A Healthy Result

Continued

A Moving Target

Unifying 67 independent, aging systems was just one of the complexities of the ESR. A trend toward what O'Connell calls "plurality of service" lent another complication. The NHS has always relied on commercial sector delivery for some of its healthcare services, but that reliance is growing significantly. "We anticipate that over the next several years, we will see many more organizations that are not part of the NHS family providing services to our patients," says O'Connell. "If you're comparing the provision the NHS could buy from a commercial provider versus from the NHS itself, then we need to have good benchmark data about our workforce. That's something we didn't have and can now get with ESR."

Internal restructuring was another factor. When ESR was in the initial design stage, NHS was comprised of 100 strategic health authorities; during the first two years of the project, that number was reduced to 28 and in 2006 was reduced again to 10. Over the last two years, NHS has begun decentralizing administrative accountability to allow the 600 local and regional healthcare trusts to innovate and flourish in a more-competitive marketplace, with freedom to make decisions based on local circumstance. These changes in governance put external pressure on the ESR team.

"Typically, when you're doing an implementation, you try to limit the amount of change that's happening around you," says O'Connell. "But for the first time in decades, our whole pay structure was being reformed, and it was happening over multiple years. We didn't have the luxury of saying, 'This is a four-month implementation, and we'll just freeze.' A lot of people thought that was going to sink us, but ultimately, it kept us agile and focused and made us flexible."

Despite the pressures, O'Connell and his team stayed on time and on budget through 39 pilots and 12 rollout waves, migrating more than 100,000 records every two months and covering more than 50 NHS organizations per wave. The first pilot went live in October 2004, the first rollout sites went live in March 2006, and the final wave was launched in February 2007 and is expected to be fully live in March 2008. They accomplished these milestones, he says, by organizing waves based on some 200 payroll groups, a number that has remained relatively constant over the seven-plus years of design, build, and implementation. "The question was, if we believe the core principle is right, that this is the right system for the health service, and we acknowledge that the health service is changing, how can we ensure an implementation that delivers on time, cost, and quality? By being creative and looking at structures that were least likely to change—the payroll groupings—we were able to stick with the business justification despite the fact that we were restructuring throughout the process," says O'Connell.