- There shall be a
single Patient record. Out go the separate G.P. clinical
social service records and hospital records. A titanic all
encompassing system was envisaged. The new system will
be handling 30 million transactions a day. This has now become
more complicated in that the whole record system will only exist within
regions (LSPs). Limited data is shared across all regions via a "spine".
IT system will be driven through the NHS, as a device to reform the
are now large I.T. providers known as Local Service Providers, LSPs.
These are delivering a single specified system in supra-regional
blocks, encompassing everything and anything to do with health and
social care. These systems will talk to a National Data spine which
will hold clinical details of the entire population. At first the spine
will have names and addresses and then all prescriptions.
The logistics behind all this are a secret, or simply not known.
Who, for example, can delete or modify the data?
advanced clinical systems, derived
from small U.K. companies in intense competition, with high user input
in their development. You seldom, if ever, see a hospital consultant
print out a prescription, with warnings and interactions pointed out
via the computer on his desk. 70% of G.P.s have been doing that for a
decade. Now, before NPfIT started, all G.P.s use computers.
The NPfIT was to destroy current G.P.
systems. One cited reason was that G.P. systems did not talk to each
other. From March 2005 G.P. Clinical systems will be able
to transfer data from G.P to G.P. when patients transfer.
G.P. systems currently communicate in a
limited way with the NHS for registration purposes, and provide data on
quality (stripped of patient details) under the new Quality and
Outcomes Framework (QOF). Limited data has gone up to the health
authorities for many years. But never the other way; the NHS has never
had access to G.P. systems and their data.
Under the new system, State control and
access is automatic, as all the systems will be owned and controlled by
the State. Data is held by the LSPs. The G.P.s and their
staff will have to have permission, via a state authorised swipe
card and pin number, to access the data of their own patients in
their own surgeries. No swipe card, no clinic, no data. All data
is held outside the surgery. If the BT broadband (N3) line goes down,
the surgery has not data on its patients whatsoever.
Under this system G.P.s would not need to
worry about backups, since the servers and data is held by servers of
the LSP outside (mine will be in Derby). However there problems
in doing that, since the bandwidth of broadband connections may
not be enough to avoid sticky cursors when we are in front of our
patients. Use of scanning documents during a busy surgery could give
2 or 3 surgeries were working (4:1 contention ratio) even using the 8MB
ADSL lines proposed for larger surgeries. To avoid that NPfiT systems
may have to "store and forward". We are then back to having
servers, in one form or another.
The new contract for G.P.s (
http://www.nhsconfed.org/gmscontract/ ) states that the NHS will
own G.P. computer systems the systems will be 100% funded by the NHS.
Curiously, and in conflict to the thrust of
the IT programme set out below, the new GP contract will allow G.P,s to
chose from any of the current accredited systems, which would include
current suppliers such as
Some Primary Care Trusts and Local Service
Providers had been attempting to impose a
monopoly of computer supply already by only agreeing to fund G.P.s
purchase of one single supplier or enforce the LSP system. This
was an anti-competitive stance to
take. The Government have recently re-affirmed that G.P.s can continue
to chose their suppliers,, see
dh link here and now
http://www.bma.org.uk/ap.nsf/Content/NPfIT0404 It is now
clear PCTs and LSPs must not bully G.P.s to change systems.
Accenture the supplier for Eastern region, as also assured G.P.s that
there is not need to change clinical systems ever, since all the
remaining G.P. suppliers are to be "spine compliant".
seeking to take control of G.P.
systems. They are obliged to fund 100% of the costs, so seek
money. There is nationalisation by depreciation. As systems need
replacing the PCTs replace and own the kit. G.P. are foolish if they
let the PCTs buy and own the servers in their surgeries. Not only does
that pass full control over to the PCTs, it also places practices in a
limbo as regards insurance of the kit and data. PCTs cannot insure
crown property, so they cannot insure the data and kit.
G.P.s, despite GPC guidance, should continue
to fund their servers and insure it for loss, and insure themselves for
data re-input in the normal way, and keep control of the data and
systems. PCTs should fund EVERYTHING else, but not the server.
Some PCTs have taken hardware contracts away
from G.P.s clinical suppliers, and then bully those suppliers, using
the clinical system supplier's help phone lines, to give detailed
instructions to those PCT employed staff, as to how to configure the
client machines and networks. PCTs did not realise the "software"
content of hardware maintenance. A few PCTs have gone so far as
to put G.P. surgeries onto their Local Area Network, potentially giving
access to everything on the G.P. systems. Once PCTs will own the
systems, they will then be able to set up lock outs, password controls,
send in software, without consultation with G.P.s.
It is not clear why PCTs need to be setting
up their own IT departments and domain controllers in this way, when
one would of thought it would be the NPfIT, the LSPs that would be
of central control has recently be
documented after a crash at DWP, see
"Building Disaster in the Network: How UK Government Does it"
The Americans are taking a different route. They plan to build
connectivity on the Internet and other existing networks without new
wires. They want to work on development of common standards using open,
non-proprietary standards for data content and transmission.
