By Tony Collins
The Wachter review of NHS technology was due to be published in June but has been delayed. Would it matter if it were delayed indefinitely?
A “Yes Minister” programme about a new hospital in North London said it all, perhaps. An enthusiastic NHS official shows the minister round a hospital staffed with 500 administrators. It has the latest technology on the wards.
“It’s one of the best run hospitals in the country,” the NHS official tells the minister, adding that it’s up for the Florence Nightingale award for the standards of hygiene.
“But it has no patients,” says the minister.
Another health official tells the minister,
“First of all, you have to sort out the smooth running of the hospital. Having patients around would be no help at all.” They would just be in the way, adds Sir Humphrey.
In the Wachter’s review’s terms of reference (“Making IT work: harnessing the power of health IT to improve care in England“) there is a final bullet point that refers, obliquely, to a need to consider patients. Could the Wachter terms of reference have been written by a satirist who wanted to show how it was possible to have a review of NHS IT for the benefit of suppliers, clinical administrators and officialdom but not patients?
The Wachter team will, according to the government,
• 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;
• Provide a set of recommendations drawing on the key challenges, priorities and opportunities for the health and social care system in England. These recommendations will cover both the high levels features of implementations and the best ways in which to engage clinicians in the adoption and use of such systems.
In making recommendations, the board will 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.
Yes, there’s the mention of “patients” in the final bullet point.
Some major IT companies have, for decades, lobbied – often successfully – for much more public investment in NHS technology. Arguably that is not the priority, which is to get existing systems to talk to each other – which would be for the direct benefit of patients whose records do not follow them wherever they are looked at or treated within the NHS.
Unless care and treatment is at a single hospital, the chances of medical records following a patient around different sites, even within the same locality, are slim.
Should a joining up of existing systems be the main single objective for NHS IT? One hospital consultant told me several years ago – and his comment is as relevant today –
“My daughter was under treatment from several consultants and I could never get a joined-up picture. I had to maintain a paper record myself just to get a joined-up picture of what was going on with her treatment.”
Typically one patient will have multiple sets of paper records. Within one hospital, different specialities will keep their own notes. Fall over and break your leg and you have a set of orthopaedic notes; have a baby and you will have a totally different set of notes. Those two sets are rarely joined up.
One clinician told me, “I have never heard a coroner say that a patient died because too much information was shared.”
And a technology specialist who has multiple health problems told me,
“I have different doctors in different places not knowing what each other is doing to me.”
As part of wider research into medical records, I asked a hospital consultant in a large city with three major hospitals whether records were shared at least locally.
“You must be joking. We have three acute hospitals. Three community intermediate teams are in the community. Their records are not joined. There is one private hospital provider. If you get admitted to [one] hospital and then get admitted to [another] the next week your electronic records cannot be seen by the first hospital. Then if you get admitted to the third hospital the week after, again not under any circumstances will your record be able to be viewed.”
Blood tests have to be repeated, as are x-rays; but despite these sorts of stories of a disjointed NHS, senior health officials, in the countless NHS IT reviews there have been over 30 years, will, it seems, still put the simplest ideas last.
It would not cost much – some estimate less than £100m – to provide secure access to existing medical records from wherever they need to be accessed.
No need for a massive investment in new technology. No need for a central patient database, or a central health record. Information can stay at its present location. Just bring local information together on local servers and provide secure access.
A locum GP said on the Pulse website recently,
“If you are a member of the Armed Forces, your MO can get access to your (EMIS-based) medical record from anywhere in the world. There is no technical reason why the NHS cannot do this. If need be, the patient could be given a password to permit a GP to see another Surgery’s record.”
To avoid having patients clog up super-efficient hospitals, Sir Humphrey would have the Wachter review respond to concerns about a lack of joined up care in the NHS by announcing a set of committees and suggesting the Department of Health and NHS England appoint a new set of senior technologists.
Which is just what has happened.
Last week NHS England announced “key appointments to help transform how the NHS uses technology and information”. [One of the NHS appointments is that of a Director of Digital Experience, which is not a fictional title, incidentally. Ironically it seems to be the most patient-facing of the new jobs.]
Said the announcement,
“The creation of these roles reflects recommendations in the forthcoming review on the future of NHS information systems by Dr Bob Wachter.
