In a March 2010 report on the future of NHS IT by think tank 2020health, attention is drawn to a quote from a 2006 policy report by the Royal Society. It reads: "Information and communication technologies (ICTs) have the potential to transform radically the delivery of healthcare and to address future health challenges."
It continues: "Whether they actually do so will depend on the design and implementation processes sufficiently accounting for the users' needs, and the provision of adequate support and training after their introduction."
Very few observers around the world deny that the principle of healthcare IT, which facilitates the likes of electronic health records (ECRs), e-prescriptions, remote healthcare and enhanced communication and collaboration throughout national and international medical communities, has immense intrinsic value, especially as healthcare becomes less centralised. The key issue, as the Royal Society quote articulates, is the complexity involved with its implementation.
NPfIT and the complexities of e-health
Originally conceived in 2002 after several studies by the UK Department of Health and the Statistics Commission, the National Programme for IT (NPfIT) set out to develop and implement an IT infrastructure for the NHS in England. Responsibility for delivering the programme was passed in 2005 to newly created organisation Connecting for Health (CfH). The overarching goals included connecting GPs and hospitals around the country through access to a comprehensive summary care record (SCR) for patients via the "Spine", a central system used to store clinical data. Other deliverables included innovations like e-prescribing, medical imaging software and a central NHS e-mail and directory system.
In the years following the birth of CfH, the programme has been dogged by accusations of skyrocketing costs (with estimates ballooning to £12.4bn from £2.3bn at the project's outset), poor patient privacy standards and a general lack of progress. NPfIT has also had little success engaging GPs.
In fact, in July the former chairman of the British Medical Association's IT committee called for a GP boycott of the SCR after it was found that one in ten patient records uploaded in Birmingham contained inaccurate and potentially dangerous medical information. Medical organisations have also criticised the fact that doctors anywhere in the country can access patients' information unless a patient specifically opts out.
2020health chief executive Julia Manning notes that the programme's problems were caused by unrealistic expectations and poor communication. "The project was over-ambitious, trying to do everything all at once," she says. "The time frame was unrealistic and politically driven. There was a gulf between those who were going to use the IT and the planners that was not appreciated for a long time and led to misunderstandings and miscommunication."
With the new coalition government making heavy cuts to reduce the UK's financial deficit, this ambitious and troubled programme might seem a tempting target for budget slashes. 2020health's report was put together to advise the new government on how to proceed with implementing NHS IT in a cost-efficient manner.
Fixing NHS IT
2020health's report, "Fixing NHS IT: A Plan of Action for a New Government", was intended to provide the incoming government with a clearly presented guide to learning from the mistakes of the past and capitalising on the obvious benefits of healthcare IT systems, according to Manning. "We were aware that with all the negativity around CfH that after a change of government, a new administration could benefit from an overview of the NHS IT situation and a considered plan of how to retain what had worked, how to develop what was good, where the gaps were and what should be ditched," she says.
The report, written by 2020health consultant director and e-health expert John Cruickshank, presents a compelling set of recommendations to get NPfIT back on track.
These recommendations are tied to five core pillars: accelerating the benefits of NHS IT, exploiting and developing on existing achievements, reviewing or repurposing questionable aspects, enabling local IT, and forming a coherent organisational strategy.
One of the primary ideas pushed by the report is a more flexible relationship between IT at local and national levels. The importance of retaining key national IT infrastructure, such as the Spine, is emphasised, as is the centre's role to establish standards and interoperability.
As the UK's medical landscape becomes increasingly federalised (with more autonomy being granted to local healthcare authorities), the report recommends that local providers are given the freedom to use IT to meet their own clinical priorities within the established national standards framework.
The report also calls for an immediate halt in the deployment of summary care records while a review can take place to address the concerns expressed by the British Medical Association and other groups about privacy and the factual inaccuracy of some files. This could go some way to engage medical staff and make them understand that IT is an asset for patient care rather than a millstone around their necks. "This was one of the key problems from the start," says Manning. "It was marketed as an IT programme instead of a healthcare improvement programme and resistance came from a lack of involvement and engagement of front-line staff, who were done-to instead of done-with."
Another way of convincing doctors that IT is beneficial is the development of collaborative technologies, allowing healthcare professionals to communicate more easily. The report specifically highlights the recently audited accident and emergency department at Nottingham University Hospital as an example of the efficiencies that IT communications technology can bring. Nottingham's A&E department has achieved a reduction of 23% and 33% in journey times for adult and paediatric patients respectively, along with a 12% increase in clinical productivity. The European Commission credited the improvements to "re-engineering the day-to-day working processes of [Nottingham's] emergency department". 2020health's report states that these benefits could be transferred if collaborative technologies were rolled out across acute care hospitals and community care systems.
In terms of international examples from which the NHS could draw inspiration, Manning praises several individual schemes while maintaining that integrated healthcare IT has not yet been seen on a national scale anywhere.
"There are impressive systems used in other countries but not at a national level," she says.
"Examples of great practice include the work done by Kaiser Permanente on patient management and prescribing; in Norway where they have automated hospitals where care comes to the patient's room and all equipment is electronically tracked, booked and located; and in Spain with the paperless hospital."
E-health in the UK stands at a pivotal fork in the road. Despite the huge investment channelled into its development during the country's boom years, progress has been tortuous and engagement (both on a public and professional level) remains low.
While the UK, and many countries, have impressive pilot projects in development, the complex task of creating a solid national system is an essential hurdle, and worth heavy investment to achieve higher levels of patient care and healthcare efficiency.
Manning remains fairly tight-lipped about whether the UK's new government is paying heed to 2020health's report, saying only that "they are reviewing the SCR and talking to us about NHS IT development." Although billions of pounds have already been spent on developing NPfIT, it remains to be seen whether Prime Minister David Cameron will see through the project's troubled past to its inherent potential.