{"id":1528,"date":"2018-05-30T10:10:09","date_gmt":"2018-05-30T09:10:09","guid":{"rendered":"https:\/\/ealingsaveournhs.org.uk\/?p=1528"},"modified":"2018-05-30T10:11:43","modified_gmt":"2018-05-30T09:11:43","slug":"the-ealing-mcap-debacle","status":"publish","type":"post","link":"https:\/\/ealingsaveournhs.org.uk\/?p=1528","title":{"rendered":"The Ealing MCAP Debacle"},"content":{"rendered":"

\u201c<\/i>You couldn\u2019t make it up, and I haven\u2019t.\u201d<\/i><\/strong><\/h3>\n

 <\/p>\n

A bizarre and costly disaster took place recently in Ealing\u2019s NHS. \u00a0<\/span><\/p>\n

 <\/p>\n

In an effort to do the un-doable, Ealing\u2019s health bosses hired a private American firm called Finnamore to \u2018fix\u2019 what they claim is the overuse of hospital beds. \u00a0<\/span><\/p>\n

 <\/p>\n

Here legendary researcher Colin Standfield lifts the lid on what actually happened, using his usual dry humour and focus on facts. Colin shows that the people who are now offering a billion-pound contract for our Out Of Hospital services really don\u2019t know what they are doing.<\/span><\/p>\n

 <\/p>\n

The Ealing MCAP Debacle<\/b><\/h3>\n

 <\/p>\n

What is MCAP?<\/b><\/p>\n

 <\/p>\n

Better start with a definition, or we\u2019ll get nowhere: MCAP seems to mean <\/span>Medical Care Appropriateness Protocols<\/span><\/i>, expanded as \u2018care planning co-ordination software to ensure patients receive care in the appropriate setting\u2019. \u00a0Sometimes it is <\/span>Making Care Appropriate to Patients<\/span><\/i> which, curiously, is what I thought doctors usually did.<\/span><\/p>\n

 <\/p>\n

It is a software tool designed to find the best place for patients to be, they say. \u00a0It was designed by The Oak Group, now part of Finnamore Oak. This is, in turn, part of GE, the American conglomerate which, among many other wonderful things, also produces the engines for the A-10 \u2018Warthog\u2019 Close Air Support fighter jet.<\/span><\/p>\n

 <\/p>\n

The Oak website says: \u2018Making Care Appropriate for Patients (MCAP) is the Oak Group\u2019s Clinical Utilisation Review (CUR) tool\u2019. \u00a0<\/span>http:\/\/www.oakgroup.com\/wp-content\/uploads\/2015\/08\/Oak_Implementing.pdf<\/span><\/a><\/p>\n

 <\/p>\n

Why was MCAP needed?<\/b><\/p>\n

 <\/p>\n

Two things were going on: \u00a0first, the flawed <\/span>Shaping a \u2018Healthier\u2019 Future<\/span><\/i> plans to close 4 A&Es in NW London and make \u00a31 billion of savings required a massive and heroic shift of tens of thousands of patients from acute, hospital-based care and into the community \u2013 the so-called out-of-hospital (OOH) experience \u2013 and the pointy-heads were desperate to find ways of doing it. \u00a0Secondly, it was \u2018known\u2019 that a high proportion of patients in A&E \u2018did not need to be there\u2019. According to the Project Initiation document*, MCAP would give the local NHS \u2018The ability to identify patients in the Acute setting that could be treated elsewhere.\u2019<\/span><\/p>\n

 <\/p>\n

The Myths<\/b><\/p>\n

 <\/p>\n

This all hung on two myths: that home was a better place to be than hospital and that there really were all those people in A&E who shouldn\u2019t be.<\/span><\/p>\n

