bioneural.net

A potted history of NHS IT strategy up to December 2000, prior to the New GMS contract and the National Programme for IT (NPfIT)...

IM&T strategy (1992)

The first NHS IT strategy of any significance. The Information Management and Technology (IM&T) Strategy (1992) cited the "lack of integration and commonality" between existing IT systems as a barrier to efficiency and progress. It was to be nationally led but implemented via a Local Action Plan. Key principles of the strategy were:

• person-based information (linking to an NHS number);
• systems integration (esp. to reduce duplication of data entry);
• deriving management information from operational (day-to-day) systems;
• ensuring security and confidentiality of patient information;
• information sharing via an NHS-wide network.

The strategy also importantly specified the need for:

• a national thesaurus of coded clinical terms (expansion of the Read Codes);
• national standards for computer?computer communication e.g. EDIFACT, EDI, X.400, GP system accreditation (RFA).

Implementation guidance in the form of a Handbook was produced in 1994. In 1996 the Handbook was updated to take account of other national developments: Developing a Primary Care-led NHS (esp. GP fundholding); Care in the Community; implementing The Health of the Nation; implementing the Patient?s Charter; and the move towards a knowledge-based NHS.

Information for health (1998)

A product of The new NHS White Paper (see below), a 7-year plan (1998-2005) broadly aiming to "provide the right information wherever it is needed in the NHS, from the doctor?s surgery to any hospital accident and emergency unit. The strategy will also ensure proper information to tackle the causes of ill-health, to plan and monitor health care, and to keep patient information confidential." It proposed to put in place the people, resources, culture change, and processes necessary for implementation. The principles on which this strategy is based are (verbatim; cf. the 1992 IM&T strategy):

• information will be person-based;
• systems will be integrated;
• management information will be derived from operational systems;
• information will be secure and confidential;
• information will be shared across the NHS.

Key areas of the 1998 strategy were as follows:

Sharing information: the NHSnet infrastructure

The NHS-wide intranet, linking NHS bodies together and providing services such as internal messaging, electronic data interchange (including NHS-wide access to electronic patient records), an Internet gateway (external e-mail and Web pages), and internal "non-public Web sites" known as NHSweb. An NHS Strategic Tracing Service would support electronic data interchanges using the NHS Number. A security policy and code of connection would ensure the confidentiality of patient-identifiable information. All computerised GP practices would be connected to NHSnet as a priority. In addition to supporting electronic patient records (below), NHSnet would be the prime vehicle for two-way communications between primary and secondary care, and support telemedical applications.

Sharing & deriving information: Electronic health records

Electronic patient records (EPRs) held by separate health (& social) care professionals or organisations would form the basis of an integrated multi-professional, multi-organisational life-long electronic health record (EHR), available around the clock at the point-of-care via NHSnet. This would require the primary care-led development of a new generation of integrated clinical systems (utilised by the whole primary health care team). Such clinical systems would also link prescribers and pharmacists electronically. In addition to being used to deliver routine care and to inform patients about their own care, "naturally" derived information (i.e. aggregated anonymised data) would be fed into performance monitoring against a National Framework (NFAP), Health Improvement Programmes (HImPs), clinical governance (quality-assured service delivery and clinical effectiveness), and epidemiological research. The disparity between the existing hospital clinical information systems was also recognised, and a minimum level of development proposed.

A National Electronic Library for Health

A new National Electronic Library for Health (NeLH) would aim to "provide easy access to the best current knowledge about health problems, their causes, prevention and treatment; and to help improve health and healthcare, clinical practice, and patient choice."

Information and services for patients and the public

There would be access to accredited information (via the NeLH), online access to specialists (via telemedical systems) for patients, and involvement in health service policy making for the public. The year 2000 would see a national roll-out of the telephone-based NHS Direct service. Opportunities to utilise the Internet via a National Gateway and digital television would be explored. The Centre for Health Information Quality (CHIQ) would assist the resource accreditation process.

Local implementation

Health Authorities would be required to produce a Local Implementation Strategy (LIS) that would support the development of Primary Care Groups (PCGs), Health Improvement Programmes (HImPs), and clinical governance. Supported by locally developed Health Informatics Services (pooling the IM&T resources and skills of Health Authorities and NHS Trusts), each LIS would include local education and training initiatives.

National IM&T standards

Overseen by the Clinical Data Standards Board of a new Clinical Information Management Programme (CIMP), the ICD-10 (diagnoses) and OPCS-4 (procedures) coding systems were reaffirmed as the UK standards for inpatient clinical terms. Clinical Terms revision 3 (formerly known as Read Codes) were highlighted as being central to the development of EPRs and EHRs and mandatory for use in clinical systems.

