Appendix: 4.3.1
MEETING:
DATE:
TITLE:
LEAD DIRECTOR:
AUTHOR:
CONTACT
DETAILS:
Islington Clinical Commissioning Group Governing Body
Wednesday, 9 September 2015
Integrated Digital Care Record & Person Held Record Full Business
Case
Paul Sinden
Nia Pendleton-Watkins, IT Programmes Director
[email protected]
SUMMARY:
1. Executive Summary
This paper provides the Governing Body with a summary of the Full Business Case (FBC)
providing the rational to procure an Integrated Digital Care Record (IDCR) and Person Held
Record (PHR) which provides business intelligence and interoperability across Islington
health and social care services.
The source and application of funds for IDCR and PHR are set out in Appendix 1 and
show:
 Initial build costs, £4.3m, are covered through a combination of central funding (£2.6m)
and local resources (£1.7m) from the CCG, Islington Council and the Better Care Fund.
A residual amount, £90k, will be found from local resources in 2017/18;
 The on-going costs including project support costs, maintenance, hosting and licences
amounts to £6.6m from 2014/15 to 2020/21 which are only partially offset through cash
releasing benefits (£3.2m) and recurrent local funds (£2.4m). This leaves a funding gap
of £1m (an average of £204k per year) from 2016/17 to 2020/21.
Work is underway to close this funding gap through the following actions:
 Broadening the population base, and therefore spreading the cost base, for the
procurement, with Haringey CCG and Enfield CCG potentially interested in procuring the
IDCR and PHR. Other CCGs would make a contribution to the build costs and on-going
revenue costs, with a potential unit price reduction for scale from the provider;
 Further realisation of benefits in particular from the change in business intelligence the
IDCR and PHR will provide for contract management and service redesign;
 A targeted approach to roll-out of the PHR to people with complex health and care needs
to maximise the pace of benefits realisation and slow the costs of licences;
 Recurrent use of Better Care Funds to support on-going costs.
The Governing Body is asked to approve the Full Business Case for the Integrated Digital
Care Record (IDCR) and Person Held Record (PHR) which provides business intelligence
and interoperability across Islington health and social care services on the basis that:
 Initial build costs are funded and the small remaining gap of £90k, in 2017/18, can be
found from future investment funds;
 The residual funding gap, £204k average per annum, will be covered by the actions
listed above.
Page 1 of 20 On 27 August 2015 the CCG’s Strategy and Finance Committee recommended sign-off of
the FBC to the Governing Body on the basis set out above.
1.1 Timetable for approval
The procurement timetable indicated that the June 2015 Strategy and Finance Committee
and July 2015 Governing Body would be asked to approve the full business case and
contract award to the preferred provider. This had been deferred for the following reasons:
 Following the supplier presentation days held on 11 and 12 June 2015 a preferred
provider was not appointed. All four of the shortlisted suppliers were asked to provide
further evidence in their offering for the Integrated Digital Care Record (IDCR), Person
Held Record (PHR), and supporting Business Intelligence;
 A final decision on recommendation of the preferred provider was made following a
second moderation meeting held on the 8 July 2015;
 A procurement report and award recommendation is also being presented to the
Strategy and Finance Committee for approval.
The timetable, as a result of the above, was revised so that the August 2015 Strategy and
Finance Committee and September 2015 Governing Body will be asked to approve the Full
Business Case and contract award to the preferred provider.
1.2 Why do we want to make this investment
At the end of 2013, Islington CCG in conjunction with Islington Council and Whittington
Health, succeeded in a joint bid to secure Pioneer Status as part of the Department of
Health’s programme to transform the way health and care services are planned and
delivered across the country. Islington was named as one of fourteen pilot sites across
England.
As a Pioneer organisation, Islington made a commitment to driving transformation and
integration. It has been developing its integrated care programme working alongside
Pioneer colleagues, partners and providers. In order to make a difference, ensure the CCG
delivers the digital vision set out by the Department of Health in 2012 and take forward our
Pioneer plans to integrate care across our partners Islington must transform the use and
publication of information to patients, residents, clinicians and other staff in health and
social care.
Developing and implementing an Integrated Digital Care Record and Person Held Record
between health providers has a number of objectives:
 Put the patient at the heart of care, empower them to manage their own care and be part
of decision-making
 Empowering clinicians with real-time, accurate information and improve patient
outcomes
 Make the shared patient data available to authorised clinicians and carers where and
when it is needed
 Support assessment and other data collection forms so that users from different care
settings can add data
 Support workflow so that clinicians and carers can perform tasks and then inform, refer
or handover to others
 Include an automated alerting facility using text messages, emails and in-system
messaging so that clinicians and carers can be notified of key events - a patient under
their care being admitted to hospital, for example.
 Create enhanced real time information to inform planning and commissioning
Page 2 of 20 1.3 What is our Clinical vision
The CCG’s member GP practices have agreed their collective aim to develop a new
partnership between patients and their clinicians that together commissions health services
of high quality and good value for money and meets the needs of the population. We have
identified four objectives together with the London Borough of Islington and agreed by the
Health and Wellbeing Board that will help us to achieve our vision:
 Ensuring every child has the best start in life;
 Preventing and managing long term conditions to extend both length and quality of life
 and reduce health inequalities;
 Improving mental health and wellbeing; and
 Delivering high quality, efficient services within the resources available.