“Rather than appoint a single chief information and technology officer, consistent with the Wachter review the NHS is appointing a senior medical leader as NHS Chief Clinical Information Officer supported by an experienced health IT professional as NHS Chief Information Officer.
“The first NHS Chief Clinical Information Officer will be Professor Keith McNeil, a former transplant specialist who has also held many senior roles in healthcare management around the world, including Chief Executive Officer at Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust and Chief Executive Officer at the Royal Brisbane and Women’s Hospital in Australia.
“The new NHS Chief Information Officer will be Will Smart, currently Chief Information Officer at the Royal Free London NHS Foundation Trust. Mr Smart has had an extensive career in IT across the NHS and in the private sector.
“The NHS CCIO and NHS CIO post-holders will act on behalf of the whole NHS to provide strategic leadership, also chairing the National Information Board, and acting as commissioning ‘client’ for the relevant programmes being delivered by NHS Digital (previously known as the Health and Social Care Information Centre).
“The roles will be based at NHS England and will report to Matthew Swindells, National Director: Operations and Information, but the post-holders will also be accountable to NHS Improvement, with responsibility for its technology work with NHS providers.
“In addition, Juliet Bauer has been appointed as Director of Digital Experience at NHS England. She will oversee the transformation of the NHS Choices website and the development and adoption of digital technology for patient ‘supported self-management’, including for people living with long term conditions such as diabetes or asthma. Ms Bauer has led delivery of similar technology programmes in many sectors, including leading the move to take Times Newspapers online…”
Surely a first step, instead of arranging new appointments and committees, and finding ways of spending money on new technology, would be to put in place data sharing agreements between hospitals?
A former trust chief executive told me,
“In primary care, GPs will say the record is theirs. Hospital teams will say it is our information and patient representative groups will say it is about patients and it is their nformation. In maternity services there are patient-held records because it is deemed good practice that mums-to-be should be fully knowledgeable and fully participating in what is happening to them.
“Then you get into complications of Data Protection Act. Some people get very sensitive about sharing information across boundaries: social workers and local authority workers. If you are into long-term continuous care you need primary care, hospital care and social care. Without those being connected you may do half a job or even less than that potentially. There are risks you run if you don’t know the full information.”
He added that the Summary Care Record – a central database of every patient’s allergies, medication and any adverse reactions to drugs, was a “waste of time”.
“You need someone selecting information to go into it [the Summary Care Record]so it is liable to omissions and errors. You need an electronic patient record that has everything available but is searchable. You get quickly to what you want to know. That is important for that particular clinical decision.”
Is it the job of civil servants to make the simple sound complicated?
Years ago, a health minister invited me for an informal meeting at the House of Commons to show me, in confidence, a one-page civil service briefing paper on why it was not possible to use the internet for making patient information accessible anywhere.
The minister was incredulous and wanted my view. The civil service paper said that nobody owned the internet so it couldn’t be used for the transfer of patient records. If something went wrong, nobody could be blamed.
That banks around the world use the internet to provide secure access to individual bank accounts was not mentioned in the paper, nor the existence of the CHAPS network which, by July 2011, had processed one quadrillion (£1,000,000,000,000,000) pounds.
Did the briefing paper show that the civil service was frightened by the apparent simplicity of sharing patient information on a secure internet connection? If nothing else, the paper showed how health service officials will tend, instinctively, to shun the cheapest solutions. Which may help to explain how the (failed) £10n National Programe for IT came into being in 2002.
Nobody will be surprised if the Wachter review team’s report is laden with jargon about “delays between technology being introduced and a corresponding rise in output”. It may talk of how new technology could reduce the length of stay by 0.1528 of a bed day per patient, saving a typical hospital £1.8m annually or 7,648 bed days.
It may refer to visions, envisioning fundamental change, establishing best practice as the norm, and a need for adaptive change.
Would it not be better if the review team spoke plainly of the need for a patient with a fractured leg not having to carry a CD of his x-ray images to different NHS sites in a carrier bag?
Some may await the Wachter report with a weary apprehension that its delay – even indefinitely – will make not a jot of difference. Perhaps Professor Wachter will surprise them. We live in hope.
Wachter review terms of reference.
