The National Programme for IT in the NHS, concerns about information governance and security, and the arrival of new information services for patients dominated the news in 2008. So what are the big themes of 2009 likely to be? And what should they be?
Sandra Hempel asked fifteen politicians, vendors, policy makers and NHS IT managers to predict what will happen in the year ahead and to set out their wish-lists for 2009.
Neil Asling, IM&T portfolio manager, The Health Informatics Service, South West Yorkshire
Phil Birchall, healthcare business systems development manager, InterSystems
Frances Blunden, senior policy manager, NHS Confederation
Gillian Braunold, clinical director of the NHS Summary Care Record and Health Space
Ray Burdge, IT infrastructure manager, University Hospital of South Manchester NHS Foundation Trust
Christine Chang, Healthcare Technology Analyst, Datamonitor; Christine Claus, market development manager, Intel
Paul Jones, chief technology officer, NHS Connecting for Health
Norman Lamb MP, Liberal Democrat health spokesman
Stephen O’Brien MP,Conservative health spokesman
Daniel Ray, director of informatics and patient administration, University Hospitals Birmingham, winner, the BT e-Health Insider Awards
Sean Riddell, managing director, Emis Group
Michael Sobanja, chief executive, NHS Alliance;
Matthew Swindells, managing director for health, Tribal
John Wiltshire, sales and marketing director, Stalis
As far as the National Programme for IT in the NHS is concerned, the situation will remain much the same now that people can pick and chose what they want and add to it as they go along. There will be no dramatic developments, but things will tick along quite nicely. In terms of technology, I think the desktop will get much smaller. The thin client is definitely the way forward.
2009 will be the last year of the present NHS settlement and so the last year of big spending. We won’t see any massive projects any more – the big improvements for clinicians are already in place – but instead smaller, localised pieces of work that will improve, for example, the GP or community nurse function.
Over the coming year, I would like to see more polyclinics or mini-hospitals in rural areas so patients won’t have to travel so far. Clinicians working at these clinics will expect to have all the facilities that they have in a large hospital and I want to see this happen. I would also like to see green issues far higher up the agenda for IT managers than they are at the moment.
NHS organisations will face more urgency to implement the IT solutions they need to compete in the rapidly-changing healthcare marketplace. This will make 2009 a defining year for the national programme, which remains the primary channel for the delivery of new systems.
We anticipate, however, that there will also be a re-evaluation of existing software and significant opportunities for new clinical solutions. There will also be an increased focus on the exchange of patient information across the continuum of care; creating ever-increasing demand for software that supports integration and interoperability.
Accessing patient information via the web or from mobile devices will become less of an aspiration and more of a reality. As UK citizens increasingly take these technologies for granted, the healthcare profession will need to focus on issues such as security, consent and information governance. There will also be much better use of patient information and medical knowledge so support real-time clinical decisions; made with the patient, or by the patient alone.
Finally, in a tough economic climate, many commercial suppliers are looking for more clarity as to how the national programme is going to move forward, so that they can prepare for growth or survival. 2009 is likely to produce a mixed crop of winners and losers.
It’s not for the Confederation to make predictions about 2009 because we are not in control. Our position as we go into the New Year, however, is one of sheer frustration and exasperation about when we are going to see an effective national programme that will allow people to get on with providing good, effective healthcare.
We are particularly frustrated about what is happening with London, BT and the Millennium products. People at the Royal Free are very critical of the service that they have received. We would be much more supportive of people being able to develop more localised solutions; but if the products aren’t available then people are in a very difficult position.
Important issues also need to be resolved about accessing and sharing records. There are fundamental conflicts about what is needed for research purposes and the demand for confidentiality. We need clarity of purpose about this so that everybody knows the ground rules. I am not optimistic it will be sorted out in the near future. We are waiting to see what Christine Connelly’s review produces, but at the moment there appears to be no real workable solution.
I hope that 2009 will be the year when GPs’ concerns settle. Information governance issues will raise their head, but staff are the concern here, not technology. It’s important to understand that people have misbehaved with records in the past, but IT now shines a light on it.
The credit crunch will mean that we will have to justify any project that needs resources. People will take hard-line positions, saying, for example, that an intensive care baby unit is more important than an IT project, when they don’t understand IT. So we will need to be able to tell stories about how IT is delivering real benefits. We also need to get to the stage where if you switch off a project people will scream and shout. I think this will happen with the NHS Summary Care Record in two years’ time.
