT staff, and in keeping the ones they have.

Also, while formerly a roughly ten-hours-on, fourteen-hours-off IT regime gave the chance to housekeep, maintain and upgrade, the new system has to be accessible, at any hour of the day or night, by clinicians and administrators throughout the Service. Once records are stored and accessed through the National IT Spine, there must be no outage, no user-perceptible downtime; everything must be permanently up and running. Why is that so vital? Test results that are not accessible mean tests being ordered again, incurring both delay and expense. Radiography images, for example, will not be accessible. Warning notes about allergies will not be presented to clinicians. Patients will suffer.

Finally, while legacy systems should not in principle pose a problem, different patient service needs and demographics in every locality have led to the development of a huge range of equipment, systems and recording methods. This presents another challenge to the Programme, because solutions learned in one place are generally not transferable to another. This is the practical read-out of the conventional wisdom that 'every Trust is unique'.

In this situation, Trust CEOs and their teams cannot be expected to develop and implement acceptable solutions without some unbiased professional assistance at strategic, implementation and technical levels. Help that introduces appropriate management and assessment techniques, then supports them with change management programmes and training. And in particular, help that provides a route map through the maze of tasks, constraints, inputs and outputs that confront the Trust as it reaches for the future.

Pathfinder questions
The process of analysis and planning, though complex, will always have to answer four questions:

- Where are we now and what are the current initiatives?
- What are the end goals for the Trust?
- How do we align activity and close the gap?
- What are our priorities and how do we identify them?

Considering these questions lights the path that leads to those end goals.

The absolute top priority of Connecting for Health is to maintain and improve patient safety . That is its purpose. It can be achieved only within a structure and an associated enabling culture that demands, fosters and promotes tangible continuing improvements for both patients and staff . The structure and its informational underpinning must also seek continually to improve patient pathways and in all regards ensure patient confidentiality .

How change is implemented also matters. Success probably cannot be achieved - and certainly cannot be sustained - unless Trusts obtain the utmost added value from the NHS's new investments in IT. And that will not be possible unless decision-making genuinely and visibly involves (and transparently uses input from) both clinicians and patients. One focus in the development of solutions needs to be on finding ways of using clinician time more effectively. Their skills are rare and costly to use. Clinicians require concentrated support to ensure that they are deployed to maximum effect, with the elimination of activities that do not add value or could be performed by non-clinicians.

An approach of this kind needs a management framework and information system, with clear and unequivocal metrics, that enable prioritisation, and are monitored and evaluated to ensure the neediest areas are addressed first. To ensure a firm grounding in reality, the change process needs to be business-led; with a steady focus on the desired outcome.

This is visionary stuff, and the practical implementations are tremendous. Implementation cannot even begin until certain laid down criteria are met. Assuming that the right IT products and services are available for local implementation (not automatic!), Trusts and their local health community must have completed all relevant pre-implementation level activities, obtain required approvals (including funding) and be ready to initiate the local Programme.

Because every Trust's needs are different, both qualitatively and quantitatively, their individual paths to the common goal will be different too. There is no magic pill and no one specific single tool, that will work for everyone. Rather, there is a bulging bag of possible tools, from locally developed best practice, through NHS proven transferable techniques and approaches from other sectors. But how do you choose among them? What's needed is a systematic, comprehensive framework for assessing, guiding and monitoring progress. A generally applicable framework that points to the specific tools needed for any particular situation, and facilitates learning as they are applied and adapted. In association with NHS Trusts, WCI has developed an approach that offers just such a lifeline. It draws upon proven techniques and best practice, and brings them together into a coherent, proven 'model for success'. But it always addresses the individual situation and goals. Some of its characteristics are outlined below.

A model for success
The model is based on an holistic view of a Trust's operations. CEOs have to be able to monitor and retain control of the whole process of change. This is not just about IT, nor even this current project, large though it is. It is about the interdependence of all parts of the organisation, and the alignment of all the other organisational changes and initiatives that are going on; all the activities of the operation, to the requirements of Connecting for Health. And the responsibility for making it happen, permanently and within budget, is squarely with CEOs and their boards.

People are key to successful change. To start, it is essential to recruit, train and set to work dedicated Project Implementation Teams that can be nurtured and developed. As implementation proceeds, they can be swiftly directed to tackle - and nip in the bud - problems that demand their particular expertise.

To move successfully into an 'always on', fully 24/7 environment, with service as its ‘raison d'etre’ and measure of success, is a very large change. Success depends on building sound foundations, which is easy to overlook in the imperatives of data migration, security worries and integration with the National Spine. Without the right foundations, 24/7 operation is impossible. These foundations - not bits of software - but new procedures, designations, access rules and security, training, monitoring and administration have to be designed and built thoroughly and to clear performance requirements. The consequences of paying insufficient attention to this aspect are severe. For example, should the integration engine which attaches local IT facilities to the National Spine become unavailable, the isolated installation then reverts to non-sharing status, getting more out of date with every passing moment. We have already seen where that leads. However, successful installation and working of the integration engine demands a sound, comprehensive foundation. Connection assumes that everything will work as it should, including security and access control, and data posting systems and services. Even in the most technically sophisticated Trusts, the connected state will be a very different environment from that of today.

Well-established tools and procedures guide the process of a Trust being ready to take successful key decisions about the project, informing the change action programme and its priorities. They encourage the use of local learning from other implementations, offer tight Project Control arrangements and require and facilitate clear metrics to be established early. The tools offer a means of establishing and balancing risks, costs and benefits. They provide adaptable monitoring and reporting systems that signal the need for adjustment to actions and parameters to mitigate risks without compromising delivery.

It must work
IT supply and installations are expected to be arranged through third parties. The critical part of the current transformation is much more about people and processes than it is about particular equipment or software. It is very important to form the right partnerships, and to create a reliable, well-informed, constantly learning team that finds it natural to share, re-use and adapt knowledge and best practice, from wherever it can be found. Getting such a team in place early and having them drive your Programme is probably the only strategy which can make this change successful, on budget and on time.

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