Comments in your article attributed to ‘a former trust chief executive’ give an inaccurate impression of the significant progress that has been made with the Summary Care Record (SCR) in England. The facts are as follows:
• The SCR is an electronic summary of key health information from the patient’s GP electronic record. This information is held securely on the infrastructure known as the national ‘Spine’ and is available for viewing by authorised staff involved in the provision of direct care to the patient .
• More than 55million people in England have a SCR – more than 96% of the population.
• As a minimum, each SCR contains details of a patient’s medication, allergies and adverse reactions.
• Information is updated in real time – whenever a relevant entry is altered in the GP electronic record then the SCR is automatically updated.
• Strict Information Governance controls are in place to protect the confidentiality of sensitive personal identifiable information. SCR viewing is only by authorised staff providing direct care to patients. The information is not used for any purpose other than direct care.
• Every access is by use of individually assigned ‘Chip and PIN’ SmartCards and all accesses are auditable.
• About 80,000 SCRs are already being viewed each week by healthcare workers providing direct care to patients in urgent and emergency care settings – that’s over 4.3 million SCRs viewed per year.
• Accessing information in patient SCRs can significantly improve safety, quality and efficiency of care.
Recent developments mean that it is now technically straightforward for SCRs to be enriched with additional information from the GP record – with the patient’s explicit consent. This additional information can include:
• Significant medical history (past and present);
• Anticipatory care information (such as information about the management of long term conditions);
• Communication preferences (as per the SCCI-1605 national dataset);
• End of life care information (as per the SCCI-1580 national dataset);
• Reason for medication;
• Record of Immunisations.
Viewing of SCRs by health professionals is becoming routine in many urgent and emergency health care settings, including Emergency Departments, Acute Admissions Units, GP Out-of-Hours services, Walk-in Centres, Ambulance Services, Mental Health Crisis Care Teams, Community Pharmacies and Community Nursing Teams. It has been agreed to extend the scope of use of SCRs to include elective and scheduled care settings, including outpatient and pre-operative assessment clinics. SCRs are also being viewed in medical facilities in Police Custody Suites and Prisons. The SCR Expert Advisory Committee, made up of representatives of professional and patient organisations and chaired by a patient representative , has approved a ‘proof of concept’ project, which is about to commence, on sharing information in SCRs with authorised staff working in care homes – exploring the potential for sharing patient information with colleagues in Social Care. SCRs provide a secure electronic method of sharing key clinical information to help deliver personalised care for people who need help away from their GP surgery.
Further information can be obtained from:
I do admire your dedication and thank you for highlighting these regular scandals. For various reasons, I’ve taken an interest in both the police service and the medical profession hoping to find ways to prevent unnecessary deaths. What a good idea it is to try and avoid both medicine and the law wherever and whenever possible.
Focusing on the IT problems, it strikes me that their dilemmas are not so much to do with the systems themselves but the bureaucratic minds’ total unpreparedness in dealing with salespeople.
The bureaucrats seem to be completely innocent as to the laser-focus and strategies of the salespersons. A good salesperson is a well-trained, expert psychologist but with no Oxbridge, certificate to prove it – just a huge salary and perks.
The bureaucrats are left wide open to the ‘problem-solving’ blandishments of a well-rehearsed and determined IT salesmen. The latter’s promotion and salary are dependent upon selling. The bureaucrat’s security is dependent upon bringing comfort to the person above him in the hierarchy – calming words, clauses and sub-clauses on papers and assuring bewildered, IT-ignorant and organizationally-ignorant personnel in all departments.
Candy from a baby.
Maybe our bureaucrats should be compelled to be apprenticed to a mega corporation’s sales department which would be as much of a culture shock for them as it was when we sent our young chaps to run the colonies in the 19th century.
Just a thought.
Thanks for the thoughtful comment. It’s always difficult to establish whether it’s the supplier or the client that’s mainly at fault when things go wrong because there’s no statutory requirement to identify possible causes as there is after a rail or aircraft crash. I am not sure it’s always naïve civil servants being taken in by articulate and impressive supplier salespeople. It’s more likely to be an irrational or ill-founded optimism on both sides. It’s true that IT suppliers seem to get paid whether the IT programme is a success or not. That’s partly because a big company’s lawyers will argue that the supplier has delivered what was specified – even if that’s not what the client now wants.
Good idea about some bureaucrats being apprenticed to a big supplier’s sales department. Civil servants would then be less likely to succumb to a well-meant but irrational exuberance. Tony Collins
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