A Standard Clinical Products Reference Source would be developed to standardise the description of medicines, appliances and medical devices. The Contract Minimum Data Set (providing a framework for NHS Trusts to report on levels of service activity, managed by the NHS-wide Clearing Service) and methods of standards application through processes such as STEP (Standards Enforcement in Procurement) and RFA (Requirements for Accreditation) would be further developed.

Professional education

Pending the development of a national IM&T training and education strategy, Learning to manage health information (1999) would be utilised (published just after Information for Health). This paper, commissioned by the NHS Executive's Enabling People Programme, itemised the IM&T/ informatics knowledge and skills that healthcare professionals should acquire as part of life-long learning.

Other national strategies and initiatives impacting on IT

Several national strategies, although not specific to IT, are closely associated with information technology goals and implementation plans. The NHS has also supported specific IT initiatives on a national level (MIQUEST, PRODIGY).

The new NHS (1997)

This White Paper outlined the benefits of the new NHS "information superhighway" (NHSnet) and identified the need for a new information management & technology strategy for the NHS (leading to Information for Health).

Caldicott Report (1997)

The Caldicott report was commissioned in reflection of concerns over the way the NHS handled patient-identifiable information. A key recommendation was the appointment of a Caldicott Guardian by all NHS organisations to oversee access to patient-identifiable information.

Data Protection Act (1988)

This Act implements the EU Data Protection Directive (95/46/EC). With implications for the protection and use of patient information, all NHS organisations are required to register with the Data Protection Commissioner and subscribe to 8 key data protection Principles. The NHS Information Authority (NHSIA) aims to ensure that NHS organizations are in compliance with the Act. The Act covers access to certain types of manual records (including all health records, replacing the Access to Health Records Act 1990) as well as to electronic records.

A First Class Service (1998)

Following on from The new NHS (above) as part of the modernisation agenda, implementation of clinical governance requires performance monitoring against specific measurable targets. Operational-level IT systems must therefore be able to derive such information: "Clinical governance needs good information to assess the quality and performance of services? Present NHS information systems are not of an adequate standard to meet these needs for information on quality." NHS organizations are asked to reassess their informatics needs and identify how they will develop the information and information technology infrastructure to support clinical governance, and to plan for this in the IM&T Local Implementation Strategy.

The NHS National Plan (July 2000)

This 10-year plan professed to make the "biggest changes to face the NHS since it was set up 50 years ago". The proposals included a Modernisation Board, a Modernisation Agency, and 10 taskforces—one of which is charged targeted at how improvements can be made via investment in facilities and information technology. Key IT-related expectations were:

• NHSnet connectivity for all GPs by 2002;
• Modern IT systems in every GP surgery;
• Electronic prescribing of medicines by 2004;
• Electronic recording of referrals to be routine by 2001;
• 24-hour access to Electronic Patient Records throughout the NHS;
• Patients to get advice from GPs and nurses via e-mail;
• Electronic booking of outpatient appointments by 2005;
• Patients to receive test results at home via e-mail;
• Telemdicine links to hospital specialists from primary care;
• Telemedicine links between patients and local health services by 2005;
• Patient access to Electronic Patient Records by 2004, (eventually) via personal smart cards;
• Hospital patients to give their views on standards of care electronically via bedside TVs;
• Patient information available via NHS Direct on the Internet & digital TV by 2004;
• Current best practice information for NHS staff and patients via the National Electronic Library for Health (NeLH).

Pharmacy in the Future (September 2000)

Following on from the NHS National Plan (above), this document discusses electronic prescribing, including the transfer of prescription data between GPs, pharmacies, and the Prescription Pricing Authority (PPA) via NHSnet. Several pilot schemes are already operating. It also discusses "e-pharmacy", the electronic sale of pharmacy-only medicines e.g. via NHS Direct online.

eGovernment Interoperability Framework (2000)

Requires all new and existing NHS systems support the major Internet standards e.g. XML. This can be enforced, at least in general practice, via the Requirements for Accreditation (RFA) which specify standards for the interchange of information which must be met in order to qualify for remuneration.

MIQUEST

MIQUEST (Morbidity QUery Information Export SynTax) is crown copyright software endorsed by the NHS Executive, and allows data from any RFA 99 accredited system to be extracted by a PCG or HA for audit and management purposes. It copes with different versions of the Clinical Terms, and thus removes any need for a single GP system on all sites. It can be downloaded from the NHS Information Authority.

PRODIGY

The prescribing decision support system, PRODIGY (Prescribing RatiOnally with Decision-support In General practice studY), gives a PCG or HA the ability to assist practices in abiding by evidence-based medicine guidance. PRODIGY is able to support guidelines developed by the National Institute for Clinical Excellence (NICE), now responsible for its development.

What social and economic factors determined this policy?

