The National Health Service (NHS) is the publicly funded healthcare system provided by the UK Department of Health (DoH). It is mostly funded by taxation including national insurance payments and the majority of the DoH's spending is on the NHS (£98.6 billion for the year 2008-2009). They claim to be committed to providing quality care to meet the needs of everyone when they need it, based on a patient's clinical record and not their ability to pay (Heath, 2008). With such bold claims and with such vast sums of money spent on the service, they are instantly placed under huge pressure to deliver a high level of service. However, they have not always delivered to the standards that they strive and so they have had to try to redeem themselves. Hence, in October 2002, they established the National Programme for IT (NPfIT) and in April 2005, a new agency called NHS Connecting for Health (CfH) was formed to deliver the programme. This extremely ambitious project was an attempt to replace an ageing patchwork of 5,000 different computer systems with a single, centrally-mandated electronic care record for patients which would connect in excess of 100,000 doctors, 380,000 nurses and 50,000 other health professionals. (Heath, 2008)
There are 10 major components which are at the heart of the NHS IT project (Heath, 2008):
The Spine
The 'Spine' is the central database where electronic patient records known as summary cared records are stored. It is part of the NHS care records service (CRS) and only NHS staff that are equipped with smart cards and pin numbers will be able to access this information. The Spine also supports 2 other key components which are 'Choose and Book' and the 'Electronic Prescriptions Service'.
NHS Care Records Service (CRS)
This will provide doctors with instant electronic access to the medical records of patients, eliminating the need for paper and saves time in manually searching through documents. Each electronic medical record will be formed from information which may be held in various locations but is brought together when needed. A summary of the record is held on the Spine so that vital information such as name, address, date of birth and allergies can be readily accessed by doctors. More detailed information such as tests, X-rays and scans are held locally.
Choose and Book
This is an electronic booking service which gives GPs the ability to make hospital appointments at convenient times and places for patients. The system should cut lengthy delays between visiting the GP and receiving an appointment from a hospital which often takes weeks under the current system.
The Electronic Prescription Service (EPS)
Instead of using paper orders for prescriptions, EPS allows GPs to generate electronic prescriptions. This should improve accuracy and safety by ensuring prescription information is only inputted once. The EPS will also be combined with the CRS to record what medicines have been prescribed and actually given to patients. EPS is being implemented in 2 releases: the first adds barcodes to paper prescriptions to speed up repeat prescriptions while the second release will add electronic signatures to authorise electronic subscriptions.
N3 National Broadband Network
The N3 will replace the old NHSnet network infrastructure and will be one of the world's largest Virtual Private Networks (VPNs). The N3 is a high-speed broadband network vital for delivering new services such as X-ray storage service Pac (Picture Archiving and Communications System) and electronic prescriptions. The estimated savings from this new network are a massive £900m over a period of 7 years.
Picture Archiving and Communications System (Pacs)
This system allows images from X-rays and scans to be stored in a digital format, eliminating the need for using film. This will speed up the delivery of information as doctors will be able to access images remotely from laptops. Costs of storing and processing film will also be saved.
The Quality Management and Analysis System (QMAS)
QMAS is a national IT system which gives GP practices and primary care trusts feedback concerning the quality of care that is delivered to patients. It monitors the performance of each practice measured against national achievement targets. Additionally, it allowsGP's pay to be linked to performance, determining up to a third of their salary.
GP2GP Record Transfer
The GP2GP is a system which allows patient records to be transferred electronically between different practices and is particularly useful when a patient changes doctor. Currently, patient records are printed and posted and requires retyping at the other end but electronic transfers will not require this retyping, making it a more accurate, secure and faster approach.
NHSmail
The previous mailing system was known as 'Contact' but the new NHSmail is a more secure national e-mail and directory service developed by Cable and Wireless, and is freely provided for NHS staff. Users ofNHSmail have a permanent e-mail address which is kept as they move around the NHS. It also has some more advanced features such as calendars, shared folders and automatic encryption of e-mails.