In 2009, I would also like to see the factions within the British Medical Association doing more to understand each other. We have the public health sector wanting data for research and the GPs wanting to hold on to it. This is not patient-centred. And I want to see patients getting a real understanding of what we are doing with HealthSpace and getting involved in a real way.
I expect to see IT equipment getting more expensive over the coming year, which will slow down or even reverse progress. We might see research and development budgets being cut back a little and people might have to make the same equipment last longer.
I can’t see the pace of the national programme changing, however, because such a large project has to be planned so much in advance. So I expect this will be business as usual. I would like to see the NHS continuing to go the way it is going in terms of getting rid of disparate systems and moving to a central system.
There has been a lot of concern about privacy recently, but how much this impacts on healthcare IT depends on how many laptops and memory sticks get left in the back of taxis or on trains over the coming months. A lot of effort is now going into protecting information and the NHS is acutely aware of the need to look after data. I don’t think the public will worry too much; unless, of course, there is another major blunder.
Overall, some familiar drivers will be the focus of the healthcare and, therefore, the healthcare technology industry in 2009. These include decreasing costs, particularly due to the economy. Electronic health records, picture archiving and communication systems and real time location systems all help bring down costs for providers because staff do not have to look for medical records, mail x-rays or store records.
Another driver will be to Improve quality of care, although this is more and more being linked to costs, for example by the National Institute for Health and Clinical Excellence. Technology such as clinical decision support, e-prescribing and business intelligence will help here. Another technology that improves efficiency, telehealth, will also increase access to care.
I think there will be two tiers of healthcare technology investments. Providers without electronic health records will invest in them, while those with electronic healthcare records will continue to invest in them, while adding more advanced technology.
As an analyst, I would like to see the following trends grow, although, in reality, they’ll move at a slow pace: increased adoption of the electronic health records; an increase in personal health record functionality (from Microsoft and Google); interoperability; and increased innovation – particularly around iPhone apps, social media and the internet.
The final report of Lord Darzi’s Next Stage Review of the NHS and the Operating Framework for the NHS in England 2009-10 highlight the role that technology can play in modernising health and social care. Primary care trusts are actively looking at new technologies such as telehealth, and the ways these can be implemented on the ground.
The Whole System Demonstrators will test the potential for telehealth to support care for those with complex health and social care needs. However, moving past these initial pilots will require the creation of a shared vision and belief in the impact of telehealth. More generally, it will also require the creation of a shared vision about the application of ICT, standardisation, training and education support for nurses, patients and carers; and access to secure funding streams. Only where there is strong leadership and a willingness to take a financial risk, will implementation be successful long term.
2009 will be a busy year. One thing that stands out is our work with the Continua Health Alliance, an industry body working on standardisation for putting technology into people’s homes. We should see the first products from these standards coming on stream in 2009. I am really looking forward to this; managing people in their own homes is one area where technology can really help.
As far as technology is concerned, I am currently thinking about how we can help community staff. I recently went on some home visits with community nurses and realised that getting out a laptop and printer in a patient’s home is completely unacceptable. Can’t we find something that better fits the way community staff work? It’s too much to expect one supplier to do it, but I’d like to get some universities involved in thinking about this.
Other technologies I am thinking about include cloud computing and Twitter – a sort of mini-Facebook that people who are constantly on the move, like me and consultants, can use for short messages to keep in touch.
The national programme is likely to be a continuing source of problems. It’s a deeply flawed project that wasn’t thought through properly from the start and I just don’t see any light at the end of the tunnel.
I’m not against investment in healthcare IT – it’s essential in order to make hospitals more efficient and to improve communication with patients. Many elements are important and successful, and telecare in particular has enormous potential, but we need to shift away from the big central record to local systems.
In 2009, I would like to see a genuine and thorough review of the whole project, just as we are having a review of the dentists’ contract. We should also be ditching any expenditure that we are not contractually committed to making until we have had that review.
Delays in the roll-out of systems such as Lorenzo are the least of the problems facing the national programme in 2009. NHS Connecting for Health’s centralised approach to procurement and data transfer may seriously inhibit IT’s capacity to improve care in the future, by failing to fulfil the differing demands of local health services and clinicians.
If the national programme is to steer a clear course through the economic hurdles ahead, a change of direction is required. But abandoning the NPfIT altogether, as the Liberal Democrats are proposing, is foolish – IT, properly harnessed, can bring real benefits to healthcare. The independent review that I have commissioned is therefore looking at the best option going forward, recognising that we do not have a blank slate. Written contributions are still welcome www.healthitpolicyreview.info.
