Time to change the record?

E-Health Insider’s Sarah Bruce gauged reaction to the Conservatives’ response to the independent review of NHS IT and found concerns that a new approach may ditch hard won gains.

This week the Tories set out plans to make NHS IT locally driven, dismantle national infrastructure, re-negotiate the main contracts for the NHS National Programme for IT and potentially put personal health records online.

The plans mostly derived from the recommendations of the Independent Review of NHS and Social Care IT, which said devolution of choice and patient record systems is essential with national systems to be kept to a bare minimum. But has confounded some critics by backing the continued need for a National Programme for IT.

The review calls for the ending of the national patient database, the personal spine information service, but the Conservative’s go much further and say they will abolish national IT infrastructure including much of the NHS spine, including the national summary care record.

Ross Anderson, a noted Cambridge University professor and information security specialist said “We had all expected the report to say that NPfIT should be shot; instead it says NPfIT should be kept but changed utterly-that’s just spin.”

Anderson added that the Conservatives had also missed the point and that: “It’s not just small and localised systems that we need as much as under clinical control to ensure decent functionality and quality. Systems have to be bought by doctors and not civil servants.”

He said he would also like to see all systems decentralised referring to “the central direction of some key clinical systems as “weak spots” leaving “too many loopholes for the centralisers to strike back.”

Dr Vivienne Nathanson, head of science and ethics at the BMA, also backed the call for devolution: “There have been major problems with the national NHS IT programme and we support the principle of greater local decision-making.”

Babies and bathwater

However, despite NPfIT’s failures- particularly on the detailed local care record systems – others argue we have come too far to let go of the vision of secure shared electronic patient records. They argue that to ditch the main thrust of the programme now would be to lose the chance of achieving this vision, just when it is coming within reach.

Ironically the review and the Conservative response both reaffirm the importance of this central vision, even if it then recommends ditching the infrastructure built up to achieve it.

Frances Blunden, senior policy manager for NHS Confederation, told EHI: “At this stage in the game we should be building on what progress has been made and not just throwing it away, however, there is a need for more local flexibility.”

She added that hard won lessons have been learned: “Trusts like the Royal Free may have had their problems but they are learning from the lessons and building on that. I’m not saying that the National Programme doesn’t need to change but I don’t think we should be throwing the baby out of the bathwater yet.”

Gayna Hart, managing director of systems integration supplier, Quicksilva, who specialise in integration with the NHS Spine, also said that “abandoning the National Programme would be “a waste of considerable time and effort.”

Move to local choice already underway

However, Mike Davis, a senior analyst at Ovum. said there was clearly a need for trusts to have more choice, with some already voting with their feet: “Already trusts are no longer just sitting there and waiting for an electronic patient record system, they realise that there is no one size fits all approach and are going out and finding systems themselves.”

Davis said the way some trusts in the South of England look likely to be offered “acute systems of choice,” funded as part of the National Programme for IT, was already providing the move towards the choice proposed by the Tories.

Connecting for Health said in a statement that the independent review and the idea for localised IT systems is “nothing new” and that “the programme is already being delivered locally.”

CfH said the local electronic patient record systems provided already store records locally. “For example, detailed records will continue to be held locally in an electronic form, enabling hospitals and GPs to easily access information in order to deliver the best service for patients.”

The crucial difference is that the CfH approach is underpinned by the standardised national infrastructure and services known as the NHS spine, which the Conservatives say they will abolish.

Lack of clarity on Tory plans

The Tories say that the same benefits will be “delivered through interoperable local systems,” able to exchange data through messaging. But details of how this will work, minus the spine, are vague. “There is no real clarity,” said Blunden.

Perhaps the most telling difference is that the spine is a reality now while a replacement approach based on local messaging may take years to specify and build. Blunden summed up the problem: “The Tories want to do a lot of things but are unsure whether they can or cannot, there are a lot of unanswered questions.”

Perhaps the most difficult of these is the reality of the LSP contracts: “They want to renegotiate the LSP contracts but they don’t know if they can they also want localised IT but they don’t know how it will be funded-it’s all very vague,” said Blunden.

Talk of Google a distraction

Much of the national media coverage has focused on the Tories decision to make headline grabbing announcements on letting Google or Microsoft host online medical records. Sources close to the review say there was a desire by Conservative Central Office to come up with ‘exciting’ blue sky thinking which the review largely eschews for practical recommendations based on the here and now.

Interestingly the Google proposal is one that has divided the Tory party, with former shadow home secretary, David Davis writing in the Times “Google is the last company I would trust with data belonging to me.”

Mik Horswell UK spokesperson for UKCHIP, and member of the UK council for health informatics professionals and ASSIST, told EHI that the idea of such companies being in control of his health “scares him stiff” and that he “cannot get his mind around the idea.”

Horswell added: “I’m really quite suspicious about it. The Tories say they want to scrap the monolithic national database but instead of the government having the records, a huge American company will have them. Who do we trust more the Department of Health and British government or Microsoft and Google?!”

The NHS Confederation’s Blunden is also skeptical about the idea. “It seems like a bit of a gimmick or window dressing by the Conservatives. They are focusing on what seems to be the patient facing side they appear to be ignoring the fact that we need proper systems in hospitals to feed such a record,”she said.

Dr Nathanson added: “The BMA strongly supports the principle of patients controlling their own medical records. However, we have concerns about the security of web-based systems, and the implications of data being held by the private sector. There would need to be very strong safeguards and an accurate audit trail making it clear what changes or deletions had been made to records and by whom.”

The Tories appear to have parked the idea for now at least and have launched a consultation, inviting responses about how much control patients want over their information. As an idea it may well return soon.

As Ovum’s Mike Davis concluded: “The whole idea is not completely off the wall, people hold all kinds of precious things online including bank details, password on sites like Google and Yahoo and pictures on social networking sites. The argument isn’t that we can’t have patient records online-it’s just that we have never done it.”