By Tony Collins
Jeremy Hunt may have forgotten what he told the FT 2013, as reported in the paper on 2 June 2o13.
Referring to the failed National Programme for IT [NPfIT] in the NHS he said at that time,
“It was a huge disaster . . . It was a project that was so huge in its conception but it got more and more specified and over-specified and in the end became impossible to deliver, but we musn’t let that blind us to the opportunities of technology and I think one of my jobs as health secretary is to say, look, we must learn from that and move on but we must not be scared of technology as a result.”
He added, “I’m not signing any big contracts from behind [my] desk; I am encouraging hospitals and clinical commissioning groups and GP practices to make their own investments in technology at the grassroots level.”
Now the Department of Health (and perhaps some large IT suppliers) have encouraged Hunt to find £4bn for spending on technology that is (again) of questionable immediate need.
Says Computing, “A significant part of the paperless NHS plans will involve enabling patients to book services and order prescriptions online, as well as giving them the choice of speaking to their doctor online or via a video link.”
The £4bn, if that’s what it will cost, is much less than the cost of the NPfIT. But are millions to be wasted again?
[NPfIT was originally due to cost £2.3bn over three years from 2003 but is expected to cost £9.8bn over 21 years, to 2024.]
Yesterday (8 February 2016) the Department of Health announced a “review of information technology in the NHS”. Announcing it Hunt said.
“Improving the standard of care patients receive even further means embracing technology and moving towards a fully digital and paperless NHS.
NHS staff do incredible work every day and we must give them and patients the most up-to-date technology – this review will tell us where we need to go further.”
The NPfIT was supposed to give the NHS up-to-date technology – but is that what’s needed?
A more immediate need is for any new millions of central funding (for the cost would be in the tens of millions, not billions) to be spent on the seemingly mundane objective of getting existing systems to talk to each other, so that patients can be treated in different parts of the NHS and have their electronic records go with them.
This doesn’t need a new national programme for IT. Some technologists working in the NHS say it would cost no more than £150m, a small sum by NHS IT standards, to allow patient data to reside where it is but be accessed by secure links anywhere, much as secure links work on the web.
But the review’s terms of reference make only a passing reference to the need for interoperability.
Instead the review will have terms of reference that are arguably vague – just as the objectives for the NPfIT were.
The Department of Health has asked the review board, when making recommendations, to consider the following points:
- The experiences of clinicians and Trust leadership teams in the planning, implementation and adoption of digital systems and standards;
- The current capacity and capability of Trusts in understanding and commissioning of health IT systems and workflow/process changes.
- The current experiences of a number of Trusts using different systems and at different points in the adoption lifecycle;
- The impact and potential of digital systems on clinical workflows and on the relationship between patients and their clinicians and carers.
The head of the review board Professor Wachter will report his recommendations to the secretary of state for health and the National Information Board in June 2016.
Members of the National Advisory Group on health IT in England (the review board) are:
- Robert Wachter, MD, (Chair) Professor and Interim Chairman, Department of Medicine,University of California, San Francisco
- Julia Adler-Milstein, PhD, Associate Professor, Schools of Information and of Public Health, University of Michigan
- David Brailer, MD, PhD, CEO, Health Evolution Partners (current); First U.S. National Coordinator for Health IT (2004-6)
- Sir David Dalton, CEO, Salford Royal NHS Foundation Trust, UK
- Dave deBronkart, Patient Advocate, known as “e-Patient Dave”
- Mary Dixon-Woods, MSc, DPhil, Professor of Medical Sociology, University of Leicester, UK
- Rollin (Terry) Fairbanks, MD, MS, Director, National Center for Human Factors in Healthcare; Emergency Physician, MedStar Health (U.S.)
- John Halamka, MD, MS, Chief Information Officer, Beth Israel Deaconess Medical Center; Professor, Harvard Medical School
- Crispin Hebron, Learning Disability Consultant Nurse, NHS Gloucestershire
- Tim Kelsey, Advisor to UK Government on Health IT
- Richard Lilford, PhD, MB, Director, Centre for Applied Health Research and Delivery, University of Warwick, UK
- Christian Nohr, MSc, PhD, Professor, Aalborg University (Denmark)
- Aziz Sheikh, MD, MSc, Professor of Primary Care Research and Development, University of Edinburgh
- Christine Sinsky, MD, Vice-President of Professional Satisfaction, AMA; Primary care internist, Dubuque, Iowa
- Ann Slee, MSc, MRPharmS, ePrescribing Lead for Integrated Digital Care Record and Digital Medicines Strategy, NHS England
- Lynda Thomas, CEO, MacMillan Cancer Support, UK
- Wai Keong Wong, MD, PhD, Consultant Haematologist, University College London Hospitals; Inaugural chair, CCIO Leaders Network Advisory Panel
- Harpreet Sood, MBBS, MPH, Senior Fellow to the Chair and CEO, NHS England and GP Trainee
Perhaps egged on by one or two major suppliers in behind-the-scenes lobbying, Hunt has apparently found billions to spend on improving NHS IT.