Secondary Uses Service (SUS)
This is a database containing more than a billion confidential patient records used to improve NHS treatment and healthcare. Records are held on almost all patients in England who have stayed in hospitals, visited outpatients or attended accident and emergency. Data is analysed internally and encrypted data fromSUS is passed to the Dr Foseter Unit - an academic body which uses this data to analyse outcomes such as death rates in hospitals, with the ultimate intention of improving NHS Care.
Hailed as “the biggest non-military IT development in the world” (Guardian News and Media Limited, 2008), and is estimated to achieve savings of £1.1 billion by 2014 (National Audit Office, 2008). The National Audit Office expects the system to cost £12.7bn over 10 years and be complete by 2014-2015 (see table below). However, it was originally only expected to cost £2.3bn over 3 years and it is also now four years behind schedule. Worryingly, some officials involved in the program have been quoted in the media estimating the final cost to be as much as £20-30bn which exceeds the original budget by approximately 440-770%. (Fleming, 2004) This project may prove to be an over ambitious project by the government and appears to have fundamental flaws in its implementation and further delay could severely damage public confidence.
There are 10 major components which are at the heart of the NHS IT project (Heath, 2008):
The Spine
The 'Spine' is the central database where electronic patient records known as summary cared records are stored. It is part of the NHS care records service (CRS) and only NHS staff that are equipped with smart cards and pin numbers will be able to access this information. The Spine also supports 2 other key components which are 'Choose and Book' and the 'Electronic Prescriptions Service'.
NHS Care Records Service (CRS)
This will provide doctors with instant electronic access to the medical records of patients, eliminating the need for paper and saves time in manually searching through documents. Each electronic medical record will be formed from information which may be held in various locations but is brought together when needed. A summary of the record is held on the Spine so that vital information such as name, address, date of birth and allergies can be readily accessed by doctors. More detailed information such as tests, X-rays and scans are held locally.
Choose and Book
This is an electronic booking service which gives GPs the ability to make hospital appointments at convenient times and places for patients. The system should cut lengthy delays between visiting the GP and receiving an appointment from a hospital which often takes weeks under the current system.
The Electronic Prescription Service (EPS)
Instead of using paper orders for prescriptions, EPS allows GPs to generate electronic prescriptions. This should improve accuracy and safety by ensuring prescription information is only inputted once. The EPS will also be combined with the CRS to record what medicines have been prescribed and actually given to patients. EPS is being implemented in 2 releases: the first adds barcodes to paper prescriptions to speed up repeat prescriptions while the second release will add electronic signatures to authorise electronic subscriptions.
N3 National Broadband Network
The N3 will replace the old NHSnet network infrastructure and will be one of the world's largest Virtual Private Networks (VPNs). The N3 is a high-speed broadband network vital for delivering new services such as X-ray storage service Pac (Picture Archiving and Communications System) and electronic prescriptions. The estimated savings from this new network are a massive £900m over a period of 7 years.
Picture Archiving and Communications System (Pacs)
This system allows images from X-rays and scans to be stored in a digital format, eliminating the need for using film. This will speed up the delivery of information as doctors will be able to access images remotely from laptops. Costs of storing and processing film will also be saved.
The Quality Management and Analysis System (QMAS)
QMAS is a national IT system which gives GP practices and primary care trusts feedback concerning the quality of care that is delivered to patients. It monitors the performance of each practice measured against national achievement targets. Additionally, it allowsGP's pay to be linked to performance, determining up to a third of their salary.
GP2GP Record Transfer
The GP2GP is a system which allows patient records to be transferred electronically between different practices and is particularly useful when a patient changes doctor. Currently, patient records are printed and posted and requires retyping at the other end but electronic transfers will not require this retyping, making it a more accurate, secure and faster approach.
NHSmail
The previous mailing system was known as 'Contact' but the new NHSmail is a more secure national e-mail and directory service developed by Cable and Wireless, and is freely provided for NHS staff. Users ofNHSmail have a permanent e-mail address which is kept as they move around the NHS. It also has some more advanced features such as calendars, shared folders and automatic encryption of e-mails.