 <\/p>\n

The <\/span>Shaping a Healthier Future<\/span><\/i> Consultation Document in July 2012 said on page 4: <\/span>We know that increasing the amount of care delivered closer to your home will help care to be better co-ordinated, and improve the quality of that care and its value for money<\/span><\/i>. \u00a0It didn\u2019t say how they knew that or what it meant. \u00a0If you are an NHS suit living in a leafy suburb with a devoted spouse, your own bed probably looks quite a good idea; \u00a0less so if you are stranded alone in a high-rise and the kid next door spends all day blasting out <\/span>The Best of Metallica<\/span><\/i>, even if you do like <\/span>Fade to Black<\/span><\/i>.<\/span><\/p>\n

 <\/p>\n

I am not sure that there has ever been a proper analysis of the costs, cost savings and clinical benefits of caring for people at home; \u00a0the idea that a succession of healthcare professionals will tour a neighbourhood taking bloods, checking vital signs, changing dressings, monitoring drugs and assuring patients\u2019 well-being seems expensive. \u00a0Or even a team of multi-skilled single practitioners \u2013 we are talking about thousands of earlier-than-usual discharges and other don\u2019t-need-to-be-theres, about 99,000 by 2025. Further problems are transport, parking, lone working policies, and the carbon footprint of the number of car journeys (they will not be taking medical bags with drugs onto the buses).<\/span><\/p>\n

 <\/p>\n

There have been various numbers placed on the \u2018don\u2019t need to be there\u2019 hospital group:<\/span><\/p>\n

 <\/p>\n

One in three people turning up at A&E have problems that were minor, and did not need the care of emergency doctors, the Health Secretary said.\u00a0(<\/span>Telegraph\u00a0<\/span><\/i>Online, 9 January 2017 at\u00a0<\/span>https:\/\/www.telegraph.co.uk\/news\/2017\/01\/09\/live-jeremy-hunt-makes-emergency-statement-nhs\/<\/span><\/a>)<\/span><\/p>\n

 <\/p>\n

Around 1.5million patients taken to A&E could have been treated in the community by GPs, nurses or at walk-in centres, if there was better provision.\u00a0(<\/span>Mail<\/span><\/i>\u00a0Online, 2 March 2018, at\u00a0<\/span>http:\/\/www.dailymail.co.uk\/news\/article-5452379\/A-quarter-visits-E-not-necessary.html#ixzz5C0OUkswv<\/span><\/a>)<\/span><\/p>\n

 <\/p>\n

Half of the capital’s A&E attendances unnecessary, report suggests.\u00a0 (<\/span>Health Service J<\/span><\/i>ournal headline, 1 June 2011, at\u00a0<\/span>https:\/\/www.hsj.co.uk\/bolton-pct\/half-of-the-capitals-aande-attendances-unnecessary-report-suggests\/5030392.article<\/span><\/a>)<\/span><\/p>\n

 <\/p>\n

Talking on Radio 4\u2019s\u00a0<\/span>Today<\/span><\/i>\u00a0programme, the health secretary said that there was a need to recognise A&E was for accidents and emergencies, with GPs based in the departments seeing the 40% of A&E patients who don\u2019t need emergency care. (9 January 2017, at\u00a0<\/span>http:\/\/www.pulsetoday.co.uk\/news\/commissioning\/commissioning-topics\/urgent-care\/gps-in-ae-and-care-homes-can-cut-unnecessary-attendances-says-hunt\/20033593.article<\/span><\/a>)<\/span><\/p>\n

 <\/p>\n

\u2018A staggering\u00a0<\/span>80% of patients<\/b>\u00a0[their emboldening] who visited A&E units did not actually need to be there\u2019\u00a0 (Chief Executive of NHS Wales, Dr Andrew Goodall, 7 July 2016, at\u00a0<\/span>http:\/\/www.nowgp.com\/blog\/ae-visits-wales-nhs\/<\/span><\/a>;\u00a0\u00a0also referenced at\u00a0<\/span>http:\/\/www.bbc.co.uk\/news\/av\/uk-wales-36728265\/nhs-wales-faces-pressure-all-year-dr-andrew-goodall-says<\/span><\/a>)<\/span><\/p>\n

