The impact of the new National Care Record Service (NCRS) on primary care will be profound; even though primary care in the UK is already distinguished both by the level of computerisation of GP practices and the percentage of practices connected to NHSNet (the NHS secure intranet), both well over 95%. The achievement of this level of installed base of IT systems has not however had any significant impact on the underlying character of primary care as established nearly 60 years ago through the creation of the NHS. GP practices remain independent small businesses, working as private sector contractors to the NHS. To a great extent the installed base of primary care systems has reinforced this character, providing more efficient billing systems with modest clinical functionality and leaving patient information in 9,000 isolated silos.
The NPfIT specifically sets out to incorporate primary care systems within a comprehensive, integrated, intelligent and boundary-free information framework. This dissolution of the differentiation of independent GP systems will fundamentally change the nature of primary care, its organisation, the services it delivers and its relationship with its patients. A process that is consistent with and reinforced by a range of government policies on GP contracts, nurse prescribing, purchasing clinical services from the private sector and the move towards ‘payment by results’.
The impact of IT systems, particularly those that integrate across existing organisational boundaries, tends to be similar:
- The nature, ownership and control of professional skills is changed and redistributed, with intermediate roles diminished
- The relative role and power of the end user is enhanced
- Entry and exit barriers for service suppliers shift in location and degree
- The capacity for supervision and planning of the whole service delivery structure is increased.
Information technologies commoditise rare skills and then distribute them to previously unskilled users. The access to comprehensive information and tools; the ability to automate supervision and monitoring; coupled with access to up-to-date knowledge, enables individuals to carry out tasks, which would previously require lengthy training and high levels of individual capability. In the context of primary care this means a shift and redistribution over time of skills for all its participants.
Access to a comprehensive patient electronic health record, covering all interventions whether in acute or primary care, coupled with a ready access to a vast knowledge base will support a move to increasing specialist skills in primary care. The progress towards GP specialists will be enhanced, as the IT catalyses the technology transfer out of the specialist silos of the acute hospital.
The same factors will enable nurses and other clinical professions to take a greater role in both the management and delivery of patient care. As in all industries the impact of IT is to challenge existing roles and distinctions. The impact on primary care will be particularly powerful, potentially releasing considerable resources for patient care – which is just what is intended.
From Patient to Partner
However this redistribution of skills is not limited to the professionals. The most powerful shift will be to the end-user, the patient and the carer. The implications of what in other industries is called ‘disintermediation’ are enormous. Whilst GPs will not follow travel agents down to the pathway to Internet oblivion, there are already signs of similar processes occurring. The use of the Internet to gain medical information and ‘advise’ is already established and the purchasing of pharmaceuticals over the web is growing explosively and not just for ‘lifestyle’ drugs. A government, which is to encourage the ‘over-the-counter’ sale of statins, is unlikely to stand in the way of repeat prescribing over the Internet. To be followed in due course by remote monitoring to support self-managed care.
What is uncertain is how this technological great leap forward, avoids leaving behind those citizens that don’t have access to the technology. For some needy or disadvantaged patients, for example some housebound disabled, the technology will deliver wonderful empowerment. But there is a danger that others will be left out, further exacerbating existing inequities.
Encouraging Supplier Plurality
The provision of primary care in the UK is a remarkable and rare example of a government organised local monopoly. Arguably for very good reasons, the ability of doctors to provide services within the NHS is strictly regulated, reducing greatly patient choice in return for controlling costs and ‘guaranteeing’ reasonably equitable and nearly universal access to services. Whilst the IT industry itself may exhibit some notable examples of an abuse of supplier power, information technologies are generally the enemy of monopolies and cartels, reducing barriers to entry and encouraging patient choice.
The impact of the NPfIT will be consistent both with this general observation and the specific policies of this Government. Patient choice is now to be encouraged both as a ‘good thing’ in its own right but also as a way of promoting competition between providers so rewarding improved cost and quality performance. So far such policies have been limited to acute hospitals but opening up primary care to new providers is very much a possibility.
Reinforcing the Regulatory Framework
The creation of a single, integrated record, the NCRS, will inevitably lead to greater transparency and enhance the capacity and capability of the regulatory regimes. Increasingly, organisations such the Healthcare Commission will develop automated audit techniques that will exploit the wealth of information generated. At a local level, Primary Care Trusts (PCTs) will progressively be able, and will want to, monitor medication and referral patterns against both external guidelines and their own internal policies. Some primary care clinicians will see such developments as a threat, whilst others may view them as a welcome underpinning of their own professional skills. It is unlikely, however, that many patients will be sympathetic to attempts to frustrate developments that appear to offer greater clinical safety and a clearer attribution of responsibility.
Consequences and Conclusions
The role and content of clinical roles will be redefined and the relationship with management roles will become increasingly blurred. The team approach to delivering care, with the GP operating as one of a group of clinicians, often led by a non-GP will be facilitated by better technology support. The increasing presence of GP specialists will place a premium on generalist skills, given the co-morbidity of many patients being cared for in the community. Primary care will become less an individual endeavour and more of a corporate enterprise. This transition has been underway for at least a decade with the NPfIT both requiring this transformation and contributing substantially to it.
This metamorphosis is increasingly reflected in changes in training at every level, which will be further reinforced by the increasing abundance of IT. Information technologies bind participants within an organisation closer together within a shared paradigm of work processes and flows, requiring a move towards greater common education and training with an emphasis on process skills over knowledge.
Hopefully this will result in clinical professionals with greater skills and access to knowledge, better equipped to deal with the highly individualised, complexities of the patient. Enhancing the capability to deal with complexity will add still further to the evolution of the clinician/patient relationship, shifting it towards shared risk management. Access to a single, comprehensive health record, is fundamental to creating this network approach to care but will also facilitate, highly personalised relationships. Pulling together the multiple threads of the network, the task of the care manager, may be taken on by the patient but is more likely to be the role of a clinical professional, who is unlikely to be a GP. If all goes well patients will experience a more intelligent, focussed and responsive service that is also more personalised – or at least that should be the human aspiration of the technological revolution.
The organisational framework for all these changes is the PCT – the focus of so much of the Government’s hopes and aspirations. In many ways the greatly enhanced flows of information, the powerful tools and decision making aids that the NPfIT will generate for PCT managers, should improve their capability to deal with the myriad challenges they face. However, it may well be that the processes the NPfIT will help catalyse – increasing transparency, greater plurality of care suppliers, the redefinition of the relationship with the patient – will ultimately expose the inherent contradictions of the PCTs’ role and function. The creation of common electronic records reduces distinctions and boundaries between organisations, facilitating yet a further restructuring of NHS primary care services.
This article is an extract from a Newchurch discussion paper, ‘The Impact of the National Care Record Service on Primary Care’ by Kingsley Manning. To obtain the full paper email firstname.lastname@example.org
Kingsley Manning will also be presenting on the issues raised in this article at the Southern Institute for Health Informatics on 1 October 2004. For details see http://www.disco.port.ac.uk/hcc/sihi/sihi2004/index.htm