Nobody doubts that NHS IT needs improving. But nearly all GPs have impressive systems, as do many hospitals. But the systems don’t talk to each other.
The missing word from the review board’s terms of reference is interoperability. True, it’s difficult to achieve. And it’s not politically aggrandizing to find money for making existing systems interoperable.
But at present you can have a blood test at the GP, then a separate blood test at the local hospital and the full results won’t go on your electronic record because the GP and hospital are on different systems with no interoperability between them.
If you’re treated at a specialist hospital for one ailment, and at a different hospital 10 to 20 (or say 100) miles away for something else, it may take weeks for your electronic record to reflect your latest treatment.
Separate NHS sites don’t always know what each other is doing to a patient, unless information is faxed or posted between them.
The fax is still one of the NHS’s main modes of cross-county communication. The DoH wants to be rid of the fax machine but it’s indispensable to the smooth running of the NHS, largely because new and existing systems don’t talk to each other.
The trouble with interoperability – apart from the ugliness of the word – is that it is an unattractive concept to some of the major suppliers, and to DoH executives, because it’s cheap, not leading edge and may involve agreements on data sharing.
Getting agreements on anything is not the DoH’s forte. [Unless it’s an agreement to spend more money on new technology, for the sake of having up-to-date technology.]
Last year I broke my ankle in Sussex and went to stay in the West Midlands at a house with a large ground floor and no need to use stairs. There was no communication between my local GP and the NHS in the West Midlands other than by phone, post or fax, and even then only a summary of healthcare information went on my electronic record.
I had to carry my x-rays on a CD. Then doctors at my local orthopaedic department in Sussex found it difficult to see the PACS images because the hospital’s PCs didn’t have CD players.
A government employee told me this week of a hospital that gave medication to a patient in the hope she would not have an adverse reaction. The hospital did not have access to the patient’s GP records, and the patient was unsure of the name of the medication she’d previously had an allergic reaction to.
Much of the feedback I have had from those who have enjoyed NHS services is that their care and treatment has been impeded by their electronic records not moving with them across different NHS sites.
Mark Leaning, visiting professor, at University College, London, in a paper for health software supplier EMIS, says the NHS is “not doing very well when it comes to delivering a truly connected health system in 2016. That’s bad for patient outcomes.”
That GPs and their local hospital often cannot communicate electronically is a disgrace given the billions various governments have spent on NHS IT. It is on interoperability that any new DoH IT money needs to be spent.
Instead, it seems huge sums will be wasted on the pie-in-the-sky objective of a paperless NHS by 2020. The review board document released today refers to the “ambition of a paper- free health and care system by 2020”.
What’s the point of a paperless NHS if a kaleidoscope of new or existing systems don’t properly communicate?
Congratulations, incidentally, to GP software suppliers TPP and EMIS. They last year announced direct interoperability between their core clinical systems.
Their SystmOne and EMIS Web systems hold the primary care medical records for most of the UK population.
And this month EMIS announced that it has become the first UK clinical systems provider to implement new open standards for interoperability in the NHS.
It says this will enable clinicians using its systems to securely share data with any third party supplier whose systems comply with a published set of open application programme interfaces.
The Department of Health and ministers need to stop announcing things that will never happen such as a paperless NHS and instead focus their attention – and any new IT money – on initiatives that are not subconsciously aimed at either political or commercial gain.
It would be ideal if they, before announcing any new IT initiative, weighed up diligently whether it is any more important, and any more of a priority, than getting existing systems to talk to each other.
Review of information technology in the NHS
EMIS implements open standards
Great piece, Tony. I’ve shared it with the Kable healthcare analyst, Andrena Logue.
Thank you David.
I share your anger and frustration at the fact that we appear to be off on another wild goose chase. Dave asks the $64.000 question.