Labour's social welfare legislation in the late 1940's nationalised hospitals and provided free medical care irrespective of income. The New Labour government came to power promising the modernisation of the NHS. At the same time it began the de-nationalisation of other institutions e.g. the rail network and energy utilities, and continues to implement a privatisation plan. The NHS was spared, although the National Plan opened the door to some private investment.

The NHS (and therefore its information strategy) is almost entirely centrally funded, which distinguishes it from most other health services which rely heavily on charges. As a result the UK spends significantly less on health care than comparative countries—less than 6% of the GDP around the time the strategy was published (ref. Encyclopaedia Britannica). Despite low levels of investment, basic health indicators (e.g. infant mortality, life expectancy) are comparable to other industrialised nations without there being vast differences in treatment related to income level.

A popular "information revolution" was permeating most aspects of society, enthusiastically hailed by the Prime Minister as bringing "new opportunities for greater prosperity, and a better quality of life" (in Our information age). The NHS would quickly be viewed as a dinosaur if it did not play catch-up, especially in relation to networking given the prevalence of the global Internet in people's homes, and the rapid evolution of telecommunications technologies. The widespread adoption of 24-hour "eBusiness" (or "dot com") strategies effectively forced government to invest in electronic ways of working and disseminating information if it wanted to be taken seriously. There was also a widespread perception that under-investment in the NHS has left many of its facilities dilapidated and its staff disheartened. Against this background information technology was seen as crucial to the drive for efficiency, convenience, and providing the performance monitoring that matters so much to politicians hoping to be re-elected. It was also critical to the implementation of other health-related policies.

Did the strategy stand a chance?

The 1998 strategy appeared to be a re-launch of the 1992 strategy—which enjoyed limited success—although it did give us the NHS Number, Clinical Terms v.3, an NHS-wide network, and the NHS-wide Clearing Service. The principle reason given in Information for Health for the failure of the 1992 strategy is that it was "over-concerned with management information" (1.33).

Although Information for Health emphasized deriving information from day-to-day work, its biggest potential weakness was that it required almost everyone employed by the NHS in patient care and management to change the way they work. Such en masse co-operation may well be the holy grail of any government, but it stands a chance only if the NHS as a whole can perceive the need for change. The strategy was developed from the top down; however, its saviour may be the emphasis on local implementation plans contributed by all stakeholders (including the public). Politically motivated collaborative processes invariably involve delay and trivial debate as part of the consultation process. This must be weighed up against the benefits of engaging the system users and end benefactors in order to foster "ownership" of the strategy and the co-operation that comes with it.

The NHS cannot, however, change the way it works through willpower alone. It must critically provide quality education to support change. It is well known that the NHS has severely rationed funding, and that it is more-or-less in "permanent crisis" (partly through understaffing). It is difficult to see how over-stretched clinicians, in particular, can be excused from delivering patient care in order to devote sufficient time to a quality IT education. Furthermore, existing education programmes are typically delivered by non-clinicians with very limited insight into the practicalities of delivering patient care (which cannot easily be modelled).

A new Information Policy Unit (IPU), part of the NHS Executive i.e. government, was established to be responsible for the national development and implementation of Information for Health, and to monitor the performance of the new NHS Information Authority (NHSIA). The NSHIA is a special Health Authority created to take the blame if? (sorry, to actually deliver the strategy).

Information for Health promised that "information technology can undoubtedly improve NHS professionals? use of information in day-to-day patient care." However, in this age of evidence-based medicine, bear in mind that there is a distinct lack of indisputable evidence that the "computerisation" of British general practice (BMJ 1995 311: 848-52) or NHS hospitals (BMJ 1996 312: 1407-10) has provided the anticipated benefits.

Protti (Oct 1999) identified the following "risks" to the implementation of Information for Health in a report to the IPU:

• The Internet as an alternative to NHSnet;
• Lack of human resources with health informatics skills;
• Competing priorities (not just in IT) causing "initiative overload";
• Uncertainties around funding;
• Resistance to change within IT departments;
• Neglect of the importance of cultural change;
• Confusion between NHS organisations regarding roles and responsibilities;
• Lack of system supplier capability to meet targets;
• Uncertainties around the nature of Electronic Health Records.

There was, however, still hope: "Meantime, a generation change has occurred whereby no doctor now finishing postgraduate training is puzzled by the Internet, and the exponential growth in business use of the medium has bred familiarity, if not love, among even those most resistant to change. Change is suddenly inevitable, and occurring." (BMJ 2000; 321: 846-847).

So what progress was made by the Millennium?

A National Information Partnership

Information for Health proposed a National Information Partnership to ensure that all stakeholders were involved in the implementation and further development of the strategy. This partnership was intended to solicit contributions from clinical professionals, suppliers, academics, public health, NHS chief executives, and the public.