The Business Case approved in 2014 set out these strategic requirements and agreed to
develop a Full Business Case and procurement to deliver 2 key objectives:
 Interoperability and information exchange between organisations by way of an
Integrated Care Record. This would allow the flow of data to be sent between
organisations for the benefit of co-ordinating service provision across care pathways
improving patient care and business intelligence;
 A person held health and social care record for the citizens of Islington (PHR), that is
across commissioners and health and social care providers, so that the individual holds
and manages their care, can input to that record, can communicate with a range of
services and providers directly and gives consent to providers of care to view their
record based on an agreed data set. Providers thereby work together to provide high
quality care.
1.4 How will this investment deliver our strategic priorities
The objectives of this business case, to implement a PHR and enable information sharing
between care providers, are underpinned by a number of national, pan-London and local
strategies and initiatives which provide the strategic context for this change programme,
including:
 Health and Social Care Act (2012);
 NHS Mandate (2012);
 NHS Information Strategy (2012) ‘Power of Information’;
 Government Digital Strategy (2012);
 Department of Health Digital Strategy (2012);
 Joint Health and Wellbeing Strategy 2013;
 Islington CCG Information and IT Strategy 2014-2016;
 Care Act (2014) – with a requirement for the NHS to provide information to, and work
collaboratively with Social Care;
 Islington Council IT Strategy;
 Islington CCG’s strategies to deliver:
 Primary Care
 Integrated care
 Planned Care
 Urgent Care
The table below provides examples against our strategic delivery programmes:
Page 3 of 20 Programme
Urgent Care
Planned Care
Integrated Care
Primary Care
Example
of
expected
benefits
o Joined up
services
aiding clinical
decision
making
o Self-management
of health
o Improved
Care
Planning
(Health and
Social Care)
o Linking across
GP systems
o Reduced
errors
o Reduction in tests
o Reduction in
missed
appointments
(DNAs)
o Joining-up
care outside
the borough
o Reduction in
missed GP
appointments
(DNAs)
2. Financial Summary
The supporting full business case (FBC) to the procurement examines two objectives that
Islington now needs to achieve:
 Having a person held health and social care record for the citizens of Islington
(PHR) that is across commissioners and health and social care providers, so that the
individual holds and manages their care and gives consent to providers of care to view
their record based on an agreed data set. Providers thereby work together to provide
high quality care;
 Interoperability and information exchange between organisations. This would allow
the flow of data to be sent between two or more organisations for the benefit of coordinating service provision across care pathways improving patient care and data
analysis.
The FBC has therefore been produced to summarise the approach, benefits and costs of
developing and implementing an Integrated Care Digital Record and Person Held Record
for the patients and people of Islington. This will allow the flow of data between
organisations in the Islington Integrated Care Pioneer organisation and with potential to
expand across London by linking with other health and social care organisations.
2.1 Source and application of funds
Appendix 1 sets out a revised source and application of funds split between the
capital/build element and the ongoing revenue costs.
The build element is straightforward and the initial build costs, £4.3m, are covered through
a combination of central funding (£2.6m) and local resources (£1.7m) from the CCG,
Islington Council and the Better Care Fund. A residual amount, £90k, will be found from
local resources in 2017/18. However, the underlying assumptions underpinning the source
and application of funds need to be transparent, as there is an element of risk attached:
 All sources of funds have been confirmed and received except the capital element from
NHS England (NHSE). Notification came through via email (24 June 2015), but the
allocation has not yet appeared on either our NHSE returns or against our cash
drawdown limit. NHSE have been contacted and whilst it is a small risk, it is worth
noting.
 Islington Council have confirmed their £600k contribution, however NHS funds must be
spent first otherwise there is a risk they will need to be returned. This is particularly true
of the capital fund, which must all be spent in 2015/16. This creates a minor timing issue
that Islington Council will need to be manage as their contributions we will not be
required until 2016/17 and 2017/18. A small risk, but again one that will need managing.
 The VAT opportunity is realisable if LBI make the payments with the funds they have
Page 4 of 20 been directly awarded for the project. This is everything associated with the build
except the £1.3m NHS capital fund, which will need to have appropriate elements of the
total costs identified and charged against it. As the VAT opportunity is significant
(£584k), LBI must be assured that the payments process is acceptable to them as they
will not be the procuring organisation. This should not be an issue as section 75
agreements exists allowing financial transactions between the Council and CCG,
however it is worth noting the risk. In the meantime, work will continue to establish the
necessary agreement between both organisations to secure the VAT opportunity.
The on-going revenue costs including project support costs, maintenance, hosting and
licences amounts to £6.6m from 2014/15 to 2020/21 which are only partially offset through
cash releasing benefits (£3.2m) and recurrent local funds (£2.4m). This leaves a funding
gap of £1m (an average of £204k per year) from 2015/16 to 2020/21.
Working through the source of funds from the top of the schedule in Appendix 1, the first
item is the £2.5m contribution from the CCG. This covers the costs incurred in 2014/15, all
the expected costs in 2015/16 and makes a contribution to the costs from 2016/17
onwards.
This fund has been identified from the existing primary care IT reserve (£323k) and a
further £77k from the vacant post for the IT lead in the primary care structure. The post
funds become available as the cost of the interim Programme Director are capitalised
within the build costs.
The reserve and the vacant IT post generate £400k each year from 2016/17 onwards. The
£205k required in 2015/16 will meet the expected support and maintenance costs from 1
December 2015 onwards, i.e. 4 months.
Support and maintenance costs have come from the preferred bidder’s schedules with an
assumption for VAT applied, i.e. the CCG can recover VAT on maintenance arrangements.
This will require formal approval by the CCG’s VAT advisors once the maintenance
contract is agreed with the provider as these contracts are subject to extra scrutiny by
HMRC due to the values involved. If the assumption to recover VAT proves to be wrong, it
could add another £1.2m to costs over the five year period.
