Hospital IT director Anthony Brewer leading efficiency drive

Few good things came out of the 2001 foot-and-mouth outbreak in the UK, but one positive by-product of the year-long crisis that decimated livestock and is estimated to have cost the economy £8 billion, is that it led Anthony Brewer taking the IT director’s role at Kingston Hospital NHS Trust.

Brewer was a strategy development manager at rural affairs department Defra when the first cases of the disease were reported early in 2001, and he recalls how the transformation from doing banal departmental work to leading a fire-fighting project, in which strategies changed by the hour and the response had to be immediate, inspired him.

“I was leading a project to establish testing facilities across the UK, involving everything from having valid tests, recruiting staff, putting up buildings and adding computer networks and computer systems,” Brewer recalls.

“It was really exciting times because you had to get stuff operational fast, turning strategy into reality over a week. The army took over a floor of our building – we were fighting a war against the disease. I said once we couldn’t do something and I was threatened with having to report to [Cabinet emergency committee] Cobra.

“All that made me think I needed a job where I could turn strategy into reality.”

Brewer arrived at the hospital in the London-Surrey border town later the same year, and while the pace of change at the trust is somewhat less dramatic than that required by the foot-and-mouth crisis, as a proven change manager he has spent the last 12 years successfully using technology to improve patient care and, in the process, saving money for the trust.

Like all public services in this age of austerity, healthcare is in the grip of an efficiency drive, with the NHS working to meet the ‘Nicholson challenge’ laid down by its chief executive Sir David Nicholson to save £20 billion by 2015. For the trusts themselves that means annual efficiency savings of 5%, a target Brewer is helping to meet with what he calls an “IT-enabled productivity programme” which includes the digitisation of everything from patient records and X-Rays to staff rostering and procurement.

Outsourcing has been seen as a silver bullet when it comes to cost-cutting, and within the public sector, local authorities are also starting to identify overlapping areas where they can procuring and manage shared services. As part of a cost and performance benchmarking study conducted by ImprovIT, Brewer and his counterpart at St George’s Hospital in Tooting, John-Jo Campbell, asked the business technology specialists to explore the feasibility of the two trusts sharing services and to investigate whether or not it would be cost-efficient for either to outsource some or all IT services. Brewer says the findings around outsourcing confirmed his suspicions, but the investigations into shared services – for which ImprovIT modelled the services of the trusts’ IT teams as if they were a single body – threw up surprising conclusions.

“I thought outsourcing was more expensive and the study proved that it was far more expensive,” Brewer explains.

“It also showed that shared services wouldn’t deliver much more than we could internally in terms of efficiency gains. If you compare the benefit of sharing services with the cost of setting up a shared-services arrangement – not to mention the governance issues and the disruption – then it wasn’t worth doing. It would also require a large upfront investment to reconfigure our infrastructures and methodologies, which in the short term isn’t worth it.”

The benchmarking, which Brewer calls “very forensic” and based on “solidly grounded facts, not facile suppositions”, did confirm that both Kingston and St George’s were running “lean and mean”, and 15% more efficiently than similarly benchmarked peers.

Brewer and Campbell may have decided not to share services for now, but that doesn’t mean they, and other IT directors across London’s hospital trusts, don’t share ideas, experiences and learnings on a regular basis.

“Our default strategy is convergence and collaboration – if we’re both procuring a rostering system, let’s get the same one unless there are good reasons to do otherwise. We might make it one project with one project manager,” says Brewer.

“We’ve got a long-standing IT directors’ forum that meets every couple of months,” he adds. “We all do things at different times, but the London Procurement Partnership will ask people what their plans are and get hospitals together to support procurement, while the London Programme for IT is part of the strategic health authority – they’ve been much more collaborative with us rather than trying to telling us what to do.”

Talk of the London Programme for IT brings us inevitably to the NHS’s National Programme for IT (NPfIT). The £12 billion programme to streamline technology uptake in the NHS – written off by the Coalition government in 2011 nine years after it was launched by its Labour predecessor – is rarely mentioned without the adjective ‘much-maligned’, but Brewer, for one, will be sad to see it go.

“The NPfIT for us has been very positive. Because of where we were it made sense for us to adopt the acute hospital systems that were being offered,” he explains.

“It gave us funding and provided contracts that we didn’t have to go out and procure, and I don’t believe there’s a great deal of difference between the electronic patient record (EPR) systems anyway.

“We went live in 2009 with [EPR system] Cerner Millennium, and we were arguably the most successful hospital to go live with the system. There was a lot of noise in the press about systems going live and failing, but you didn’t hear anything about us because we did it successfully.

“So for us the National Programme has been a good thing. We also took PACS (Picture Archiving and Communications Systems) so all our X-Rays are digital, and the EPR was a huge leap forward.

“We’re still plumbed into that until October 2015 and we’re going live this summer with electronic prescribing and with putting a lot of clinical documentation onto our system. That’s quite a big step forward. We’re not at the vanguard but we are one of the first to do it – not many hospitals have that and we’re one of the first to do it through the programme.”

