From a primary care viewpoint, a summary of NHS IT strategy from Jan 2001 to April 2004, outlining the National Programme for IT (NPfIT) and the implications of the New GMS Contract...
What came before?
In case you missed it, here is a potted history of IT strategy in the NHS up to December
2000.
Building the Information Core (Jan 2001)
Building the Information Core: Implementing the NHS Plan was essentially an update to Information for Health (1998) in the light of The NHS Plan (2000), which had some effect on priorities and their delivery dates. It also had to take account of the e-Government Interoperability Framework (e-GIF), all about standards for information interchange in the public sector. The "clarified" targets were:
- By March 2001: 95% of GP practices and 25% of Trust clinical staff with NHSnet connections and using NHS information services such as the National electronic Library for Health;
- By March 2002: desktop connections for NHS clinical staff to basic e-mail, browsing and directory services, and roll out of NHS cryptography support services begins
- By March 2003: migration to national standards for e-mail, browsing and office systems completed and all NHS staff with desktop access, and clinical information systems start to use the SNOMED Clinical Terms;
- By March 2004: major national payroll/HR systems implemented;
- By 2005: a vibrant networked NHS, with booking systems in place, electronic transfer of records within primary care, all acute Trusts with level 3 Electronic Patient Records and first generation Electronic Health Records.
Delivering 21st Century IT Support for the NHS (Jun 2002)
If Building the Information Core was the strategic "what", then Delivering 21st Century IT Support for the NHS: a National Strategic Programme was the "how". This document fleshed out the vision and encompassed the IT recommendations within the Wanless Report (June 2002) and the patient-centred focus of Delivering the NHS Plan (April 2002). Plans to be completed by April 2003 included recruiting a director general for a National Programme for Information Technology.
National Programme for IT (October 2002)
The National Programme for Information Technology (NPfIT) was established formerly in October 2002 with the appointment of its Director General. A budget of £2.3 billion was
announced in December 2002. The NPfIT set four primary goals:
- More NHS intranet bandwidth (512 Kbps-1 Mbps for GP practices i.e. finally broadband)
- The NHS Care Records Service (NHS CRS; a record summary in a national repository, a.k.a. "the spine")
- The Electronic Booking Service (EBS; outpatient appointments made online from primary care)
- The Electronic Transmission of Prescriptions Service (ETP; scripts sent online to pharmacies and the PPA)
The first goal would be the responsibility of a National Infrastructure Service Provider (NISP). National Application Service Providers (NASPs) would be tasked with delivering application components of the new services that are common at a national level. Five Local Service Providers (LSPs), each covering approx. 20% of the population, would oversee regional development of GP clinical systems, including integration with the new national services.
Other notable goals include a centrally-managed e-mail and directory service, Picture Archiving and Communications Systems (PACS) for digital images, and support for the New GMS Contract (see below).
What was the visible state-of-play as of April 2004?
Five steps forward:
- The NISP contract for the New National Network to replace NHsnet, "N3", went to BT (Feb 2004);
- The NASP contract for the NHS CRS went to BT (Dec 2003);
- The NASP contract for the EBS went to Atos Origin (Oct 2003);
- ETP pilots concluded in June 2003; a national model has yet to be developed;
- The LSPs (BT; Accenture x 2; CSC; the Fujitsu Alliance) were contracted between Dec 2003 and Jan 2004.
One step backward:
- Although it went live in Feb 2003 with "do-it-yourself" registration, the NHS cancelled its contract with EDD for the NHSmail e-mail (using SSL encryption) and electronic directory service, citing under-utilization, and offering no firm assurances to users about continuity of service.
What will the NPfIT mean for current GP clinical systems?
The NPfIT could necessitate the replacement of some existing GP systems, although unless clearly justified this is opposed by the General Practitioners Committee of the British Medical Association (BMA) and the Royal Collage of General Practitioners (RCGP). Significant upgrades, if not replacement, are inevitable. Suppliers of the three major systems (EMIS, Vision, Torex), among others, are expected to offer NPfIT-compliant software in due course.
The New GMS Contract
The New GMS Contract (nGMS) was accepted by GPs in June 2003. Primary Care Trusts (PCTs), rather than individual practices, will be responsible for fully funding and supporting integrated IT systems, and telecommunications services, on the basis of a Service Level Agreement with system suppliers. PCTs will therefore own the hardware and software installed in GP practices. Practices are guaranteed a choice from "a number" of nationally accredited systems, although that choice may be limited by some PCTs. Note how well this fits with the role of the LSPs as described above. According to the New GMS Contract (4.41), "Work is continuing to develop a minimum functionality specification for practice systems that defines the information requirements to deliver integrated care..." [qv. NHS CRS] "...and meet the requirements of the new GMS contract." Among these later requirements is electronic reporting for quality points payments (e.g. 90% of hypothyroid patients with TFTs done in the previous 15 months = 6 points = £max.) - a new type of performance-related pay for GPs. The importance of enabling GP-to-GP transfer of electronic records (i.e. system interoperability) is also emphasized.
Other considerations
As GPs, not only must we use our clinical systems to earn points under nGMS (or PMS), but also to effectively manage the patient in accordance with other demands. This means that our clinical systems should take into account and integrate:
- Collection of data to support the nGMS quality framework;
- Support good practice guidelines for general practice electronic patient records (see here);
- Support implementation of National Service Frameworks (NSFs);
- Support adherence to NICE national clinical guidelines;
- Support adherence to other significant national clinical guidelines e.g. BTS, BHS;
- Support adherence to local (PCT) clinical guidelines;
- Support adherence to in-house clinical guidelines;
- Support adherence to local (PCT) Clinical Terms formularies;
- Support adherence to in-house Clinical Terms formularies;
- Support adherence to local (PCT) prescribing formularies;
- Support adherence to in-house prescribing formularies;
- Support cooperation with PCT audit requirements;
- Support adherence to national referral practices e.g. The National Cancer Plan;
- Support adherence of local referral practices e.g. proformas for arthroplasy, open-access gastroscopy, etc;
- Take account of in-house policies and procedures e.g. divulging of responsibility among PHCT members;
- Patient access to medical records, copying of referral letters, and other "patient participation" initiatives.
It's a lot to ask: can the systems deliver? Some of the things on this list seem to be in competition—especially the various guidelines—creating confusion and frustration. What has priority? How do we satisfy all these external demands, together with our own 10-minute consultation schedule, and of course, the patient? As of April 2004, this all-signing all-dancing integration (or any hint of convergence) is lacking and seemingly outside of the scope of the NPfIT. Unfortunately, the goal posts will have surely moved before they even come close...
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