Secondary Uses Service (SUS)
This is a database containing more than a billion confidential patient records used to improve NHS treatment and healthcare. Records are held on almost all patients in England who have stayed in hospitals, visited outpatients or attended accident and emergency. Data is analysed internally and encrypted data fromSUS is passed to the Dr Foseter Unit - an academic body which uses this data to analyse outcomes such as death rates in hospitals, with the ultimate intention of improving NHS Care.
Hailed as “the biggest non-military IT development in the world” (Guardian News and Media Limited, 2008), and is estimated to achieve savings of £1.1 billion by 2014 (National Audit Office, 2008). The National Audit Office expects the system to cost £12.7bn over 10 years and be complete by 2014-2015 (see table below). However, it was originally only expected to cost £2.3bn over 3 years and it is also now four years behind schedule. Worryingly, some officials involved in the program have been quoted in the media estimating the final cost to be as much as £20-30bn which exceeds the original budget by approximately 440-770%. (Fleming, 2004) This project may prove to be an over ambitious project by the government and appears to have fundamental flaws in its implementation and further delay could severely damage public confidence.
(National Audit Office, 2008)
Implementation of the programme was divided into 5 areas of England known as "clusters" and a different Local Service Provider (LSP) was responsible for delivering services to these regions. In total, 4 suppliers were contracted who were CSC Alliance, BT Health London, Accenture and Fujitsu. This strategy was effective in reducing risk as committing to only one supplier would mean that the whole project could fall apart if they did not deliver to expectations. However, the NHS has been putting its main suppliers under immense pressure as it has tried to keep within budget and there have been consequences. In July 2007, Accenture pulled out of the project and in May 2008, Fujitsu had their contract terminated and now only half of the of the original IT providers remain.
A number of these programmes have met their deadlines and have been implemented across the NHS such as the N3 broadband network,Pacs digital X-ray scheme and an Electronic Prescription Service. However the Summary Care Records Scheme has been delayed due to technical problems relating to iSOFT’s Lorenzo patient software and disagreements over patients being asked for their consent for their medical records to be digitized. Consequently the dates for the new systems to “go live” have been delayed.
One of the most important issues with regards to the patient record system is that information stored is kept confidential and secure. The NHS has developed ‘Care Record Guarantee’ guidelines which must be adhered to in handling this electronic data. Access to records through smartcards and passcodes are dependent upon the role and level of involvement within patient care and can be audited. Any departures from these rules result in strict disciplinary measures being taken for unacceptable misuse of this information.
It is questionable whether this level of security is enough, with 50 million people’s records on the database. In 2004, the NPfIT won the "Most Appalling Project" Big Brother Award for their plans to computerise patient records whilst neglecting the need for adequate privacy safeguards. Another reason which underlines the opinion that security is a fundamental issue is that there is actually no option to opt out of having your demographic details stored unless there are special circumstances such as if the police or social services requests these details to be kept off the database. Therefore many public and private sector workers can quite easily gain access to details such as your address and phone numbers from social workers and pharmacists for example. Reasons such as this have prompted civil liberties campaigners such as the anti-database state pressure group, NO2ID, and The Big Opt Out to voice their concerns over confidentiality and the security of medical data uploaded to The Spine. The adoption of encryption and digital signatures would help to reinforce the security of this information but question marks still remain over whether the level of security will be sufficient.
There are a number of issues that must be considered in the government’s decision to go ahead with this massive investment in the NHS. Past experiences highlight the government’s incompetence in the management of such large scale IT projects.
The Rural Payments Agency (RPA), who are responsible for managing farm subsidy payments in the UK were prevented from achieving targets they had set due to a combination of IT failures and poor management. A Single Payment Scheme was established by EC Council Regulation 1782/2003 which replaced eleven separate payments to farmers.
The RPA developed custom software and created databases where data was stored on computers disconnected from the main system. However this was a fundamental error as the system required the data in order to function correctly. Overall this project highlighted incompetence in terms of project management, inexperience and poor planning. This had a detrimental effect upon farmers who required such subsidies in order to maintain their activities.
