Primary care inspires review

The source of inspiration for most of the ideas in this week’s independent review of NHS IT backed by the Conservative Party is not too hard to find. While the review is packed full of suggestions for secondary care it is in primary care that many of the proposals have already been translated into action.

National standards for functionality and data, a national accreditation system, e-prescribing systems and local choice of system form the bedrock of IT in primary care.

The review draws on what is established in primary care IT and seems to find little to fault in GP-land either. From a 185 page document and dozens of recommendations made, there are relatively few suggested changes to primary care IT.

Acute care diagnosed for treatment

In secondary care, however, the review sets out a very large change agenda which the Conservatives have now adopted as policy. Key elements of that policy include a pledge from the Tories to “dismantle” the current central NHS IT infrastructure and halt and renegotiate the contracts Labour have signed for local service providers. This is not cosmetic change but radical surgery.

In their evidence to the review panel the LSPs argued, not surprisingly, that centrally drawn contracts were a better bet for the NHS because local procurement in use before NPfIT had been expensive, haphazard and inefficient as well as inhibiting interoperability.

However the review group, drawn from across the NHS and led by former GP and health informatics doyen Dr Glyn Hayes, argue that the LSP contracts should be ended because National Programme for IT strategy must shift towards local choice of IT systems for trusts.

Halting the LSP contracts

Halting the LSP contracts will, of course, be no easy or cheap job for the Conservatives as the government have already found to their cost with former LSPs Fujitsu and Accenture but the review group argue it would be worth the effort.

The review group points out it had no information on the costs involved in the LSP deals but says costs could be mitigated by overcoming the LSP failure to deliver and could also be set against the large amounts of money being lost due to delays.

Hospital Systems of Choice

In its place the review group appears to be proposing a sort of ‘Hospital Systems of Choice’, following on from GP Systems of Choice introduced in 2006 by Connecting for Health. GPSoC sets out a minimum specification for GP systems with additional rewards for those who deliver NPfIT functionality. Once on the framework GPs, theoretically, can select from any of the systems to use in their surgeries.

GPsoC was the result of a lengthy battle between GPs and the Department of Health over GPs right to choose their own IT systems against the LSP-led model of one size fits all. It was a battle that hinged on the commitment to system choice given in the 2004 GP contract, which CfH then reluctantly had to meet.

In practice the system has worked well with practically all GPs not on LSP systems using the framework although the tension between the right of GPs to choose and the overall IT direction of local health communities remains a contested issue.

Systems accreditation

The concept of accreditation though goes back even further to the Requirements for Accreditation (RFA) model for funding GP systems, last issued in 1999. Although ten years old it provides a model for the review panel.

For secondary care the review wants to see centrally set standards and functionality with assessment and accreditation of systems to prove that they conform to those standards. The review group argued that this would provide the freedom to choose that had been available in pre-NPfIT days with the control on costs and specification potentially offered by LSP contracts.

The review says some smaller trusts that lack the expertise to choose systems, and says they should have the option to bring in ‘integrators’ to help them make the leap to a new IT system. It also calls for more IT training for trust boards and more health informatics expertise.

Against such a background the review group says systems can be procured locally from a catalogue of successful systems with agreed NHS prices. It argues this will provide trusts with systems that are nationally compliant and yet flexible enough to cater for specialised needs.

Only buy proven products

It says such a system would also free government from the need to foot the cost for the design and development of systems and instead buy finished and fit for purpose IT products “off the shelf”.

One of the arguments against the centralised LSP approach has been the question mark it has placed over systems their users would argue are already fit for purpose. At times CfH has appeared to be focused on replacing ageing patient administration systems with expensive alternatives offering essentially the same, or even reduced functionality.

On this the review says that locally developed systems that can be adapted to achieve interoperability should be not be subjected to a ‘rip and replace’ strategy.

It adds: “Every effort should be made to integrate these systems into the National Programme for IT so as to avoid unnecessary disruption to patient care and unnecessary expenditure on new systems.”

Scrapping the NHS database

However one clear target for the scrap heap is the concept of a national NHS database. The review argues that the Conservatives should consider alternative solutions to “one monolithic central spine of data” and the Conservative Party has wholeheartedly accepted this idea. It claims the government’s national structures are outdated and irrelevant and that centrally held data also raises security and privacy concerns.

The review document is surprisingly quiet on the subject of the Summary Care Record, a derivative of the Spine. The national element of the SCR is what gives it its unique selling point but the review group has little to say about whether it should go or stay although it does say that “only the services which unequivocally require a central architecture should be provided centrally”. What it avoids is the notion of a limited use national SCR such as the Emergency Care Summary in Scotland.

Significantly at the launch of the review Stephen O’Brien said that a SCR could be one of the products included from a catalogue that NHS organisations could choose to purchase, if they identified a need.

Google grabs the headlines

The headline grabbing aspect of the review is the Conservative pledge to investigate personal health records. The review wants to see further investigation into the use of personal health databases such as HealthSpace, HealthVault and Google Health and argues once again that there is no need for the NHS to reinvent the wheel – an argument that already appears to have been won in Whitehall if latest steps to shelve the development of HealthSpace are anything to go by.

One other aspect which takes its lead from primary care is the call for faster implementation of electronic prescribing systems in secondary care. The review group argues that waiting for the “utopia” of Detailed Care Records has prevented the NHS from installing e-prescribing systems in secondary care.

It points out that GPs have been using computers for electronic prescribing for many years but that secondary care is missing out despite evidence showing such systems could reduce the national £500m annual cost of drug errors by as much as 70%.

Transplant or nip and tuck?

In all the raft of recommendations run to several pages but Dr Hayes and his co-authors are keen to emphasise that NPfIT should not be abandoned but rather “adapted and recast” to better meet the needs of patients. However, while a nip and tuck may be the order of the day for some elements of the NHS the review means others could be facing a wholesale body makeover.