Connectivity "respects and serves patients" and is built on the premise
of patient control and authorization (as
per my original Medibank vision). Crucially for G.P.s
data in the USA will be decentralized - stays where captured; quite the
opposite of the NHS vision. Lastly they want the Health
Information Environment to facilitate growth, innovation and
competition in private industry. The Monopoly approach taken in the
UK...monopoly of purchasing in the main, stifles competition. The
small firms are regarded as "legacy" and in the way of Micro$oft and
other mega organisations now feeding at the NPfIT.
How we got here:
Granger was appointed as The Director General of NHS IT, a man in
a hurry. He came
from Deloitte Consulting, where he led the team
working on the London congestion charging scheme. He is the most highly
paid civil servant, and he may well deserve every penny. He impresses
everyone as he sets about delivering the most radical procurement
policy the NHS has ever seen.
Granger at first told clinical suppliers that current clinical systems
“crap”. We know that IM&T in the NHS is a mess, with
the vast majority of NHS Trusts unable to handle even Office
software, let alone understand the needs of clinicians and
departments within the Trust; the purchasing procedure is very
long and complicated; implementation has been late, and very often
unsatisfactory, and there is little if any central planning or
requirement for co-ordination or the ability to communicate with
other Trusts and General Practice - or sometimes even with other
departments within the same Trust. G.P. computer enthusiasts have all
been deploring this for years. But at least G.P. use their systems on
their desks unlike most of their consultant colleagues.
clinical software suppliers have tied up with a LSPs.
suppliers have been stripped of their hard won customers, their asset,
at a stroke. There is only one customer now; Mr Granger. The
small suppliers’ only remaining asset is some experience and
manpower, and having systems years ahead in development and
LSPs contracts are held by the Centre, in Whitehall. PCTs will
control the computer systems for primary care, or have anything to do
with I.T. At one time it seemed that even the tin, the
hardware, will be
provided by central contracts. The National Programme for IT does not
include networking or hardware. It is software only.
Granger stated that some of the current functionality of current
systems would be lost in the move to a common standard. We can
see that advanced paperless G.P. practices have most to loose by the
changeover. But they do not need to change.
the new GMS Contract G.P.s. will no longer be required to help fund
their IT systems or be involved in their maintenance. Another piece of
the jigsaw fits into place
NHS IT specification document was here
includes the Treasury’s Public Service Agreement with the NHS, “Targets
for Department of Health, Spending Review 2002”. Here the targets are
spelled out, and the software must deliver the answers. This is the
first time clinical software specification has included Treasury
specification includes the requirement it is vital that it “captures
the overall requirements for all health and social care
users” Since G.P.s are the only members of the health
service that get round to seeing the entire U.K. population over three
or four years, it must fall to G.P.s to input and verify the data that
is to be used by the entire NHS and Social Care monolith.. G.P.s see 6
million patients a week while hospitals only see 800,000 a week both as
inpatients and outpatients.
patients accept that their data is on the surgery computer knowing that
it stays there unless the doctor makes a referral. How will
patients view Primary Care when it is seen as the state’s data
collector? Perhaps it is no accident that the NHSIA is
undertaking a consultation process about confidentiality at this very
Granger pointed out that current G.P. systems did not talk to each
other. Patients transferring practice have their data
re-inputted, even if the practices involved are using the same clinical
software supplier. This was not software house
protectionism. There have been professional concerns about data
transfer without agreed security in place. G.P.s may have had a
better grip of the complexity and vagaries of medical data than many
NHS managers. G.P.s. dare not trust the data inputted by another
practice, and certainly do not trust data put in by a hospital. In the
Fundholding era practices checked the hospital data against the
front of them, and found 30% coding errors, which only improved to
about a 10% at the end of the Fundholding. Data tends to closely
verified more closely when £s are attached to it.
project has come back to life and data will be transferred
electronically between practices, and is starting between some systems.
single system does not resolve the issue of accuracy of data entered.
Training needs are generic. It is fun to ask different practices
what are their definitions of family history of ischemic heart disease,
of asthma, of heart failure. How vigilant is each practice and
user about data entry? A one-system-fits all could disperse the
responsibility of data ownership, and its veracity. It is likely
that the G.P. will end up being responsible for the entire NHS
record. The Medical defence unions have already advised
G.P.s that they have to take responsibility when patients fail to
attend hospital appointments so G.P.s will be very exposed.
Granger’s original policy may be changing for many pragmatic reasons.
current systems should communicate and work with a central Electronic
suppliers would be competing interfaces to the central service
Electronic Clinical Record Service could even an international service,
akin to VISA or MasterCard. Patients must be able to access, even
own, their records, so that they know what is there, and who has
accessed it. There are dangers in creating a State medical record
service fed by family doctors.
Mr Granger was the one person who has the methodology to
avoid the contracting mistakes of previous state-wide
I.T. projects. He
ensured that the NHS had fall-back suppliers should any one get behind or
fail. The original regime was an abuse of the monopoly purchasing
power of HMG. It would have been more honest of the Government to
Nationalise the current clinical suppliers, rather than killing them
off by taking way their customers, at a stroke, without parliamentary
debate. Stealth Nationalisation without compensation.
of Central Control
Primary Care Specialist Group
52 High Street
Herts HP3 0HJ
Dr Bulger's original
fantasy (circa 1999) on medical records is here
Filing like this should end !