The only other cost element is depreciation. The annual charge is the £1.3m capital cost
spread across 5 years, the expected life of IT projects in the NHS.
To meet the costs over and above the CCG’s internal resources, i.e. the £400k mentioned
above, cash-releasing and deliverable savings have been identified. These include
avoiding unplanned admissions and A&E attendances, support for referral management for
new, follow-up and consultant to consultant attendances, reductions in duplicate diagnostic
testing, a reduction in medicines wastage, and avoidance of emergency admissions caused
by medicines errors.
This still leaves a £1m gap (an average £204k per annum) and actions to close the gap are
outlined below.
2.2 Actions to close the funding gap
Work is underway to close this funding gap through the following actions:
 Broadening the population base and therefore spreading the cost base, for the
procurement, with Haringey CCG and Enfield CCG potentially interested in procuring the
IDCR and PHR. Other CCGs would make a contribution to the build costs and on-going
Page 5 of 20 revenue costs, with a potential unit price reduction for scale from the provider;
 Further realisation of benefits in particular from the change in business intelligence the
IDCR and PHR will provide for contract management and service redesign;
 A targeted approach to roll-out of the PHR to people with complex health and care needs
to maximise the pace of benefits realisation and slow the costs of licences;
 Recurrent use of Better Care Funds to support on-going costs;
 Additional QIPP savings target over and above the 3% per annum currently targeted
from 2016/17 onwards.
2.3 Benefits realisation
Undertaking the IDCR and PHR will support delivery of the expected benefits associated
with other key work programmes in Islington. The table below provides examples against
our strategic delivery programmes:
Programme
Urgent Care
Planned Care
Integrated Care
Primary Care
Example
of
expected
benefits
o Joined up
services
aiding clinical
decision
making
o Self-management
of health
o Improved
Care
Planning
(Health and
Social Care)
o Linking across
GP systems
o Reduced
errors
o Reduction in tests
o Reduction in
missed
appointments
(DNAs)
o Joining-up
care outside
the borough
o Reduction in
missed GP
appointments
(DNAs)
Benefits from implementing such functionality are centred on the patient and improving
their experience, as well as assisting clinicians in decision-making and improving patient
outcomes. The benefits identified are split into three categories:
 Non-Financial benefits focused on quality and outcomes improvements for patients,
workforce and improving outcomes as shown below
 Quantitative (financial) benefits such as productivity benefits focused on improving
productivity and allowing clinicians to spend more time with the patients or attend more
patients within the available time
 Quantitative (financial) benefits which release cash savings within the system
Appendix 1 sets out the financial benefits for implementing a Person Held Record and
interoperability with savings estimated in terms of cost efficiency and productivity savings.
This high-level analysis is based on published evidence and statistical information for the
potential benefits where possible, and provides a top-down view of the magnitude of
benefits that could be achievable.
There will be a push to increase the pace of uptake of the programme, in particular for
complex health and care patients where a higher proportion of benefits will accrue, and
therefore the benefits which are realised could realistically be increased further.
Areas with potential for further cash-releasing benefits include:
 Greater transparency on patient pathways to support service redesign;
 Enhanced business intelligence to support contract challenges with providers, and
ensure the correct counting and coding of activity.
Page 6 of 20 In addition to the cash releasing benefits included in the FBC there will be significant noncash releasing benefits that accrue from:
 Secondary care clinical letters being sent electronically;
 A reduction in patient transport requirements;
 A reduction in do-not-attends (DNAs) for first and follow-up appointments through the
use of SMS messaging;
 Using SMS to report negative test results and reduce appointments used to
communicate negative test results in primary care;
 A reduction in outpatient doctor and nurse time from the above.
These benefits will be realised across a wide number of organisations in the Islington
Integrated Care Pioneer, including Primary Care Trusts, General Practitioners and Social
Care providers, such as Islington Council. The Benefits Management Strategy has been
agreed by the Informatics Steering Group and Benefits will be regularly reviewed and replanned throughout the life of the programme.
The table below summarises the non-financial benefits focused on quality and outcomes
improvement, quantitative (financial) benefits from improving productivity, and quantitative
(financial) benefits which release cash savings within the system:
Quality and Outcomes Benefit Description Patients Patients put at the centre of care and are empowered to manage their own care and be part of decision‐making Online real time access to their records and improvement to online transactions e.g. online registration, booking appointments, ordering repeat prescriptions Improved communication, can make contact with healthcare more efficient and can improve access for patients, especially those with disabilities Receiving text message reminders and screening programmes via mobile phones Greater access to health information, data and knowledge, helping to maintain health and wellness, not just treat illness Patient wishes and preferences of care available to all care providers Improved experience:  Smoother assessments due to less repetition of health history every time treatment is accessed in different organisations, as up to date information will be available through the data sharing agreements once consent is given  Lower risk of clinical errors for conflicts of treatments prescribed  Care is co‐ordinated between providers across health and social care giving patients greater reassurance, confidence and trust in the clinicians treating them  Improved understanding of treatment and recovery process  Reduction in unnecessary admissions, and treatment in more appropriate care settings  Reduced effort and cost for arranging and attending unnecessary face‐to‐face appointments Clinicians and Care Providers Better and faster / real time clinical decisions based on richer and more timely information Access to enhanced real time patient population information to inform risk stratification and Public Health activity and spend Productivity improvements and reduced pressure as more patients can be seen as a result of faster assessment times and better coordination More flexible working patterns and opportunities to transform whole service Page 7 of 20 Improved staff satisfaction as organisation is seen to be investing in staff skills development Improved communication between patients and clinicians Reduction of clinical errors and risk of litigations through access to patient history Reduction in duplication of efforts as data is entered only once Improved communication between referrers and service providers across organisations Improved continuity of care across provider organisations Clinical Quality & Improving Outcomes Reduced prescribing errors Enables more timely and effective treatments Better informed OOH services Better informed OOH services Increase safety and reduced risk in relation to vulnerable individuals and children Reduced length of stay due to accurate, up to date information to aid clinical decision making Improved patient outcomes due to improved self‐management of post‐operative care Could cumulatively, lead to a reduction in NHS spend on the resolution of clinical negligence claims and litigation Better use of resources across Health and Social Care 2.4 From Outline Business Case to Full Business Case
In September 2014 the Governing Body approved the Outline Business Case (OBC), and
approved the option to “Procure a best-of-breed Person Held Record (PHR) solution and
combine this with an integration engine that has Health Specific connectivity functions and
supports open standards” as the preferred option upon which to move forward into the Full
Business Case (FBC) stage.