 <\/p>\n

\u2018It has been thought that up to six in ten patients attending A&E departments do not need to be there and could instead be treated at walk-in centres, minor injuries units or health centres.\u2019 (Dr John Heyworth, President of the College of Emergency Medicine), at<\/span><\/p>\n

https:\/\/www.telegraph.co.uk\/news\/health\/news\/7644567\/Do-not-downgrade-AandEs-president-of-college-of-emergency-medicine.html<\/span><\/a>)<\/span><\/p>\n

 <\/p>\n

But<\/b> Dr Heyworth: \u2018described the idea that 60 per cent of people did not need to be in A&E as a ‘fiction’.\u2019<\/span><\/p>\n

 <\/p>\n

Whether it is 15% or 80%, it is still a myth: it is only after skilled clinical examination that the need is apparent or not \u2013 a headache could be a migraine or it could be a subdural haematoma; \u00a0a rash could be a minor irritation or it might just be meningitis. I don\u2019t think we\u2019ll ever get to the stage where the population can safely triage itself and until somebody funds all GPs to be open 12 hours a day for 7 days a week (and finds enough GPs to go round in the first place), the obvious place to go, for safety, will be A&E.<\/span><\/p>\n

 <\/p>\n

OK, there <\/span>are<\/i><\/b> people who go to A&E because they have run out of aspirins, but anybody who wants to wait for 4 hours to get what a corner shop could provide probably needs some other kind of help.<\/span><\/p>\n

 <\/p>\n

MCAP at Ealing Hospital<\/b><\/h3>\n

 <\/p>\n

    \n
  1. The Lead-Up<\/b><\/li>\n<\/ol>\n

     <\/p>\n

    Volume 5 of the <\/span>Shaping a Healthier Future<\/span><\/i> Decision-Making Business Case (DMBC) of February 2013 said, in the Ealing Commissioning Intentions, <\/span>Furthermore, to facilitate this work, we are keen that acute hospitals in NW London review the benefits of and adopt the use of MCAP decision support tool (or similar system). The system is designed to enable acute trusts to accurately assess risk and to make informed decisions about not admitting patients (in A&E) and about timely discharges.<\/span><\/i><\/p>\n

     <\/p>\n

    We believe the system shows great potential and would provide a significant contribution to help the wider health economy to ensure patients are seen in the appropriate care setting. It also allows the systematic collection of data about service demand which in turn would constitute an invaluable source to inform commissioning and service development decisions.<\/span><\/i><\/p>\n

     <\/p>\n

    We understand that for a decision support tool like MCAP to be effective it would need to be rolled out across all NW London hospitals. We have asked for NW London cluster support in driving this forward. In the meantime, we are keen to work with EHT <\/span><\/i>[Ealing Hospital Trust] <\/span>to become the pilot site for NW London<\/span><\/i>. (page 133)<\/span><\/p>\n

     <\/p>\n

    So it was important for the Decision Making Business Case, and <\/span>Shaping a Healthier Future<\/span><\/i> wanted to foist it on Ealing Hospital. \u00a0In fact, the Minutes of the Ealing CCG Governing Body meeting of 22 May 2013 record: \u201c<\/span>The project is linked to CQUINs and will lead to financial penalty if not implemented by the trust<\/span><\/i>.\u201d \u00a0A Freedom of Information reply in March this year said: \u2018SaHF thought\u00a0that this could be a major tool\u00a0to deliver the acute activity reductions needed through improved care pathways. SaHF led the procurement process to appoint them and SaHF provided the funding.\u2019<\/span><\/p>\n

     <\/p>\n

    The scheme was presented by Kevin Atkin, Deputy Director Strategy Transformation Team, who had also sat on the 7-person panel that approved the winning Finnamore Oak bid.<\/span><\/p>\n

     <\/p>\n

    By coincidence, the following year he was a Director of Finnamore and the year after that he was seconded back to NHS NWL under a GE Healthcare Finnamore\u00a0contract valued at \u00a349,000.<\/span><\/p>\n

