Last month, the Commons’ public accounts committee published a pretty damning report on the NHS National Programme for IT in England, Connecting for Health. The committee’s analysis looked specifically at the development of a single care record. This is a set of electronic notes for each patient that can – with the patient’s permission – be accessed by clinicians working in different parts of the health service. MPs noted how progress on this central aim of the programme is running severely behind schedule and has failed to demonstrate value for money.
Single care records offer huge advantages over the alternatives, namely paper records or fragmented electronic records that can’t be accessed across the primary/secondary care divide. So has the time come for a radical rethink on how to deliver them for the NHS?
First a word about costs. A striking feature of Connecting for Health is the vast sums of money involved. The programme has an overall budget of £11.4 billion, with £2.7 billion spent so far on care records and another £4.3 billion in the pipeline. But I don't think we should necessarily be alarmed by these high numbers.
The NHS is a huge organisation, and around the world, top-performing health care systems typically spend above-average amounts on IT. For example, Kaiser Permanente recently bought a $5 billion IT system for its 8.7 million members (the NHS in England covers 50 million people). What's more, investment in health IT can sometimes lead to overall savings. For instance, an analysis published in Health Affairs last year found that the Veterans' Health Administration (VHA) had made a net saving of over $3 billion by investing in health care IT.
Clearly, then, the point is what is achieved for the money rather than simply how much is spent. Like many of the world’s best health care systems, Kaiser and the VHA have fully-functioning, single electronic medical records. These records are accessible, with strict access controls, to clinicians working anywhere in the health care system – and they can typically be accessed by patients and their carers as well.
Currently in the NHS, we have first class IT within our GP practices. But the clinical record in hospitals is still almost always paper-based, supplemented by a range of idiosyncratic IT systems for requesting and viewing test results. Moreover, the ability to transfer records between different parts of the NHS is underdeveloped to say the least.
In its report, the Commons committee acknowledged that the original intention of creating a single electronic care record was still a "worthwhile" goal. I agree entirely, but things have moved on considerably since that original aim was first agreed.
In the recently "liberated" and "listened-to" NHS, the new name of the game is "competition and collaboration". Personally, I can't see how either of these two improvement levers can be deployed effectively unless there is a single care record in place to facilitate them.
Why? Well, for there to be meaningful competition, patients will need the theoretical ability to transfer access to their electronic notes easily between different providers – both between different primary care clinics and between the primary, community, secondary and tertiary sectors.
Equally, for care to be truly integrated, it is essential that professionals working across all of these different sectors – and indeed in social care – should have the ability to read and write in a single set of electronic notes. Only then will the real benefits of integration be fully realised, namely the avoidance of duplication and a reduction in the number of "gaps in care".
All of this suggests that the need for a single electronic record is more pressing than ever. So it’s rather a problem that the Department of Health has announced it cannot deliver them.
What to do? Well, perhaps the time has come for a radical re-think. One sweeping change might be to mandate the use of open-source software across the health service. Yes this would be disruptive in the short term, but it could promote inter-operability between different parts of the NHS because the open standards would be published openly.
At the same time, going open source could help contain costs for a number of reasons. Firstly because open source software is free to download and use. Secondly because it can be cheaper to customise and adapt. But most importantly because the use of open-source software should promote a more competitive market in IT support for the NHS by avoiding so-called vendor lock-in.
This fully open-source option is the route being taken by the national health service of Jordan, which is currently rolling out the VHA's open-source system, “VistA” across the whole country – linking every primary care clinic and all 43 hospitals across the land.
When the National Programme for IT was first launched, a delegation visited the VHA in Washington but chose not to implement their open-source IT system here. Has the time come to revisit that decision?
This blog is also available to read on the Health Service Journal website.
Lewis G (2011) ‘Open to suggestions: can the National Programme for IT be saved by open source software?’. Nuffield Trust comment, 12 September 2011. https://www.nuffieldtrust.org.uk/news-item/open-to-suggestions-can-the-national-programme-for-it-be-saved-by-open-source-software