Approval from the Governing Body was predicated on affordability on receipt of the FBC,
which in turn would be informed by the costs of more detailed service offerings from
suppliers. The OBC was also based on potential financial support, £1.7m, from the national
Digital Technical Fund held by NHS England, and the Governing Body indicated that a
fresh view of affordability be taken when a decision on the receipt of Digital Tech Fund
monies was received.
The OBC approved in September 2014 was predicated on the following assumptions:
OBC September 2014
With
VAT
£000
Build costs
Support and roll-out costs
On-going costs for licences and maintenance
Total project costs
3,488
460
6,880
10,828
Excl.
VAT
£000
2,907
383
5,733
9,023
Costs in the Outline Business Case were based on a ten year period.
Page 8 of 20 To identify costs for the OBC the market was tested in three different ways to estimate
expenditure for building and configuring the solution:
 Building a bottom-up estimate based on those functional and integration components
listed within the conceptual architecture, industry standard metrics for the
implementation of such projects, and a range of assumed productivity factors should a
specific PHR product and Health specific integration engine be selected. The effort
calculated for this was 793 person days;
 Asking for Rough Order of Magnitude (ROM) costs from incumbent vendors, in other
NHS organisations, based on a high-level requirements brief plus one other supplier not
on the original long-list as a comparison;
 Reviewing the likely license costs for Open Source offerings for integration engines;
 In addition, approximate hosting costs have been obtained from two hosting service
suppliers. Finally, we project a programme cost based on the management and
technical resources required to run the competitive tender and to run the implementation
project.
From this process costs for the preferred option were estimated to be £10.8m, over ten
years, including VAT and £9.0m excluding VAT. Total expenditure costs, including VAT
were then broken downs as:
 £3.5m for build costs;
 £0.5m for support and roll-out costs; and
 £6.9m for on-going revenue costs including licences.
The OBC assumed receipt of the £1.7m requested from the Digital Tech Fund held by NHS
England in full, and this was to be used to support the build costs. Receipt of any monies
from the Digital Tech Fund was predicated on local match funding. The table below
summarises the sources of funding for the initial build costs included in the OBC:
NHSE Tech
Fund
£1.744m
Council
contribution
£0.600m
CCG
contribution
£0.564m
Joint
contribution
£0.580m
Total funding
required
£3.488m
The OBC indicated that the CCG and Council match funding would be drawn from the
Better Care Fund, underspends on pooled budgets, and the AdSS Transformation Fund in
the Council.
On 23 February we received notification that Islington would receive £1.35m from the
national Digital Tech Fund, compared to the original request of match funding of £1.7m.
This meant that local resources of £2.05m were required to fund the project rather than the
original £1.7m.
In a briefing to the Governing Body in March 2015 it was indicated that the local funding
requirement would be covered through the return of the CCG's non-recurrent surplus from
2014/15 and the Better Care Fund.
Following confirmation of the Digital Tech Fund monies sources of funding for the build
costs were revised as set out below:
NHSE Tech
Fund
£1.350m
Council
contribution
£0.600m
CCG
contribution
£0.958m
Page 9 of 20 Joint
contribution
£0.580m
Total funding
required
£3.488m
The full business case (FBC) prepared in September 2015 updates the financial
information set out in the outline business case (OBC) approved by the Governing Body in
September 2014 for the following:
 The greater specificity on service requirements for the IDCR and PHR provided through
the procurement process, in particular supported by provider responses to the functional
checklist prepared by the project team;
 Advice from the procurement team in Northeast London Commissioning Support Unit
(NELCSU) that the business case be based on a five-year period rather than a ten-year
period, as the initial contract could only be let for a maximum of five years. The shorter
timeframe is likely to have resulted in providers adding a risk premium to costs.
The FBC costs are based on the costs in the proposal from the preferred provider. The
costs shown in the table below are set out according to VAT rules, and compared to the
comparative costs set out in the OBC:
Comparison of OBC and FBC costs:
OBC
FBC
OBC September 2014
£000
£000
FBC September 2015
Build costs
3,488
3,798
Support and roll-out costs
460
640
On-going costs for licences and maintenance
6,880
6,545
Total project costs 10,828 10,983
Key points to note are:
 Build costs in the FBC are 9% (£310k) higher than those included in the OBC;
 Support and roll-out costs are £0.2m higher in the FBC compared to the OBC, and will
be reduced;
 Annual on-going revenue costs for licences, maintenance and depreciation in the FBC
are £1.3m compared to £0.7m once full-roll out has been achieved;
 The FBC is based on a five-year period and the OBC on a ten-year period.