     <\/p>\n

    The decision was made \u2013 MCAP was coming to Ealing.<\/span><\/p>\n

     <\/p>\n

      \n
    1. Procurement<\/b><\/li>\n<\/ol>\n

       <\/p>\n

      The tender was advertised on 7 March 2013 through a Southampton-based outfit, Solent Supplies (\u2018our procurement specialists\u2019) for a mere 10 days \u2013 I have found no-one who can believe such a short time frame for a quarter-million pound contract, but it was \u2018the recommended 10 working days\u2019. \u00a0When I asked who recommended it, the response to a Freedom of Information request was: <\/span>\u201cThis is not documented\u201d.<\/span><\/i> \u00a0Very handy!<\/span><\/p>\n

       <\/p>\n

      Surprisingly, there was only one bid, from Finnamore, and it was approved on 4 April. \u00a0Perhaps all the others were delayed in the post. The CCG Governing Body was being asked to rubber-stamp this deal in May.<\/span><\/p>\n

       <\/p>\n

      Nobody bothered to check three important things: <\/span>ONE: <\/b>Did the cost figures in the Bid document add up (they didn\u2019t). \u00a0<\/span>TWO:<\/b> Did the software match the NHS computer systems (it didn\u2019t). \u00a0<\/span>THREE: <\/b>How much time would be spent by front-line nursing staff just to gather the data on their hand-held computers? \u00a0Who would have known? Well, I could have told them: taking the 8,000 patients attending Ealing A&E each month (I used the 8,265 in July, when I expected the scheme had started) and allowing, as Mr Atkin said, 3 to 4 minutes for each, you arrive at a total of between 413 and 551 hours. \u00a0<\/span>10 to 14 working weeks<\/b>. \u00a0Just to put the data in. \u00a0That\u2019s somewhere between \u00a37,500 and \u00a310,000 a month.<\/span><\/p>\n

       <\/p>\n

      But it was a done deal.<\/span><\/p>\n

       <\/p>\n

        \n
      1. Implementation<\/b><\/li>\n<\/ol>\n

         <\/p>\n

        Here\u2019s where it gets hazy. \u00a0It looks like the start was delayed: \u00a0it was meant to \u2018go live\u2019 on 12 August but that was put back to w\/c 26 August; \u00a0that slipped as well, owing to <\/span>the planned physical demographic link<\/span><\/i> (no, me neither) taking longer than estimated. \u00a0A <\/span>supported soft GO LIVE in w\/c 16 September<\/span><\/i> was mooted in the 4th MCAP Steering Committee notes of 2 September.<\/span><\/p>\n

         <\/p>\n

        Ten of the twenty Action Points in those Minutes were flagged as <\/span>\u2018show stoppers\u2019 if they are not resolved by GO LIVE<\/span><\/i>. \u00a0There is no record of when GO LIVE happened, soft or otherwise, but by December there were still problems with training, staffing, MCAP process flow and data. \u00a0The Notes from a 10 December meeting include lines such as: <\/span>The ED department continues to have issues with unfilled nursing shifts\u2026<\/span><\/i>, <\/span>organising<\/span><\/i> extra nursing shifts may prove to be difficult\u2026<\/span><\/i>, <\/span>Users are complaining\u2026<\/span><\/i>, <\/span>A crucial bit of information that is missing is the report on \u2018service intensity\u2019\u2026<\/span><\/i><\/p>\n

         <\/p>\n

        A plan to implement MCAP in one of the hospital wards was abandoned owing to \u2018winter pressures\u2019.<\/span><\/p>\n

         <\/p>\n

        I had heard that MCAP lasted no more than 6 months and my enquiries at the Hospital turned up one particular response \u2013 I apologise for the technical language: \u2018Oh god! \u00a0That dreaded thing. V expensive booking nurses to just enter data in. Should be used live on the shop floor but takes too long.\u2019<\/span><\/p>\n

         <\/p>\n

        When I finally got a response under Freedom of Information after nearly 3 months the answer was startling, even for me. \u00a0The first two paragraphs are, including a bit you\u2019ve already seen:<\/span><\/p>\n

