New guidance on information and information systems for primary care organisations produced by the Primary Care Information Modernisation Programme (PCIMP) concludes that the NHS stands at a crossroads in the development of primary and community care information systems

The guidance, read alongside a newly published review of the primary care clinical systems market carried out on behalf of the Primary Care Information Management Board, suggests that existing leading suppliers such as Torex and EMIS face a major challenge as their existing customer base is superseded by primary care trusts.

In an exclusive interview with E-Health Insider, Steve Walker, head of the PCIMP team, stressed that a new approach to IT was essential to the success of primary care trusts.

The programme was established in September 2001 as part of the NHS Modernisation Unit to co-ordinate the development of primary care IT. By 2003 the new NHS primary care trusts will have direct responsibility for 70% of NHS expenditure, but they are only just beginning to identify what IT systems they will need.

“It’s very hard to imagine them being effective without IT,” said Walker. "It’s absolutely essential in terms of modernising the care they are delivering and working collaboratively."

A key challenge will be to move away from the fragmented, practice-based systems currently in place to integrated PCT-wide systems that will enable primary and community care electronic patient records (EPR) to be delivered.

“There are currently 9-10,000 practices, each an island of computing,” said Walker. "We either need to join together these islands or build something entirely new". He suggested that both approaches will probably be needed.

The extent of the challenge is highlighted in the separate review of the primary care IT market, completed in April 2001, which was quietly released on the DoH website at the end of December.

The review makes uncomfortable reading for existing suppliers of primary care systems such as EMIS and Torex, with its conclusion that PCTs have fundamentally new and different IT needs, not yet being met by existing suppliers.

It describes the GP clinical system marketplace as an "oligopoly" in which a handful of suppliers dominate, new suppliers face major barriers to entry, and the cost of switching between suppliers is too high.

Noting the leading suppliers’ dominant position and the degree of uncertainty over what IT systems PCTs will need, the review says that "suppliers are unlikely to lead developmentally as they risk significant revenue loss as the market develops".

The extent of existing suppliers’ conservatism is highlighted by the conclusion that “none of the suppliers is yet committed publicly to the development of an EPR clinical system to serve a whole PCG/PCT”. The biggest opportunity to change the marketplace "lies in improving the potential for substitution", states the review.

"I think the whole situation needs to be rationalised," commented Walker, who added that a balance needs to be struck to maintain enough diversity in the market to ensure innovation and competition.

The PCIMP guidance document on IT for Primary Care Organisations meanwhile makes clear that far greater national co-ordination will be introduced into primary care computing, with a sharp move away from fragmented local procurements.

One key change will be the move to PCTs buying organisation-wide systems, rather than the antiquated system of GPs buying individual practice systems, for which they are reimbursed through their contract. This is likely to be removed from the GP contract currently being renegotiated.

Walker suggests that the web services model of a local low-level infrastructure across which layers of shared applications are provided -– the OSI stack model set out in ‘Building the Information Core’ — may offer the best way ahead. "You could argue that the NHS should pursue more of these layers and get better value for money," he told EHM.

The market review document is less explicit, but also clearly points to the potential of the web services model: "The potential exists for PCT clinical systems to be delivered with a much smaller requirement for locally located hardware and IT skills".

As a first step the PCIMP team is establishing which systems and software are already in place and working with PCOs to ensure IT developments are integrated and co-ordinated. It has issued its guidance paper to give PCOs some clearer direction on IT.

“Our role has to be about getting some sense into this,” says Walker. "At the core of this is target IMT10 (the objective of establishing integrated primary and community Electronic Patient Records (EPRs) by 2005)".

Guidance on the architecture for primary and community care EPRs was originally due in September 2001. The new Primary Care Organisation IM&T guidance document provides an initial roadmap on EPR, and Walker promises detailed guidance, "defined in functional terms", will available by 31 March this year.

PCIMP IM&T Guidance for Primary Care Organisations 

Primary Care Information Management Board – GP Clinical Systems Supplier Market Review