2.5 Overview of content of the full business case
A copy of the full business case can be made available on request.
The full business case sets out:
 The programmes’ background and context, with the IDCR and PHR enabling service
developments in the Islington Integrated Care Pioneer programme and Primary Care
Strategy, and fit with IT strategies - national (Department of Health Digital Strategy
2012; NHS Information Strategy ‘Power of Information’ 2012), London and local
(Islington CCG Information and IT Strategy 2014-16; Islington Council IT Strategy);
 A description of the scope and what it provides;
 The Case for change - why this new functionality is required. The key drivers for
transforming and standardising the ways in which care providers interact with citizens
and each other and share patient data are based on the need for Islington to give its
residents and staff the knowledge, skills, and tools to embrace a digital vision. Nationally
and locally, the NHS is having to adapt the way it provides healthcare in response to
both needing to provide better treatments at lower costs as budgetary pressures demand
more for less and ensuring that the patient is at the heart of what is done. Seizing the
opportunities that new technology brings will assist in achieving this;
 Options examined to provide the scope. In September 2014 the CCG’s Governing
Body agreed the option to procure a best-of-breed Person Held Record (PHR) solution
and combine this with an integration engine that has Health Specific connectivity
Page 10 of 20 functions and supports open standards;
 The potential benefits, with benefits accruing for patients (empowerment, experience,
and access to health information), clinicians (effective Information Governance,
continuity of care and access to real-time information for clinical decisions), and
improved outcomes such as reduced prescribing errors, reduced lengths of stay in
hospital beds, increased safety for vulnerable children and adults, and improved patient
outcomes through self-management;
 The likely economic costs of delivering the project and ongoing support;
 The funding required and budgets available;
 The procurement approach through an Open OJEU process;
 How the project will be managed through to implementation through the established
multi-agency Informatics Programme Steering Group has been established incorporating
key stakeholders from Islington Council, Islington CCG and local organisations
representing acute, mental health and third sector organisations. This Group reports into
the Integrated Care Board. The Board Assurance Group established for the procurement
will also oversee the procurement process and subsequent implementation. The
Governing Body received a report on governance arrangements in May 2015;
 How benefits realisation and risk management will be carried out. Risks and
mitigations are set out later in the report.
3. Delivery Assurance
In recognition of the materiality of the Integrated Digital Care Record (IDCR) and Person
Held Record (PHR) project in terms of support to delivery of our strategic objectives,
complexity of the project and supporting procurement, and financial impact (and risk) a
Governing Body IT Assurance Group has been established to oversee the procurement,
and implementation should the Governing Body approve the Full Business Case and
contract award.
Through the procurement process and development of the Full Business Case the project
team have been asked to provide further evidence on the delivery and sustainability of the
project by the Governing Body IT Assurance Group and others.
The questions have strengthened the procurement process, development of the Full
Business Case and mobilisation plans (should approval be given to go ahead).Responses
are summarised below:
Scalability
The approach to integration with existing and new systems is pivotal to the programme’s
approach. The scalability of the programme may extend to other CCG’s and organisations
across North Central London or beyond. The model approach to licensing and rollout
means that other organisations can join the programme if they wish based on sharing the
revenue costs of licensing, technical support and programme management.
Sustainability
The NHS Modernisation Agency defined sustainability as follows:
‘Sustainability is when new ways of working and improved outcomes become the norm. Not
only have the process and outcome changed, but the thinking and attitudes behind them
are fundamentally altered and the systems surrounding them are transformed in support. In
other words it has become an integrated or mainstream way of working rather than
something ‘added on’
The sustainability of the project requires a number of elements being in place linked directly
Page 11 of 20 to our project activities including:
 Creating champion and leads across organisations;
 ensuring executive sponsorship;
 Using the innovation the programme aims to deliver to define an effective
communications plan;
 Tracking delivery of key benefits;
 Undertaking evaluation and outcomes.
Risk Appraisal
The risk management approach is to:
 Ensure that potential risks are identified and managed;
 Review the risk register at least weekly;
 Proactively manage the mitigation and action plans for each risk;
 Ensure that risks are afforded a high degree of visibility throughout the Project and, if
appropriate, right up to the CCG Governing Board.
The risks are identified later in the paper and have been developed on an ongoing basis
through the governance structure.
Procurement
The approach identified by the procurement team included an options appraisal and
recommended an Open OJEU procurement approach with a contract length of 5 years; this
was chosen given that any supplier from across the entire information technology sector
could bid. Initial use of a framework approach did not yield a strong enough market
response to proceed. The OJEU compared favourably against the initial Framework
approach in the number of bids received.
Proposed Contract
The Model Services Contract (ICT) and the Combined Schedules, drafted by the Cabinet
Office, will form the basis of the terms and conditions contract. This was issued to suppliers
in the tender pack. The procurement and project team are currently in the process of
compiling the information required for the contract so that discussions with suppliers can
take place immediately after the award notice is made. The timetable for both procurement
and proposed contract is as follows:
OJEU Open Procurement and Timetable Dates Issue OJEU notice 27th February 2015 Supplier Day for Open Dialogue (1 Day) Additional Day arranged due to supplier demand 9th – 10th March 2015 Bidders Submission end date (12noon) 29th Apr 2015 (Extended from 15th April 2015) Evaluation Period 29th Apr ‐ 29th May Moderation Meeting ‐ Evaluation Panel agree shortlisted th
4 June 2015 Bidders for Interview/Presentation Supplier Presentations (1.5 Days) 11th ‐12th June 2015 Consensus Meeting (0.5 days) 12th June 2015 Post Presentation Clarification Period 17th June – 1st July 2015 Final Moderation 8th July 2015 Award Recommendation Report Completed 20th August 2015 Page 12 of 20 Contract Content Meeting 1st September 2015 Governing Body Meeting 9th September 2015 Contract Negotiation Meeting 10th September 2015 First Meeting with Preferred Supplier 14th September 2015 Contract Content Meeting 14th September 2015 Contract Negotiation Meeting 15th September 2015 Supplier Award and Project commencement (includes OJEU 21st September 2015 mandatory Standstill period which is a legal requirement) Contract Negotiation Meeting 22nd September 2015 Contract Negotiation Meeting 29th September 2015 Contract Negotiation Meeting 6th October 2015 Commence Weekly/Bi Weekly Supplier Meetings (Based on supplier preference) 12th October 2015 (TBC) Contract Signing 16th October 2015 (TBC) Evaluation Plans
An evaluation plan will be developed with suppliers that outline the key evaluation activities
and data activities that we may need to undertake, such as surveys.