         <\/p>\n

        \u201cThe US team that developed MCAP were commissioned initially either by\u00a0<\/span><\/i>SaHF (Shaping a Healthier Future)<\/span><\/i><\/a>\u00a0or the CCG who did a relatively small audit that concluded that we had some patients where admission could have been avoided. SaHF were keen then to introduce the methodology as a real time decision support programme \u2013 as opposed to just providing an audit.<\/span><\/i><\/p>\n

        \u00a0<\/span><\/i><\/p>\n

        SaHF thought\u00a0that this could be a major tool\u00a0to deliver the acute activity reductions needed through improved care pathways. SaHF led the procurement process to appoint them and SaHF provided the funding<\/span><\/i>.\u201d<\/span><\/p>\n

         <\/p>\n

        Paragraphs 4 and 5, with my emboldening, have to be quoted in full:<\/span><\/p>\n

         <\/p>\n

        \u201cThere were a couple of trial periods lasting a few weeks where the system was intermittently being used but <\/span><\/i>very little useful data came from it<\/i><\/b> and after a period of time The Trust ceased to interact with the MCAP team.<\/span><\/i><\/p>\n

        \u00a0<\/span><\/i><\/p>\n

        Although the pilot phase did not generate a lot of information the monies were of the order of magnitude suggested – in part that was due to <\/span><\/i>the need to backfill some of the frontline senior nursing staff for shifts to free them up to enter data<\/i><\/b>. That was also one of the reasons <\/span><\/i>the whole project was felt not to be transferrable to our systems<\/i><\/b> as the <\/span><\/i>IT did not integrate with our clinical systems<\/i><\/b> and needed bespoke clinical data entry thus <\/span><\/i>making it very expensive to run<\/i><\/b>. Also the system had been developed in USA and many of the \u2018decisions\u2019 coming from it <\/span><\/i>did not fit UK practice<\/i><\/b>.\u201d<\/span><\/i><\/p>\n

         <\/p>\n

        The 7th paragraph concludes:<\/span><\/p>\n

         <\/p>\n

        \u201cLondon North West Healthcare Trust did not then pay anything further as the project was pulled after 3-6 months<\/span><\/i>.\u201d<\/span><\/p>\n

         <\/p>\n

        All of the paperwork has gone missing apart from the two sets of Meeting Notes and an Agenda for a 14 November meeting.<\/span><\/p>\n

         <\/p>\n

        Despite this abject failure, Finnamore were awarded a further \u00a395,200 contract in the December for \u2018MCAP implementation support \u2013 extension\u2019, even though the bid document clearly included <\/span>The total cost to implement at Ealing Hospital including change management, training and the system licence\/connectivity to required systems for 1 year is \u00a3249,000. \u00a0<\/span><\/i>And even though (or perhaps because) the wheeze was still beset by problems.<\/span><\/p>\n

         <\/p>\n

        \u00a3344,200 all up, plus expenses of up to 8%. \u00a0Money well spent. I\u2019m sure you\u2019ll agree.<\/span><\/p>\n

         <\/p>\n

          \n
        1. Results<\/b><\/li>\n<\/ol>\n

           <\/p>\n

          None.<\/span><\/p>\n

           <\/p>\n

          At least, none in response to my detailed FoI request.<\/span><\/p>\n

           <\/p>\n

            \n
          1. Aftermath<\/b><\/li>\n<\/ol>\n

             <\/p>\n

            By happy coincidence, Finnamore data are still being used to try to breathe life into the dead horse that is the NW London <\/span>Strategic Outline Case<\/span><\/i>.<\/span><\/p>\n

             <\/p>\n

            The organisation that committed to this monumental folly is the one which is now proposing to spend between \u00a3500 million and \u00a31 billion of <\/span>our money<\/span><\/i> on a Single Provider contract for Ealing.<\/span><\/p>\n