Why can’t the NHS keep its “customers” informed as well as Amazon does?
Whilst I agree that integration would help in that regard, I worked at AT&T ISTEL in the 1980s when we drove through the first EDIFACT standards in the UK, the more effective solution is to redesign public service computing for today’s ubiquitous, global, real-time, computing platform, i.e. the same design as Amazon and eBay and Airbnb and Uber. The current public service applications were designed for a very different, pre-InterWeb world.
Design for communities, not organisations. A few applications replacing tens of thousands.
Here is my response to Ed Vaizey’s request for suggestions on the UK Digital Strategy. http://goo.gl/XGyFfr Healthcare is one of the examples.
In summary fundamental transformation is required if we are to realise the full potential of today’s computing platform for public services.
The second point is that the transformation requires rigorous engineering.
This is explained in the link.
John. Thanks for the comment. You’re right to ask the question (as Dave Orr does) about why the NHS cannot follow Amazon’s example of keeping people informed.
You’re also right to ask whether NHS IT needs fundamental transformation. I don’t think that’ll ever happen. So my advice (though it’s worth little) is that the NHS to do what’s practical, cheap and doable.
I’d ask health ministers, DoH civil servants and their advisers to forsake ideals. Compromise means getting things done. No goals of a paperless NHS (which one day may be recognised as an impossibility). No new nhs.uk website, healthcare apps or free Wi-Fi across the NHS. Not yet anyway.
Where there’s the enthusiasm to do it, have video links between doctors and patients. But that’s icing on the cake. What patients need now are the basics.
The DoH and ministers have, it seems to me, put together an advisory board to help plan a luxury spa in the middle of a devastated earthquake zone. That’s an exaggeration I accept but there may be a little bit of truth in it.
Keep e-records where they are (many hospitals, clinics and GP practices are proud of their IT strengths), and install add-on systems in each location to provide secure access to existing records. Those records could then be accessed by patients and any clinicians who are caring or treating them, including GPs.
As a nationwide project that’s possible to start almost straight away, I am told. Some of the smaller healthcare IT suppliers already run joined up e-records schemes to a limited extent. The DoH could learn lessons from these suppliers instead of always trying to install the latest technologies.
Keeping existing records and plugging into them from anywhere is not a major transformation in financial terms. It’s not even a huge change-management programme. It’s not grandiose in any sense of the word.
But for patients – who seem to be at the back of the queue when the DoH comes to dishing out its ideals and visions – it could be a transformative. Tony Collins
Quote ‘Review and articulate the factors impacting the successful adoption of health information systems in secondary and tertiary care in England, drawing relevant comparisons with the US experience’;
The terms of this investigation focus on the systems but appear to omit one major element CRUCIAL to making the solutions deliver — the professional competence of staff to check ‘fitness for purpose’, use the functionality to support them in their daily health care roles, and articulate when things need fixes or could usefully be enhanced. There are a number of ‘people’ initiatives planned (some multi-national) that should be recognised as a key part of the equation to achieve efficiency, effectiveness and efficacy from the technological solutions emerging for adoption and adaption.
Thank you Jean for pointing that out – especially as the “people” element was largely sidelined in the NPfIT until the later years when an understanding of its importance came too late to help redeem the programme. Maybe one or two members of the advisory board will take note of your concern.
Thanks for the comment. Yes I too wondered why so many US-based people are on the advisory board. It’s not as if the US is leading the world in making sure e-records keep up with the treatment of patients, wherever that takes place. Perhaps the DoH should ask Amazon to suggest a representative for the advisory board. There again, could an advisory board with so many members do any useful work?
Why are there so many American Members on the National Advisory Group on health IT in England?
I do hope that they aren’t there because of commercial links with big suppliers.
Perhaps Tony you should ask the Board to provide all disclosures of conflicts of interest for all Members of the National Advisory Group on health IT in England.
My recent experience and that of a friend, is that it is very difficult to know where you are on a waiting list; whether the referral and operative booking process is working (there is little or no communication on what & when the next steps are etc) and tracking your progress on-line is non-existent.
I have had a situation where my notes, within the same general hospital, were sent to the wrong section and when I queried why nothing had been heard, it turned out that I had “dropped out” of the (minor) day surgery operative booking process i.e. silence did not mean progress was being made or not!
Yet when I order from Amazon I can track the progress of an order and a delivery at all times and know if something is “stuck” or a problem has occurred.
Why can’t the NHS do the same?