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The drive towards clinical systems hosted in secure data centres is a direction which enjoys central support from all four of the UK home countries. However, it also generates nervousness and, in some cases, resistance from general practice. This is not helped by current suspicions among the profession about government motives.
One English GP told EHI Primary Care that he believed the government was gradually overcoming the obstacles to mass privatisation of primary care, one of which was access GP records.
He adds: “Many GPs, including myself, perceive that hosted systems are mainly about allowing private providers access to health records in order to farm off as much of GMS from GPs to private providers. The clinical benefits to patients from hosted systems are minimal.”
The arguments in favour of hosted solutions are firstly the potential benefits in terms of resilience and data recovery. Proponents of managed services argue that data centres are specifically designed with resilience and fault tolerance in mind and that managed services offer high availability through mirrored services at remote locations with alternative electrical supplies. Other perceived benefits include the impact on system management and technical support and the knock-on effect on integration with other sites and access for NHS staff working from multiple places.
Ewan Davis, former chair of the British Computer Society’s Primary Healthcare Specialist Group, says: “On performance and technical standards I believe data centres are the way to go. The Quality of Service offered by hosted providers should mean they are able to offer much better service in terms of protection against catastrophic data loss and physical control against hazards such as theft, flood and fire.”
Those in favour of maintaining practice-based systems emphasise the benefits of keeping patient data securely housed within their own premises and the flexibility practice-based systems afford practices with strong IT skills in terms of tailoring their systems to their own requirements. They also point to a couple of well-publicised failures of data centres by local service provider-run systems.
Davis says the profession remains rightly concerned about the control of data once practice systems are hosted off site.
“Government has recently demonstrated – in an absolutely horrifying way – the way in which it is willing to look after personal data and GPs are rightly concerned that once data is off site they will lose control over who looks at their patient information and for what purposes.”
Dr Paul Cundy, co-chair of the joint IT Committee of the BMA and the Royal College of General Practitioners, said continuing revelations about data loss by health bodies and government organisations would not encourage GPs to move to hosted solutions.
He adds: "To be quite honest I think it’s entirely reasonable for GPs to be very wary of taking their data off site for that very reason."
So far, hosting remains a minority choice although by June 2007 16% of practices in England, equivalent to almost one in six practices, had already moved to a hosted solution and Connecting for Health hopes to encourage more migration to such systems over the next few years.
Dr Grant Ingrams, co-chair of the Joint IT Committee of the BMA and Royal College of General Practitioners, believes that the majority of GPs will be happy to move to hosted systems eventually.
He says: “Most GPs are not too interested in semantics. So long as the system in front of them does the job well and stays resilient they are happy. There are a few GPs who like to fiddle with their system who are concerned.”
The strategic direction in England is underlined by CfH’s GP Systems of Choice (GPSoC) initiative which sets out the roadmap for development of GP systems. The scheme rewards suppliers for developing their functionality to comply with the National Programme for IT over a six stage maturity model and includes rewards for delivering a hosted system.
Clinical systems at levels one to three may be provided using a clinical server based in the GP practices but at levels four to six systems must be hosted to CfH standards.
In a separate initiative designed to encourage implementation of hosted solutions the Department of Health negotiated an IM&T directed enhanced service (DES) with GPs which is running over two years to March 2008, but may be extended for another year for those who have already signed up to it. The DES has four components covering such issues as data accreditation and compliance with Choose and Book and the Electronic Prescription Service but the last element involves a payment, 22p per patient, for those who switched to a hosted solution that has met CfH standards.
CfH argues that it is not in the business of forcing GPs to move to a hosted solution although it has recommended that capital funding for replacement practice-based servers under GPSoC should only be forthcoming if a suitable hosted system is not available to the practice. It hopes more practices will choose to move to a hosted solution as more suppliers win approval for their hosted solution through GPSoC.
Under the DES only one local service provider solution, BT’s Vision 3 in London, has so far been approved as a hosted solution by CfH. Under GPSoC no systems are yet accredited as hosted solutions.
However this is likely to change with both systems suppliers EMIS and TPP hoping to receive accreditation for their EMIS PCS WAN and SystmOne products shortly.
All four of the major GP system suppliers in the UK now offer hosted solutions or are about to do so. The newest entrant, TPP, offers only hosted solutions for its product SystmOne and has used this feature as a selling point from day one. The other three established GP suppliers, EMIS, ISOFT and INPS, have offered practice-based systems for more than 20 years but all have now developed hosted solutions of varying kinds. In the case of EMIS its latest offering, EMIS Web, will operate from a centrally-hosted data centre but practices will retain their local server-based systems as well, which the company claims offers the best of both worlds.
In Wales the Assembly government has also set national minimum standards for GP systems through a strategic framework and has chosen four suppliers to provide GP systems and services to practices. A requirement to move to a hosted environment is not included in the framework although NHS Wales acknowledges that 12% of Welsh practices were already hosted by the end of last year and is currently conducting a technical options review for hosting.
In Scotland the strategic direction is also towards hosted systems, a move supported by the GP committee of the Scottish BMA.
For those who continue to have reservations Dr Ingrams points out that, in England at least, there is no need for practices act immediately.
He adds: “The long term plan is for all practices to move to a hosted system but practices would only have to migrate once there are level six accredited systems, whenever that might be, and Joint GP IT Committee sign off is needed for this level.”
Fiona Barr