Change specialist

The secret of successful implementation of the programme’s various units, Brewer suggests, has been in his approach to change management, gained and honed since running a change management programme to merge two government departments in the 1990s. With 3500 staff across the hospital boasting varying degrees of technology know-how, a balance of training, coaxing and rigid enforcement has seen the new technology adopted with the minimum of resistance.

“Once the EPR was in place we added facilities for the electronic ordering of diagnostic tests. We knowingly went live with a ‘big bang’ which is quite high-risk but that’s how we’d get the change we needed,” Brewer explains.

“One of the constant challenges is changing the way people work. To adopt these systems is no small challenge – it’s actually easier if you enforce it in some ways, so with electronic ordering we took away paper forms on the day we went live and if anyone had paper forms, pathology and radiology refused to accept them. With levers like that it’s easier to change.

“I’ve established a change management team as part of my department so we’re out there helping people through changes, redesigning their existing processes to take advantage of the new technology.

“With electronic rostering, we’re linking it to payroll and temporary staff, so if you don’t roster on the system as a manager, your staff won’t get paid and you won’t get the temporary staff. Sometimes people have to go through some pain to make them change.

“It’s like pushing a penguin off a cliff to make them swim.

“There are two factors holding IT back – one is the amount of money and people it takes to get it in and get it working, and the other is the change management aspect. If you can’t get people to use these systems effectively and change their working practices, all you’re doing is throwing money at it. Managing change drives out savings.”

Wireless gains

A new wireless network will drive efficiency further, cutting out even more paper from hospital processes and speeding up the transmission of data around the wards and beyond.

“The new wireless network is RFID-compliant so we can track things going across hospital whether it’s valuable equipment or blood or whatever. We’re about to put a layer of software across the network to make it much more efficient for clinicians so they’ll have single sign-on to multiple systems and session persistence so they can go from using one device to another, leaving the system at a certain point in a patient record and joining it on another device at exactly the same place.

“We’ll also have mobile device management so doctors can use tablets and laptops for electronic prescribing.”

But IT isn’t only being used to address broad issues, and specific targets can be met with an application of new technology.

“Last year one of the targets was that 90% of qualifying patients [by age or illness] needed to be assessed for VTE (deep vein thrombosis) so we incorporated something into our patients record system which not only allows you to do the assessment on the system but also lets you order surgical stockings. It sounds trivial but it helped make sure we met the target and ensures we deliver better care.”

Having all this data on portable devices could post a greater security threat than even the outgoing paper-based systems, but Kingston’s wireless network helps guard against any such breaches.

“We can wipe devices remotely, while some of the software doesn’t store data on the device so if a device is lost there won’t be any patient data on there. There have been scares about lorries dumping patient records in the street, but because of the way we’re setting it up it can’t happen. Information security is absolutely vital.”

As for the spectre of BYOD, Brewer plans to take a cautious approach. “We’re going to do it but let’s make sure we’ve got all the controls in place first or mayhem could break out,” he warns.

One type of data that is permitted to leave the hospital grounds is patient notes, now increasingly delivered electronically to GPs’ surgeries across the Kingston area. These are being dictated digitally too, using the BigHand speech recognition system to reduce bottlenecks caused by delays in typing up patients’ notes, waiting for the doctor’s signature and the postal service itself. The next step will be to reverse that flow of information by making GPs’ referrals electronic, and again Brewer is comparing notes with fellow NHS CIOs.

“[Connectivity with GPs] is something that King’s College Hospital has done. We can talk to them and learn from them. There used to be a lot of reinventing the wheel but that’s reduced enormously in the 10 or 12 years I’ve been here and that can only be a good thing.

“I’m a great believer in learning lessons. When we went live with our NPfIT system I created a learned-lessons log to discuss issues with CIOs, CFOs and CEOs, and we’ve done it again since.”

Brewer says he’s fortunate to be backed by a supportive chief executive in Kate Grimes. “My chief executive’s ears are already open before I start talking,” he jokes. After several changes in his reporting line he currently reports to the trust’s commercial director, but what matters most, he says, is that IT has a voice on the board when it needs it.

“During my time here I’ve reported to the CEO three times, the FD twice and the COO once. I don’t think it matters so long as you have a voice on the board. You need the support of people who can see the opportunity but it’s up to you to influence people. The board are very IT-aware – they want an app so they can use their tablets at meetings – and are aware of the human side of change management.

“I think we’re on the cusp of huge opportunity. There are lots of opportunities for IT to enable cash-releasing savings or at least efficiency gains. But you can’t keep reducing IT team numbers or you won’t be able to do it. The way we’re starting to do it is to cost in our own IT support. We can’t deliver the same for less each year so unless you invest in the people as well as the technology, it’s not going to work.”

Anthony Brewer CV

2001-present:IT Director, Kingston Hospital NHS Trust 2000-2001: Veterinary Surveillance Strategy Development Manager, Defra 1997-1999: Springboard Change Programme Manager, VLA