I do not wish to prejudice the outcome of that review but it is becoming increasingly clear that a successful national programme would equip IT and health professionals for collaboration on a local level, freeing them to cooperate and build solutions organically from the grass roots upwards. Whether and how more control can be handed back to end users – the clinicians themselves – will characterise the debate that yet continues.
As we go into 2009, trusts are still at a bit of a crossroads as far as NHS Connecting for Health is concerned. Trusts will have to make a decision about whether to continue waiting or whether to develop their own, local systems further. At University Hospitals Birmingham NHS Foundation Trust, for example, we have developed our own e-prescribing solution and clinical dashboard; so I don’t think we will be taking up the CfH version in the foreseeable future.
One development I should like to see in 2009 is a national patient data set that we are defining already at this trust that includes patients’ views and experiences. I would like to see every trust in country having to submit a patient experience data set, because without that information you can’t work out how patients feel about their care.
I think that over the coming year, there will also be more use of data technology to help organise care, and push data-driven information out to operational staff. So, for example, if patient reaches the end of their expected length of stay, an automatic notification can be raised saying this, so the case can be reviewed.
From our point of view, the emphasis in 2009 is going to be on tools that are going to be utilised, not so much on what’s happening in the national programme. As an organisation, we will be focusing more and more on clinical benefit. People see IT as a vehicle for change; but change to do what? You need to look at a project and ask ‘does it deliver clinical benefit?’ If not, why do it? And how do you know whether it’s giving clinical benefit or not?
The other big thing for us will be mobilisation of data. At the moment, information is too often locked up in silos. But, for example, by looking at local population data you can start creating an individualised risk index based on what has happened to millions of patients. Then you can start asking questions like ‘is it safe and worthwhile for this patient to take statins?’ This leads to patient-centred care rather than organisation-centred care. Up to now NHS Connecting for Health has been producing silos of data, rather than operating in the outside world.
Clearly the national programme is behind schedule and one wonders if the credit crunch will force the government to review its investment priorities. I hope not, as effective information technology underpins the modernisation of the health service.
We feel full, contemporaneous record access will enhance safety and shared decision-making, so we are pleased that the General Medical Council, defence organisations and the Information Commissioner support this development as an extension of current good practice. However, we are concerned that the NHS Connecting for Health design of the Spine may pose risks to security and confidentiality – and that it will only be available in England. NHSA recommends a mix of the Spine and a distributed database approach, which is already available to 60% of practices in the UK.
It is clear that record sharing will become standard practice across the NHS over the next few years and that a culture shift is needed to root it into NHS consciousness. Training should be made available to ensure professionals and patients are confident in the process. In addition, NHSA is keen to extend discussions on the issue with national patient groups who have so much to gain from the introduction of record sharing.
2009 will be the crunch year for the national programme. We can’t have another year of not being successful in the acute sector. I am optimistic about it, but we need a balance between the NHS’ need to go further, faster and the programme’s need to maintain its structure so that we end up with an integrated national record.
There’s a need to keep this balance between local freedom and having a central record. The most important thing is to create inter-operability standards that will allow the NHS to do things locally, confident that they will be able to plug into the national system.
The financial position will also be very important. The NHS got a very good settlement, but we could now be into several years of no growth. The focus will be very much on value for money. In terms of informatics, there will be a focus on real-time operational management and clinical systems that can tell you about your bed occupancy now, not two years ago.
The government had planned that the rate of increase in healthcare funding would reduce from the high levels of recent years. Because of the current financial climate, it is certain that public spending will tighten further. I feel that healthcare IT generally will be focused on getting and maintaining best value for money in support of driving cost efficiencies and commissioning.
For 2009, I would hope to see a general opening up of the healthcare IT market. The pressure on NHS finance will mean that trusts will need to “sweat” the assets of existing information systems and to surround and supplement these where possible with clinical applications and better reporting capabilities.
The advent of newer technologies and standards will mean that clinical data capture and reporting become available on ever more convenient mobile devices, while integrated clinical portals will begin to deliver evidenced based protocols and fast drill down access to case-relevant diagnostic and treatment information.
I also hope we will see the information barriers between the government agencies, information stakeholders and authorised users finally being negotiated in the best interest of the patient, so that a mutually beneficial collaboration between social care and health care can emerge.