Exit Strategy / Year 6
An exit plan will be put in place for any remaining assets to the programme such as
licensing agreements, any assets such as data and how this will be managed. This
requirement will also be included in the contract negotiation approach document which
outlines the key elements for definition in the contract. The exit plan will include any
remaining assets to the programme such as:
 licensing agreements,
 Data and how this will be managed.
 Risk assessment for patients currently using the system
 Developing individualised care plans for patients currently using the system
 Communication process for patients, staff and key stakeholders
 Process for dealing with patients not returning equipment/lost equipment
 Changes required to IT and reporting systems
 Any staff re-deployment
 Assets and any depreciation
 Risk assessments for health and social care staff using he system
 Loss of engagement with health and social care professions with loss of the system
 Loss of productivity and caseload capacity
 Documents and information created in the lifetime of the system such care plans
prior to removal of the system
 Management of any intellectual property
The exit plan has also been added to the project risk register, so that it is reassessed on a
regular basis.
Outline Project Plan / Deployment
The project will be managed through to implementation through the established multiagency Informatics Programme Steering Group has been established incorporating key
stakeholders from Islington Council, Islington CCG and local organisations representing
acute, mental health and third sector organisations. This Group reports into the Integrated
Care Board. The Board Assurance Group established for the procurement will also oversee
the procurement process and subsequent implementation. The Governing Body received a
Page 13 of 20 report on governance arrangements in May 2015;
A revised project deployment plan is attached in Appendix 4 which is based on the
assumption the procurement award recommendation is approved on the 9 September 2015
by the Islington CCG Governing Body
4. Mobilisation - How are we going to ensure that this IT Enabled Transformation
and Change Programme is Successful
The transformation approach for Islington CCG’s Integrated Digital Care Record Project
focuses on the intersection of:
 People – Who will use and manage the system;
 Technology – The Integrated Digital Care Record (IDCR) and the Person Held Record
(PHR);
 Processes – How the system will be used (who by, where and when).
In order to address the relationship between these three aspects of the project, the
transformation approach identifies six key elements we have put in place to ensure the
project to be successful.
Processes & Procedures
This work stream focuses on developing processes and procedures that ensure the correct
operation and maintenance of the system. The processes we develop will promote the
efficient use of the system, enabling users to complete routine tasks quickly and accurately.
They will also help users understand the relationship between different parts of the system
and why correct operation is important. The processes and guidance will be compiled into a
series of Standard Operating Procedures that will act as a reference for all categories of
user.
We will undertake this work in conjunction with the chosen supplier, drawing on their
subject matter expertise to ensure that the processes created are viable. We will start this
work in conjunction with the system design and configuration work. The primary output from
this work stream will be operating guidance documents for care professionals and citizens,
which will be shared with users pre-Go live.
We have established a technical working group to work operationally with stakeholders in
ensuring their contribution to the project technically and operationally:
On a technical level:
 we are asking providers to share the information about individuals by way of a data
tie which will involve one of back-loading of patients data;
 And maintenance of an ongoing data tie to provide updates and changes to patient
data directly into the IDCR and back to their own systems
On an operational level:
 We are asking providers to be part of the Informatics Steering Group, Information
Governance and Technical working groups
 We will be developing a change programme involving programme leads identified in
each organisation to enable to health and care system to access the benefits of the
IDCR and PHR
Engagement
Our engagement work stream has already started directly working with targeted groups of
potential end users to raise awareness of the project and to gain their buy-in into the
Page 14 of 20 projects objectives. Engagement is also being undertaken with key user communities and
representatives of local citizens via the Public & Patient Engagement Group. As well as
raising awareness, certain groups will give direct input into the development of the system
and its implementation. The Public & Patient Engagement Group and the Clinical & Social
Care Reference Group in particular which we have set-up will play a key part in this. By
directly engaging with end users across the spectrum, the project team significantly
increases the chance that the system will be successfully adopted.
The Public & Patient Engagement Group has held is inaugural meeting with excellent
attendance. The group will convene on a monthly basis and is made up of both local
citizens and third sector representatives. Informal discussions will also take place between
meetings. One of the first activities the group will undertake is identifying branding
requirements for the PHR, including selecting a more user-friendly name for the system.
We have also begun the work of reaching out to partner organisations to establish
relationships with key stakeholders at different levels. Partner organisations and interested
bodies are already represented on the Project’s steering group and have had significant
input into the procurement of the IDCR. A full stakeholder map has been development to
enable the effective targeting of key groups and individuals. Once on-board, the chosen
supplier will further assist with engagement by supporting roadshow events and other
promotional activities.
