A massive 274,000 outpatients, spread from Berkshire to the white cliffs of Dover, rely on care from Central and North West London NHS Trust, along with a further 6,000 in-patients. As one of the largest NHS trusts in South East England, a new way of working and a new way of serving patients was required. These demands led to Mark Large making the short walk down London's over-congested and polluted Euston Road from Great Ormond Street Hospital to Central and North West London (CNWL) in November 2013. The past 18 months have been busy, but as the CIO explains, the changing landscape of public healthcare in the UK means there is a lot more to do.

CNWL provides a wide range of care, including physical health, long-term treatment, mental health, learning disabilities, addiction and eating disorders, as well as clinical treatment in some of the country's overcrowded prisons and offender care institutions. The majority of its care is provided in the community, which frees up the trust from operating hospitals, but creates its own challenges.

Serving about 1,000 beds, the trust has a budget of £440 million and employs 6,400 staff across 300 buildings. It's a very different organisation to the world famous Great Ormond Street children's hospital. "It's complex and interesting because we have to win contracts from clinical commissioning groups (CCG) and we may lose contracts, too," he says of the nature of health provision since the shake up by the Conservative-led governments since 2010.

"Because we are a large geography that means we are dealing with a number of CCGs," the CIO adds.

Rationalise and modernise

CNWL has grown through a set of trust mergers, and as Large's private sector peers know, mergers means disconnected technologies. "We have four instances of Rio and one of Jade, a mental health patient administration system," he says of the needs for him to standardise the platforms the trust operates. Rio is the healthcare platform delivered into a wide part of the NHS by the Labour government's botched National Programme for IT. It is coming to the end of its useful life, which has added urgency to Large's strategy.

"The BT national contract is coming to an end, so this, alongside needing to enable more efficient working has been our main driver to procure and exit Rio," he explains. Large led a procurement that involved as many as 400 staff from across the trust, which has selected the TPP SystemsOne set of modular healthcare applications to replace four instances of Rio and the single instance of Jade that he inherited. "This, together with the infrastructure renewal, means we are moving away from an old infrastructure to a uniform platform that can scale and support mobile and unified communications," he says.

A challenge for an organisation like CNWL that provides healthcare into many CCGs is that many of those CCGs would like Large and his team to adopt the technology platforms they use. However, the CIO has had to remain strong and focus on a platform that suits his organisation and is interoperable.

"It's all about loose coupling of systems and interoperability, which was not possible with the previous systems. Interoperability will make this a better place for all of us. The consolidating down the versions has taken a large amount of effort. But, it's about the conversations and providing the rational for why a decision has to be taken and it is about a finite resource pot," Large says.

That interoperability is more than a technology vision. The CIO and his leadership team at the trust are trying to improve the processes within the organisation. "We have lots of people zigzagging about carrying a lot of paper. With electronic access to information our teams can plot the best route to those patients, access the information and give them flexibility. It is a different type of future. My mantra is always think about the customer and if we can increase efficiency we can increase throughput.

"The users, in general are pragmatic and when you explain their needs, they understand and reach sensible solutions with us," Large says of the rationalising and modernising. To do that, he has changed the shape of his team to be "50% business engagement".

"Also, how do we protect CNWL in the future? We can do that by reducing the cost per patient transaction," he adds.

As stated above, CNWL has to compete for contracts in the modern English healthcare. Clinical Commissioning Groups were set up by the Conservatives to enable greater competition in healthcare. "I'm always cautious about competitive language," says Large.

Transition of people and tech

Just before Large joined CNWL, the organisation decided to outsource its infrastructure to CGI, so the new CIO's first task was to manage the transition of infrastructure and supporting staff. He was pleased the trust took the decision, as the infrastructure was "operational and was not strategic to the business".

Large describes the contract with CGI as being outcomes based. "That is new to both of us and it is harder than we both envisaged, but we will make it progress. The benefit for CNWL is that the contract does not have a single target, it is a stretchy target. An outcomes-based contract means that if CGI can deliver an outcome through a different way, then the way it is done doesn't matter, the outcome does. This is the new area for all parties concerned. We have to keep checking with each other and finding new ways of doing things, the flexibility is key.

"IT is operating at the speed of the business, it is about their pace, but also we are able to be two to three steps ahead and carrying the business with us," he says of the freedom of not operating the infrastructure and the flexibility of his agreement. Everyone is trying to drive down what they pay for services," Large says of both what the CCGs want to provide NHS trusts, and what the trusts want from vendors.

The CIO, did, however, have to manage the Transfer of Undertakings (Protection of Employment) of the infrastructure team to CGI. "It is about being open and honest and we worked with the union representatives. The staff were frightened, but we made sure we sat down with them. It's about those human relationships, the staff and the patients," Large says of the CIO role in healthcare.

"There was an infrastructure replacement decision that had to be made because it had to be replaced as it was falling over and it was a live system. The new platform will be more robust. CGI will bring in virtualisation as we reduce our applications down. It also meant I could do a new business case and start with a clean sheet," Large says of the restructure he put in place, so that his team included a small design organisation, project management team and customer engagement also a small communications team.

"For me, the key is that we are engaging with the customer. When I was at Oracle, the key driver was in providing a service that people want to consume, or you are dead in the water. It is the same in the NHS. You have to provide a service that people want to consume," he explains. We are partially removed, but we are involved in the patient and it does have an impact with the patient."

Large's business relationship management team are assigned to geographies and services within CNWL. "These roles are about taking the problems away from people. The key qualification they must have is an ability to talk in plain English." He says the business relationship team helps healthcare workers formulate their change requests and really get IT to understand the outcome the clinicians are working towards.

"The key is that they don't make it the customer's problem," he says. Large has recruited the relationship managers through the NHS jobs channels and has secured ex-clinicians and former nurses. "That to me is a real win, as they have an immediate rapport," he has also secured junior and senior testers into this team.

Information is always key to good relationships and this is where Large has worked to ensure his peers are fully aware of developments from his organisation.

"The chief executive was getting reports every month, but they were all different, so we have created a one-page dashboard that is simple," reveals the CIO. "It gives a heads up on what is working and what is not, and that means we can then have conversations. Communications, transparency and governance are what the business wanted from IT. It really builds people's confidence and will make a difference."

Large is drawn to healthcare and the difference technology can make to the lives of patients and the increasingly pressured and under-funded lives of those delivering care. He constantly refers to the importance of the patient experience throughout the conversation, and no CIO remains in healthcare for just over a decade unless they enjoy the challenge, but also see they are making a difference.

"The NHS is still rapidly moving forwards. I am not interested in house-keeping and I need a challenge, and there are plenty of those in the NHS."