Another example of mismanagement is the failure of the upgrade to the Air Traffic Control System (NATS). The failure of the project was due to poor management, its lack of managerial and technical competence. The use of three different service providers did not help to maintain effective control over the system and despite 450,000 hours of testing two million lines of code (Erskine, 2002) it still had a number of breakdowns. This was due to bugs, a lack of stability and reliability in the system which resulted in flight delays and cancellations.
In summary, the implementation of IT software to create an electronic patient database is necessary in order to improve efficiency and the standard of care. When the project is eventually completed, the benefits should become apparent, with patients benefiting from having shorter waiting times and faster treatments. However, it is essential that such an investment must provide significant savings in the long term to an already expensive health system. Otherwise taxpayer’s money which should be spent on patient care and wellbeing is squandered on untested technology.
A number of these programmes have met their deadlines and have been implemented across the NHS such as the N3 broadband network,Pacs digital X-ray scheme and an Electronic Prescription Service. However the Summary Care Records Scheme has been delayed due to technical problems relating to iSOFT’s Lorenzo patient software and disagreements over patients being asked for their consent for their medical records to be digitized. Consequently the dates for the new systems to “go live” have been delayed.
One of the most important issues with regards to the patient record system is that information stored is kept confidential and secure. The NHS has developed ‘Care Record Guarantee’ guidelines which must be adhered to in handling this electronic data. Access to records through smartcards and passcodes are dependent upon the role and level of involvement within patient care and can be audited. Any departures from these rules result in strict disciplinary measures being taken for unacceptable misuse of this information.
It is questionable whether this level of security is enough, with 50 million people’s records on the database. In 2004, the NPfIT won the "Most Appalling Project" Big Brother Award for their plans to computerise patient records whilst neglecting the need for adequate privacy safeguards. Another reason which underlines the opinion that security is a fundamental issue is that there is actually no option to opt out of having your demographic details stored unless there are special circumstances such as if the police or social services requests these details to be kept off the database. Therefore many public and private sector workers can quite easily gain access to details such as your address and phone numbers from social workers and pharmacists for example. Reasons such as this have prompted civil liberties campaigners such as the anti-database state pressure group, NO2ID, and The Big Opt Out to voice their concerns over confidentiality and the security of medical data uploaded to The Spine. The adoption of encryption and digital signatures would help to reinforce the security of this information but question marks still remain over whether the level of security will be sufficient.
There are a number of issues that must be considered in the government’s decision to go ahead with this massive investment in the NHS. Past experiences highlight the government’s incompetence in the management of such large scale IT projects.
The Rural Payments Agency (RPA), who are responsible for managing farm subsidy payments in the UK were prevented from achieving targets they had set due to a combination of IT failures and poor management. A Single Payment Scheme was established by EC Council Regulation 1782/2003 which replaced eleven separate payments to farmers.
The RPA developed custom software and created databases where data was stored on computers disconnected from the main system. However this was a fundamental error as the system required the data in order to function correctly. Overall this project highlighted incompetence in terms of project management, inexperience and poor planning. This had a detrimental effect upon farmers who required such subsidies in order to maintain their activities.
Another example of mismanagement is the failure of the upgrade to the Air Traffic Control System (NATS). The failure of the project was due to poor management, its lack of managerial and technical competence. The use of three different service providers did not help to maintain effective control over the system and despite 450,000 hours of testing two million lines of code (Erskine, 2002) it still had a number of breakdowns. This was due to bugs, a lack of stability and reliability in the system which resulted in flight delays and cancellations.
In summary, the implementation of IT software to create an electronic patient database is necessary in order to improve efficiency and the standard of care. When the project is eventually completed, the benefits should become apparent, with patients benefiting from having shorter waiting times and faster treatments. However, it is essential that such an investment must provide significant savings in the long term to an already expensive health system. Otherwise taxpayer’s money which should be spent on patient care and wellbeing is squandered on untested technology.
This assignment was produced in collaboration with Rishi Chada
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