Communications
In order to reach out to an audience that is greater than we are able to directly engage with,
a significant amount of communications work will need to be undertaken by the project.
This will promote the system borough-wide, raising awareness of the value of the IDCR
initiative to all citizens and care professionals within the health economy.
We’ve drawn up a high level communications plan which we will refine with input from the
supplier, who will be bringing their own campaign materials. A number of different
communication channels have been identified as suitable, including the CCG’s public and
intranet sites as well as those of partner organisations, Twitter, local newspapers and NHS
publications, posters and leaflets displayed in public places and communal areas in partner
organisations, roadshows and direct email updates. We will also be working closely with
the CCG Communications Lead to leverage the work that already been undertaken in this
area.
Benefits Realisation
We have developed a strategy, framework and plan for approaching with the management
and delivery of benefits which has been agreed by the Project Steering Group. The
Benefits Realisation Plan will contain specific information regarding how the projected
benefits will be realised with clear measurement and tracking mechanisms. The proposed
method of tracking benefit realisation is through standard activity reporting, however we will
confirm this and further develop the approach in conjunction with the preferred supplier and
the wider partner network. For cash releasing and productivity benefits the metrics used to
determine the potential benefits will act as a baseline against which achieved benefits will
be measured.
The benefits stream of work has 4 key responsibilities: a) to identify additional benefits over
and above those outlined in the original business case, b) quantify and baseline the
benefits, c) develop benefits realisation plans for key groups of users, d) measure the
benefits derived from the systems implementation. The key value of the benefits work
stream to the project and to end users is that it will help identify what benefits can be
achieved and how these can improve the delivery of care for both care professionals and
Page 15 of 20 care recipients.
The chosen supplier will help support the benefits work stream by providing additional
benefits and suggesting opportunities to exploit these one the system is live.
Training & Education
The Project’s training and education work stream will be responsible for bringing together
much of the work of the other streams. Our trainers will be responsible for training partner
trainers in the use of the system so that they can effectively cascade that knowledge
throughout their own organisations. We will also develop educational materials for local
citizens to empower them to learn about the system at their own pace. The training and
educational materials provided will explain the features of the system but will also reinforce
the processes, guidance and benefits identified by the other areas of work.
Training is an area of the project where we will expect the chosen supplier to provide
significant support, both in terms of personnel to deliver training and training
courseware/collateral. To ensure educational materials reach as many users as possible,
we will develop a public-facing web portal for local citizens containing information about the
IDCR and PHR, including how to use the system, who to contact for support and how to
give/withdraw consent. This work will begin once the design and configuration stage of the
project comes to a close and structurally, the system is ready to populate with data.
Equalities
Potential suppliers have been asked to set out functionality in their solutions that supports
users with accessibility issues in line with the Equalities Act. The CCG, with Public Health,
is undertaking a digital inclusion audit to ensure all Islington residents can benefit from the
person-held record.
Suppliers have also been asked to provide detail that describes what features each solution
provides that supports users with accessibility issues, in line with the Equality Act.
Suppliers were additionally asked to describe what support they provide in terms of video
communications and sign language facilities in the PHR, the development path and
recommended solutions along with demonstrating these to the Evaluation Panel.
Suppliers have been asked to:
 Detail of what features supports users with accessibility issues, in line with the Equality
Act;
 Language of the IDCR solution;
 Provide detail that describes what features your solution provides that supports users
with accessibility issues, in line with the Equality Act. This to include what support they
provide in terms of video communications and sign language facilities in the PHR;
 If their proposal does not include any features, suppliers are asked to describe the
development path or recommended solution.
In addition to this, the Patient and Public Engagement group has now been established to
support the Person Held Record (PHR) Project from a public and patient end user
perspective. The Group will provide feedback on the development of the system and the
Project overall, including suggestions regarding design, functionality, access mechanisms
and data presentation. A key function of the Group will be to identify the most appropriate
means of raising awareness of the system and increasing its uptake post-deployment and
including equality and diversity requirements into patient aspects of the programme.
Page 16 of 20 Governance
We have identified a number of governance changes that will be required to support the
IDCR. These include new management structures and protocols that will need to be put in
place to ensure the system and the data it holds are managed appropriately. We are
exploring this through the Technical, Information Governance and Business Intelligence
Working Groups, who will be responsible for putting in place the correct controls to manage
the system once it’s operational. Risk management is a key component of all the working
groups and is assessed and examined across the project at every meeting.
We have already established the Technical Working Group and Information Governance
Working Group, which are meeting monthly and are working on pre-deployment activities
and looking at decisions that can be taken prior to the project commencing deployment. We
will launching the Business Intelligence Group once the project enters the contractual
period and the supplier is in a position to share their systems reporting schema. They will
also be expected to provide direction regarding the type of governance necessary to
correctly manage the system once it is in operation.
This report contributes to: All CCG strategic priorities
 Ensuring every child has the best start in life;
 Preventing and managing long term conditions to extend both length and quality of life
and reduce health inequalities;
 Improving mental health and wellbeing; and
 Delivering high quality, efficient services within the resources available.
Prior consideration by Committees and other partners:
The development of the business case for, the Integrated Digital Care Record (IDCR) and
Person Held Record (PHR) has been to the following Committees:
 Strategy and Finance Committee;
 Integrated Care Programme Board;
 The CCG Executive Management Team;
 CCG Chair’s Seminar;
 Governing Body Seminar;
 GP Forum;
 Islington Council Senior Management Team;
 Islington Pioneer Informatics Steering Group;
 Islington CCG Governing Body Assurance Group;
 PHR and IDCR Evaluation Panel;
 Islington Borough Health & Well Being Board.