Education for change

The original IM&T strategy included an implementation guide suggesting specific actions to various user groups with an implementation timetable. It also stated that all NHS staff have a responsibility to "seek appropriate education and training opportunities in IM&T, including professional qualifications in IM&T". Although IM&T departments were developed with an education remit, these were largely ineffectual and were perceived as being distant from the staff they proposed to educate.

Working Together with Health Information (1999) from the Information Policy Unit is the national education, training, and development (ETD) strategy promised to support the implementation of Information for Health. It identified what needed to be done to help develop new skills and change the culture of information management and use in the NHS. The vehicle for the delivery of the ETD plan is the Local Implementation Strategy (LIS).

A plain-language guide to Information for Health for clinicians, Information for Practice (1999), was produced by the ETD programme.

Information Matters, seemingly aimed at nurses, provided a framework for assessing educational needs in relation to IM&T (essentially a list of questions!).

PRIMIS (Primary Care Information Services) is a no-charge support service launched in April 2000 and funded by the NHS Information Authority "to help primary care organisations improve patient care through the effective use of their clinical computer systems" by supporting information facilitators employed by PCG/Ts (not end users directly).

NHSnet: a rocky start

NHSnet went "live" in October 1995. GP connection to NHSnet was initially hamstrung by the BMA urging that doctors should not co-operate with it until security and confidentiality issues had been resolved (BMJ 1995 310: 1540). A further setback in meeting connection targets occurred as a result of concerns about NHSnet reliability and performance following high-profile problems in mid-1999, the focus on Y2K issues, and GP concern over NHSnet call charges. This resulted in the "re-launch" of NHSnet offering 24 hour/ 7 day access from general practices at no local cost.

Project Connect (formerly confusingly referred to as GPnet), which includes the "change management" Ways of Working Project, was involved in encouraging GPs to connect to NHSnet.

Keen and Wyatt suggested that a dedicated network for the NHS may have been the wrong choice, alleging that the Internet (and not NHSnet) meet the requirement for "secure and reliable communications, open membership, use of sustainable technology, and cost effectiveness compared with alternatives" (BMJ 2000; 321: 875-878).

The original goal that "all computerised practices will be able to receive at least one type of test result over the network by the end of 1999" was not achieved. Kelly reflected that "networking was lost in a swamp of inappropriate standards and bad contracting" (BMJ 2000; 321: 846-847). Issues around joint working (e.g. giving social services staff access to NHSnet) were not resolved.

Security and confidentiality

A strategic framework for the adoption and use of cryptography (data encryption) in NHS was under development. The case for using the Internet as an alternative to access patient records confidentially was made (BMJ 2000; 321: 612-614).

Electronic health records

Good practice guidelines for existing general practice electronic patient records were produced (August 2000) to support the implementation of EHRs. Pilot new generation or "beacon" EHR projects were initiated. Little actual progress was made against the original timeframe as "the software to support the proposed electronic architecture did not exist, and neither did the hardware in primary or secondary care." (BMJ 2000; 321: 846-847).

GPs were able to legally keep electronic patient records without also making paper records since October 2000, following a long-overdue amendment to their Terms of Service.

The NHS historically supported competition in the market place to drive the development of GP clinical systems. Information for Health acknowledged that divergent systems used different and often incompatible standards. The Requirements for Accreditation (RFA) are an attempt to converge the specifications of these systems so that data may be aggregated and exchanged. However, this proved only a partially effective mechanism. "Open source" (non-proprietary) systems were proposed as one solution to make the EHR a reality (BMJ 2000; 321: 976). Clinical systems using familiar Internet-derived standards were developed e.g. the Web-based "evolve" product from Exeter Systems.

A further thorn in the side of progress with EHRs was a fixation with informed consent. The General Medical Council argued (see Duties of a doctor: confidentiality) that there is no such thing as "implied" consent, and that explicit consent must be sought over any use of patient information. This advice immediately threatened information sharing to the cancer registries (BMJ 2000; 321: 849).

NeLH

Opened to both patients and clinicians, the pilot NeLH website comprised four virtual "floors": a patient and public information floor (NHS Direct Online), a know-how floor (guidelines and audit), a knowledge floor (best current evidence, in partnership with NICE), and a knowledge management floor (training, in partnership with medical informatics bodies).

Information for patients and the public

The National Gateway to accredited information on the Internet evolved into NHS Direct Online, which went live in December 1999.

National IM&T standards

Clinical Terms (Read Codes) version 3 were to be superseded by SNOMED Clinical Terms, developed by collaboration between the NHS and the College of American Pathologists. There was a gradual migration towards Internet standards e.g. SMTP for e-mail instead of X.400.