Two of the major healthcare concerns of the coalition government have been primary care and NHS IT. The interesting question is whether its policies on these subjects are aligned and, if they are, what the consequences will be.
Dr Glyn Hayes, president of the Primary Healthcare Specialist Group at the British Computer Society, and Simon Gill, software architect for iSOFT, believe the policies work in the same direction. However, they differ in how they see the immediate future.
Thesis and practice
The general thesis is this: the white paper ‘Equity and excellence: Liberating the NHS’ sets out a vision of clinically led commissioning, with GP consortia taking the lead. The recently announced adaptation of the NHS Programme for IT envisages more local autonomy. You can’t have one without the other.
Gill says his recent discussions with GPs suggest that the priorities for primary care IT are sharing information, using information to support the commissioning agenda, and finding ways to record outcomes.
The starting point for all this is enabling IT to work across care boundaries, something that has proved difficult in the past. However, Gill contends that the white paper puts GPs in the driving seat, and will lead to the wider adoption of technologies to support cross-care setting working.
Dr Hayes agrees with Gill’s policy analysis, but not with his conclusion. He says: “There is remarkably little demand for more IT. The ordinary GP is interested in what they need to make care for an individual patient – and by and large they have that.”
Dr Hayes argues that GP consortia, which will lead commissioning, may not have the clout or the inclination to drive through IT projects. “The value of informatics has to be driven into a lot of people before we will get movement,” he says.
It’s an argument that bears closer examination. Gill gives an example of the sort of technology he has in mind – delivering discharge summaries to GPs.
Despite a target to deliver these within 24 hours, despite the target being written into the NHS Operating Framework for 2010, despite the existence of mature technology, and – perhaps most damning – despite the acknowledged patient safety and efficiency benefits, few health economies have managed to achieve this.
Gill says: “In this day and age, with the technologies now available, 24 hours seems a long time. The discharge summary should be available to the GP and patient at the point that the patient exits the hospital.”
It’s not the only example. Direct electronic referral management and booking into local systems and GPs’ ability to order secondary care services – such as laboratory or radiology tests – and to see a full set of diagnostic results are also readily available as mature solutions. Yet they are not deployed as widely as they could be.
Gill suggests that the lack of local autonomy when it comes to IT has delayed the speed with which health economies have moved on these relatively easy gains. “There is a sense in which people have sat around waiting for the large scale national developments at the expense of working locally to address locally fixable problems,” he says.
In his view, the adaptation of NPfIT and the white paper will give primary care a chance to drive secondary care to move on these mature technology spaces. “The balance of power should shift to some degree.”
The issue, he says, is one of working across care provision boundaries. “At the root of this issue is the ability of the NHS to address boundaries where there is not a direct responsibility by any one organisation to fix the problem. The white paper is very much focused on removing these organisational boundaries. And it will remove the barriers to reasons why these fixes are not implemented.”
Dr Hayes, however, is sceptical. True, he says, the technology is in place and could deliver real benefits for individual patients under the care of a GP.
But, he says: “The problem is that these developments are now going to have to be done on a local level. Will there be the resources, inclination and capability to do them? Will a group of GPs in a consortium have the ability to drive hospitals to do it?
“It all has to be resourced. Hospitals by and large have said that they have other things that they need to spend their money on. Will the commissioning bodies say that instead of having 12 more cataract operations, they will have an IT project? We just do not know the answers to these questions.”
Breaking down boundaries
Beyond the quick wins, there are bigger and more evolving technologies – such as shared records. Gill says: “There are solutions, but fewer organisations have deployed capability in that space.
“We are talking tens rather than hundreds of UK health economies that have successfully started providing shared records, with agreed data sets moving from primary to secondary care and from secondary to primary care.”
Sharing is also an issue for telehealth. There is a debate to be had about how information from telehealth records can be incorporated into wider healthcare records.
And there is another to be had about creating a shared electronic prescribing record that would enable GPs and clinicians in secondary care to exchange information in a safe and structured way.
“These are all areas where a whole systems approach is needed,” says Gill. “Changing the boundaries changes the whole system.”
But is this what GPs want – and is moving the boundaries enough to deliver it? Again, Dr Hayes is sceptical. Sharing prescribing information, yes, but he sees record sharing as a “red herring”.
“As a GP, I do not need to know the results of tests done in a hospital ITU. I need the conclusions and details of the drugs a patient was put on. I do not see sharing of records being a high priority over discharge information and referral.”
He also questions whether the technical challenge is more complex than a matter of interoperability. “A lot of people talk about standards as being standards for interoperability; what they forget is you need standards for functionality too. The functionality is not there and this is a big technical challenge.”
The commissioning agenda
Another big question for primary care is how IT can support the commissioning agenda, for example how information can be used to inform decisions about what services are provided where, then monitoring the service that is actually being delivered.
Gill says: “We need smarter solutions in this space. There will be a big opportunity for business intelligence and resource management tools to help consortia with this issue.”
Feeding into this is the requirement in the white paper to measure patient outcomes, whether clinically recorded or patient reported outcome measures where patients report on the quality of services.
“This is a whole new agenda,” says Gill. “While there is an inherent functionality within our applications to address this, it has yet to be explored fully.”
The advent of self-service kiosks – generally touch screens where patients can announce their arrival for an appointment rather than speak to a booking clerk – are the start. Such systems can relatively easily be adapted to allow patients to feedback their views.
He expects to see a rapid increase in the development of patient portals where patients can book services on line. “They will make patients’ lives easier and facilitate electronic communication and structured recording of information,” he says.
Dr Hayes thinks this may be putting the cart before the horse. “Get somebody to define patient outcomes,” he says. “Whoever you ask will give you a different answer.”
The private sector has had some success using patient related outcome measures, for example by defining a patient’s problem as pain and difficulty moving, intervening with a hip replacement and the patient outcome being able to walk without pain. But much of general practice does not lend itself to this approach.
“With chronic diseases you do not have a defined start or end or point where you measure,” he says. “There is a huge amount of effort going into this. But what it means for general practice is very difficult to know.”
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