The outline business case was approved the CCG’s Governing Body in September 2014.
In September 2014 it was agreed that if the Digital Tech funding was not available the
Governing Body would reconsider the case in the light of the availability of local funds for
the project.
On 27 August 2015 the CCG’s Strategy and Finance Committee recommended sign-off of
the FBC to the Governing Body on the basis set out above.
Page 17 of 20 Patient & Public Involvement (PPI)
This paper supports the wish of patients with long-term conditions for health and social care
professionals to share their data in order to better co-ordinate their care. The Council’s
‘Making it Real’ Board objectives, and national voices also puts sharing of data and using
technology to help them support themselves in managing their health and social care
needs.
As part of the development of the project, patient and carer representatives have been
invited to join the Programme Steering Committee, engaged in developing the minimum
data sets required to populate the Integrated Digital health and social care records, been
involved in ensuring the PHR meets their requirements and incorporated into the Output
Based Specification (OBS), and formed part of the stakeholder panel to evaluate supplier
responses and select a preferred provider.
The Engagement Team have consulted with patients on the idea of a patient held record
and commissioned Body and Soul and Age UK. Findings from these activities were
reviewed in the Islington Pioneer Informatics Steering Group.
A Patient and Public Engagement group has now been established to support the Person
Held Record (PHR) Project from a public and patient end user perspective. The Group will
provide feedback on the development of the system and the Project overall, including
suggestions regarding design, functionality, access mechanisms and data presentation. A
key function of the Group will be to identify the most appropriate means of raising
awareness of the system and increasing its uptake post-deployment.
Other key objectives include: • Provide input to PHR development, focusing on content and
usage • Give a citizens perspective on key topics associated with the PHR including:
security, confidentiality and accessibility • Consider the practical implications of the PHR for
Islington citizens • Identify ways of raising awareness of the PHR • Evaluate and test PHR
prototypes • Give input into the deployment approach, particularly around Go Live support
and considerations
Equality Impact Assessment:
Potential suppliers have been asked to set out functionality in their solutions that supports
users with accessibility issues in line with the Equalities Act. The CCG, with Public Health,
is undertaking a digital inclusion audit to ensure all Islington residents can benefit from the
person-held record.
Suppliers have also been asked to provide detail that describes what features each solution
provides that supports users with accessibility issues, in line with the Equality Act.
Suppliers were additionally asked to describe what support they provide in terms of video
communications and sign language facilities in the PHR, the development path and
recommended solutions along with demonstrating these to the Evaluation Panel.
Page 18 of 20 Risks
The main risks and mitigating factors for the Full Business Case are summarised in the
table below:
Risk Risk Mitigation High percentage of patients choose to opt out Development and execution of a robust thereby reducing the achievement of potential communications and engagement plan system benefits If a proprietary solution is identified as the preferred option later in the project, partners may require a larger number of patients than are present in the Islington area If a proprietary solution is chosen, it may be necessary to look for opportunities to partner with neighbouring boroughs to meet minimum patient thresholds There is a risk of reputational damage if the solution does not perform in the manner intended or technical problems prevent the solution working Ensure that the contract with a partner(s) is constructed so that the risk that the solution is built to specification and technological risks are borne by the partner. Future organisational changes within the NHS mean that existing organisations such as Islington CCG change As the number of patients/citizens that connect and share data grows and becomes large, there is greater opportunity for data to leak There is a risk of the system being too open and patients share data more widely than has been traditional in a clinical context Vulnerable patients may feel under pressure to share data or have data shared, whilst having little control themselves; e.g. domestic violence Legacy organisations continue to own the system but any new organisation will be able to utilise the functionality provided A robust Consent and Information Governance Model will be put in place along with strong controls over accreditation for systems that connect with the PHR Communications will make patients aware of the implications of sharing records but it will ultimately be their decision Patient safety will be ensured by working with clinicians and patient groups to agree standards to protect vulnerable individuals RECOMMENDED ACTION:
The Governing Body is asked to APPROVE the Full Business Case for the Integrated
Digital Care Record (IDCR) and Person Held Record (PHR) which provides business
intelligence and interoperability across Islington health and social care services on the
basis that:
 Initial build costs are funded;
 The residual funding gap, £204k per annum, will be covered by the actions listed below.
Work is underway to close this funding gap through the following actions:
 Broadening the population base, and therefore spreading the cost base, for the
procurement, with Haringey CCG and Enfield CCG potentially interested in procuring the
IDCR and PHR. Other CCGs would make a contribution to the build costs and on-going
revenue costs, with a potential unit price reduction for scale from the provider;
 Further realisation of benefits in particular from the change in business intelligence the
Page 19 of 20 IDCR and PHR will provide for contract management and service redesign;
 A targeted approach to roll-out of the PHR to people with complex health and care needs
to maximise the pace of benefits realisation and slow the costs of licences (the base
case for the FBC is based on a roll-out of the PHR for an average Islington resident);
 Recurrent use of Better Care Funds to support on-going costs.
On 27 August 2015 the CCG’s Strategy and Finance Committee recommended sign-off of
the FBC to the Governing Body on the basis set out above.
SUPPORTING PAPERS:
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Appendix 1 (4.3.1.1) – Source and Application of Funds
Appendix 2 - Full Business Case (available on request)
Appendix 3 (4.3.1.2) - Delivery Functionality Checklist from Final Moderation
Appendix 4 (4.3.1.3) - Revised Project Plan
Appendix 5 (4.3.1.4) –Frequently Asked Questions to accompany the IDCR & PHR
Full Business Case and Procurement Recommendation Report
Page 20 of 20