             <\/p>\n

            You couldn\u2019t make it up, and I haven\u2019t.<\/span><\/p>\n

             <\/p>\n

            Colin Standfield<\/span><\/p>\n

            17 May 2018<\/span><\/p>\n

             <\/p>\n

            * <\/span>http:\/\/www.ealingccg.nhs.uk\/media\/1630\/Paper-11a-EHT-ECCG-MCAP-PID-v2.pdf<\/span><\/a><\/p>\n

             <\/p>\n

            Freedom of Information request in full:<\/span><\/p>\n

             <\/p>\n

            Under the terms of the Freedom of Information Act, please tell me, for the year 2013 to 2014:\u00a0<\/span><\/i><\/p>\n

            \u00a0<\/span><\/p>\n

              \n
            1. How many patients were assessed using the MCAP software at Ealing Hospital?\u00a0<\/span><\/i><\/li>\n
            2. How many were adjudged to be better suited to a different setting of care?\u00a0<\/span><\/i><\/li>\n
            3. How many were successfully transferred to that setting?\u00a0<\/span><\/i><\/li>\n
            4. What was the cost per patient of the transfers?\u00a0<\/span><\/i><\/li>\n
            5. What were the clinical or convalescent benefits to the transferred patients, using patient-reported measures?\u00a0<\/span><\/i><\/li>\n
            6. What were the net cost savings as a direct result of the use of MCAP?\u00a0<\/span><\/i><\/li>\n
            7. What were the total bed occupancy savings as a direct result of the use of MCAP?\u00a0<\/span><\/i><\/li>\n<\/ol>\n

              \u00a0<\/span><\/p>\n

              For the years 2014 to 2015 onwards, please tell me:\u00a0<\/span><\/i><\/p>\n

              \u00a0<\/span><\/p>\n

                \n
              1. How many times was the annual \u00a360,000 software licence extended and paid for at Ealing Hospital?\u00a0<\/span><\/i><\/li>\n
              2. How many patients were assessed and how many transferred in each of those years?\u00a0<\/span><\/i><\/li>\n
              3. How many nurses were recruited specifically to administer the software?\u00a0<\/span><\/i><\/li>\n
              4. How many other Hospitals in NW London used the software, and over what periods?\u00a0<\/span><\/i><\/li>\n
              5. What are the net cost savings across NW London as a direct result of using the MCAP software?\u00a0<\/span><\/i><\/li>\n<\/ol>\n

                \u00a0<\/span><\/i><\/p>\n

                 <\/p>\n","protected":false},"excerpt":{"rendered":"

                \u201cYou couldn\u2019t make it up, and I haven\u2019t.\u201d   A bizarre and costly disaster took place recently in Ealing\u2019s NHS. \u00a0   In an effort to do the un-doable, Ealing\u2019s health bosses hired a private American firm called Finnamore to \u2018fix\u2019 what they claim is the overuse of hospital beds. \u00a0   Here legendary researcher 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Standfield","author_link":"https:\/\/ealingsaveournhs.org.uk\/?author=18"},"uagb_comment_info":0,"uagb_excerpt":"\u201cYou couldn\u2019t make it up, and I haven\u2019t.\u201d   A bizarre and costly disaster took place recently in Ealing\u2019s NHS. \u00a0   In an effort to do the un-doable, Ealing\u2019s health bosses hired a private American firm called Finnamore to \u2018fix\u2019 what they claim is the overuse of hospital beds. \u00a0   Here legendary researcher…","jetpack-related-posts":[],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=\/wp\/v2\/posts\/1528","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=\/wp\/v2\/users\/18"}],"replies":[{"embeddable":true,"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1528"}],"version-history":[{"count":1,"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=\/wp\/v2\/posts\/1528\/revisions"}],"predecessor-version":[{"id":1530,"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=\/wp\/v2\/posts\/1528\/revisions\/1530"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=\/wp\/v2\/media\/1529"}],"wp:attachment":[{"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1528"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=1528"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/ealingsaveournhs.org.uk\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=1528"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}