This time last year, there was no global picture of just how the NHS was going to cope with the year 2000 information technology bug. Any scenario was possible for the critical time of midnight on new year's eve 1999 - ranging from complete meltdown to the ultimate anti-climax of nothing untoward happening at all.
Since then there has been a year of frantic activity by trusts and health authorities, stern-sounding circulars from Quarry House, and all NHS bodies have faced a rigid schedule of quarterly self-assessments and independent checks by the Audit Commission. There's still a long way to go, but now there is a route map. What does it show?
Nick Atkins, IT manager at Oxford's John Radcliffe Hospital, says: 'There is a sense here that most of the IT issues are mopping themselves up, though obviously we still have work to do.'
The hospital suffered a minor disaster one Sunday in November, when the telephone switchboard failed for a whole day while engineers were trying to upgrade it to year 2000 compatibility (news, page 8, 26 November).
But there is now a shift of emphasis, says Mr Atkins. 'It's beginning to dawn on people that the staffing problem over the meltdown period is the real problem we have to face now.'
The combined effect of demand for holidays and increased sick leave, on top of the inevitable staff shortages, always stretch IT support teams to their limit - in a season when patient demand on the service is at its peak.
But this time, there is a danger that the limits will be overstepped. For one thing, says Mr Atkins, it is far from certain that over the coming year trusts will be able to retain even the often minimal IT staffing levels they have currently.
'There's always been a steady turnover of people in IT support departments, who often leave the service to search for bigger bucks in the world of commerce.
'We haven't yet seen any big increase in the numbers leaving, but what we have found in the last six months is that it is becoming increasingly difficult to recruit replacements. And it's not just Radcliffe - I know that other trusts are having the same problem.'
Wirral Hospital, an acute trust with a turnover of£108m which has spent about£1.2m on hardware, software and retraining, is already short of programmers. But it was ready to meet the critical systems deadline of 31 December. The hospital's major information management and technology problem is its pioneering electronic patient record system, which is now central to the care process.
Paul Charnley, head of the trust's year 2000 programme, says: 'We have had to ensure that staff can easily revert to the down-time manual processes. But we have run through the millennium change and are confident the electronic patient records will work.'
But he is concerned about continuity and emergency planning. Wirral runs its major IT systems from the IBM data centre in Warwick, so it is totally dependent on the utilities to maintain this communications link. 'BT/Mercury is not willing to give us a cast-iron guarantee, and we have been told to plan for a few hours of power supply problems. It's a worry. But at least that's better than the few days they were telling us about earlier this year.'
The trust is still negotiating rates for staff during the millennium period and so does not know what its operational costs will be.
Howell Huws, director of IT at Hammersmith Hospitals trust, is sanguine about the state of affairs. 'We have no real systems concerns now, and I don't think we need any further help to get it sorted out. We are pretty sure we will get through the century change unscathed.'
In fact, Mr Huws is somewhat unusual in that he has no complaints about the way the programme has been handled. The trust is well ahead with its compliance targets. 'Our September self-assessment returns (to the regional office) were pretty good - we are in the upper quartile of trusts. And we submitted our complete draft compliance plans two months ago.'
These plans - which all trusts and HAs had to submit to the regions by 31 December - specify exactly how each organisation intends to solve or defuse all its year 2000 problems before the final deadline of 30 September this year.
'We now have contingency plans for every piece of equipment that might fail,' says Mr Huws. 'Even if we have assessed something as highly unlikely to fail, if it's critical to patient care then there will still be a plan allowing us to cope if it does go wrong. So we aren't expecting any last- minute panics.'
Hammersmith's location poses special problems. Being in the middle of a densely populated metropolitan area means its disaster contingency planning must tie in closely with those of many neighbouring organisations.
'Our district - covering Ealing, Hammersmith, Hounslow and Chelsea - has a joint-planning group that has met every two months for the past year to share information and develop communications protocols for use on The Night. For example, we are very closely co-ordinating our discharge planning with the social services people.'
Like many other trusts, it is also planning to
make sure inpatient numbers are as low as
possible in advance of the critical night - partly because of the expected higher than usual casualty rate and partly to guard against internal or external system failure. But here, too, there is still much uncertainty about staffing.
John Wilshire, director of IM&T at West Berkshire Priority Care Services trust, says: 'At the moment we are expecting the workload to be within the bounds that we can cope with. Assuming that things stay as they are, we've put enough limitations on our people to ensure that we won't be short of staff - there are people we aren't allowing to have leave who normally would get leave at that time of year.'
