Archway Surgery.       Archway Development & Consulting Ltd
Primary Care Computing Specialist Group
NHS Organisations impacting Primary Care

Archway Development &   Consulting Ltd
54 High Street
Herts HP3 0HJ
Tel 01442 817217
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A view from Dr Gerard Bulger  Comments to Gerard Bulger  please
 NHS Connecting for Health 
The plan was that there is a single NHS Medical Data system, called the spine, fed from large regional blocks called LSPs.  Hospitals and G.P.s would no longer have their own systems. The programmes and data are held offsite.  In Hertfordshire our G.P.s patient data would be held in Derby and Sheffield. Clinical systems would be unified in these LSP areas.

By April 2007 a more pragmatic approach was being taken.   Clinical systems of choice in general practice going to be a reality and it looks as if current system providers have a role.   CfH has taken a different tack for some months although many PCT have continued to apply a monopolistic concept forcing G.P.s to change their clinical systems, partly because the LSP "solutions" have been free to them.  The General Practice System of Choice process has demonstrated to CFH,  PCT and regional managers the dynamism amongst suppliers and in particular as shown by some of the smaller companies who clearly now have a role within CfH.

Another change is that GP systems will continue to have some sort of "serving" within their practices, so if the BT broadband connections get cut there will still be useable system and patient Data in the surgeries.  This was not the original concept which was that all data was off site.  The up to date debate (26th April 2007) is here in the Health Services Committee Investigation whose documents are here and my contribution is here

GP Systems of choice

Choice of GP Systems 

More background to CfH

May 2006:

The arguments listed below may be winning.  Details gleaned from a Connecting for Health conference April 2006 are here  The Government announced that G.P. can continue to use accredited clinical systems, although they will still be housed on central servers outside their practices.  Current G.P. systems are very advanced, destroying them was going to be an act of vandalism.  There are still many problems to resolve and the smaller clinical system companies have to get contracts with the local service providers. DH press  release here (as at late March 2005)

Connecting For health has its defence to the problems here

It is dawning on the NHS the scale and cost of transferring data from GP systems, most of which have at least 10 years worth of data to the new NHS systems. It takes up to 6 months and cost £5000 per practice. See E-health Insider news item here
It no appears that the population of the central spine with diseases and problem will be a manual event with the GP and patient agreeing what goes up there.

Prison Service Health IT was thinking of Biometric authentication..don't go there! See why here

  • There shall be a single Patient record.  Out go the separate G.P. clinical records, 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".
  • The new IT system will be driven through the NHS, as a device to reform the NHS.

  • There 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?

G.P. have 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 problems if 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  ( ) states that the NHS will now 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 Microtest.

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  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".

PCTs are seeking to take control of G.P. systems. They are obliged to fund 100% of the costs, so seek value for 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 doing that.   

The risks of central control has recently be documented after a crash at DWP, see "Building Disaster in the Network: How UK Government Does it"

Another Way.  See
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:
Richard 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.

Richard Granger at first told clinical suppliers that current clinical systems were “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.

Some clinical software suppliers have  tied up with a LSPs.   Current 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 functionality.   

The LSPs contracts are held by the Centre, in Whitehall.  PCTs will not 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.

Mr 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.

Under 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

The new 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 documentation.

The 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.

Currently 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 moment. ( )

Richard 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 patients in 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. 

GP2GP project has come back to life and data will be transferred electronically between practices, and is starting between some systems.

A 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.

Richard Granger’s original policy may be changing for many pragmatic reasons.

Instead current systems should communicate and work with a central Electronic Current suppliers would be competing interfaces to the central service

An 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.

Confidentiality: NHS Site
Disaster of Central Control
Expenditure Claims
Primary Care Specialist Group
USA Model

Gerard Bulger
Archway Surgery
52 High Street
Herts HP3 0HJ
Dr Bulger's original fantasy (circa 1999) on medical records is here

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Filing this way shoud cease!Filing like this should end !



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