But he adds: 'It's a chicken and egg problem. Obviously, whatever the staffing requirement is, we will aim to meet it. But until we know for sure what staffing will be needed we can't plan for definite.
'As yet we haven't encountered particular problems on IT staff turnover or recruitment, but it's certainly something we are going to be watching for during 1999.'
Another unknown is just what level of service trusts will be expected to deliver. 'We are planning on the assumption that there will be more pushing people out of hospital a bit earlier than usual, but no huge changes. Of course, if there is a directive next year telling hospitals to get bed occupancy down by 50 per cent, then all that would have to change.'
As a non-acute trust, West Berkshire is relatively low-technology, with few medical devices to worry about, and Mr Wilshire is fairly happy about his
inhouse IT systems. 'We've had some issues and there's no room for complacency, but it's all in hand,' he says.
Investment of time and money
The trust, which has a turnover of£57m, is spending£300,000 to correct its year 2000 problems - half of it in 1999 alone. 'That doesn't include all the time we've spent on it - I have had 15 to 20 people working on the project across the trust. But it's quite a modest total, I'd say.
'Some trusts I know of have put in quite adventurous bids for upgrading all their PCs, for example, but we've not gone for that. We have mostly looked to replace equipment where we can get other long-term benefits at the same time as getting year 2000 compliance.'
Instead, Mr Wilshire's main worry is service planning in the almost total absence of any guidance on the level of the external risks. 'There certainly is a measure of concern about contingency planning. We started it six months ago, but there is such a lot to do. It is going to need several iterations to get it right.'
What he needs, he says, are some 'risk tables' to give a quantitative indication of the probabilities of certain events. 'For example, what's the risk of the local power grid going down? Is it one in a million, or one in 10 million?'
A clearer danger, he thinks, is an overload of the public telephone network as everyone phones their friends and families.
'I'm trying to get social services and the health authority to document some risk tables on these issues, so that (if challenged after the bug strikes) we can show that we were acting reasonably at the time.'
But at least there is some hope that the software problem is largely resolved and the great majority of embedded chips in electrical equipment will not fail. Clive Colley of University College Hospital, London, estimates that, of 200 IT systems in the trust, and 10,000 items of electrical equipment, only 200 need to be modified or replaced.
Of course, one of the main worries was always that the degree of year 2000 compliance of most software was, or is, not so much lacking as simply unknown. Several key systems have turned out to be essentially compliant.
Mik Horswell is project manager of the national user group for the IRC PAS software - the ICL-designed patient administration system now supported by Siemens Healthcare Systems, which still has a user base of about 40 hospitals, mostly in the north of England. The group has been working with Siemens to 'witness test' the year 2000 compliance of IRC's latest release of software, which is in a beta test site now.
'Our report shows the software is year 2000 compliant as far as witness testing can demonstrate,' says Horswell. 'Since this PAS software is one of the originals, and therefore a good example of the potential for year 2000 problems, I'd say this is good news.'
The Audit Commission is rather more wary about the situation than the NHS itself. Its latest update on the service's year 2000 programme noted that 70 out of the 95 trusts it audited most recently had failed to reach satisfactory levels of compliance checking.1
'The performance gap between best and worst is quite large,' says Keith Dixon, one of the report's authors. 'Even the best performers have much to do, but some have an awful lot more to do than others.'
'There is only a small window between now and the summer in which the NHS can catch up', he says. 'Any bodies that delay further are going to find their choices more and more restricted. For example, if they are going to need to organise a standby power generator, they need to know that now, not late in 1999. It'll be too late by then.'
One daunting task - especially for heads of acute and ambulance trusts - is to 'develop a communications strategy for managing public concerns'. That is not going to be easy if - as seems likely - hysteria mounts through the second half of the year. More system failures are certain to occur during 1999 due to the 12-month forward date problem, especially in some of the older forecasting, budgetary and ledger programmes.
These have a month-end roll-forward function, and which generate dates 12 or 13 months in the future. In some cases this is going to render the software useless.
If there are many such failures, the public perception of the problem is going to be fuelled by panic. It will not be helped by the recent ministerial suggestion that the Territorial Army might be needed to combat millennium bug-triggered anarchy in the UK, or the reported advice from Gwynneth Flower, head of the government's own bug advisory body Action 2000, that people should stock up on food before the bug strikes.
The NHS is a prime candidate for this sort of paranoia. It looks like a tough year for hospital public relations departments.