The Obstetrician & Gynaecologist 2008;10:1:27-32
doi: 10.1576/toag.10.1.027.27374
Copyright © 2008 by the Royal College of Obstetricians and Gynaecologists.
NHS Connecting for Health and the National Programme for Information Technology
Su-Yen Khong, MRCOG, Specialist Registrar1,
Ian Currie, FRCOG, Consultant in Obstetrics and Gynaecology2 and
Simon Eccles, FRCS(Ed) FCEM, National Clinical Director, NHS Connecting for Health; and Consultant in Emergency Medicine3
1. Department of Obstetrics and Gynaecology, The Women's Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
2. Department of Gynaecology, Stoke Mandeville Hospital, Mandeville Road, Aylesbury HP21 8AL, UK Email: ian.currie{at}buckshosp.nhs.uk (corresponding author)
3. Homerton University Hospital NHS Foundation Trust, Homerton Row, Homerton, London E9 6SR, UK
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Abstract
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Key content:- NHS Connecting for Health aims to introduce modern computer systems into the National Health Service (NHS) nationally to integrate patient care.
- The NHS Care Records Service (NHS CRS) comprises national (the ‘Spine’) and local databases.
- The maternity Do Once and Share (DOAS) programme looks specifically at the needs of maternity units through locally based action teams.
Learning objectives:
- To understand how engagement with clinicians and representatives from the RCOG will be paramount in the successful development of the National Programme for Information Technology (NPfIT) in maternity care.
- To learn about the Secondary Uses Service (SUS), which uses anonymous patient data to study public health trends, efficacy of treatments and planning of NHS needs.
Ethical issues:
- What concerns will there be regarding breach in patient confidentiality with accessibility to electronic health records, particularly in obstetrics and gynaecology?
Please cite this article as: Khong S-Y, Currie I, Eccles S. NHS Connecting for Health and the National Programme for Information Technology. The Obstetrician & Gynaecologist 2008;10:27–32.
Keywords confidentiality / Do Once and Share (DOAS) / NHS Care Records Service (NHS CRS) / NHS Connecting for Health / National Programme for Information Technology (NPfIT)
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Introduction
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NHS Connecting for Health is an agency of the Department of Health, which aims to deliver the National Programme for Information Technology (NPfIT). This multibillion pound investment started on 1 April 2005 and was intended to span the following 10 years.1 Its purpose is to bring modern computer systems into the NHS. This will improve patient care and services by connecting over 100 000 doctors, 380 000 nurses and 50 000 healthcare professionals in England to almost 300 hospitals; it will also give people access to their personal health and care information.2
Implementing the NPfIT is a huge undertaking because of its size and complexity. Previous large-scale health service IT projects in the UK and other countries, such as Australia and the USA, have proved very difficult or have failed because of organisational, sociocultural and technical factors.3–5 Despite the anticipated range of benefits from the NPfIT to patients, staff and the NHS, there has been much criticism and scepticism regarding the largest and most costly healthcare development programme in the world.
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Implementation of NPfIT
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New technology and information systems are implemented in planned phases both at national and local levels. National Application Service Providers are responsible for purchasing and integrating IT systems common to all users nationally. Locally, this will be provided by Local Service Providers across ten strategic health authorities in England (see Figure 1) grouped into three regional programmes. They will ensure that existing local systems are compliant with national standards and that data are able to flow between local and national systems. Each regional programme has an alliance with its chosen supplier of software and services and this varies from region to region as illustrated in Figure 1.6–8
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Figure 1
The National Programme for IT in England: the country is split into three areas, each of which has a Local Service Provider (LSP)
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There are several key components within this programme that have been set up to deliver the new IT systems and services:- N3 (the National Network)—this provides the IT infrastructure and broadband connections for the NHS to enable patient information to be shared between organisations.9
- NHS Care Records Service (NHS CRS)—every patient in England will have an individual electronic NHS care record, which can be accessed easily and securely by the patient and healthcare professionals. This aims to enable efficient treatment and diagnosis, while reducing administrative and clinical errors. Information held at national (the Spine: see below) and local levels (for example, the Picture Archiving and Communication System: see below) will together form the NHS CRS.2,10,11
- Spine—a national central database, which stores the summary of patient records and forms the backbone of the NHS CRS records. It contains key data such as NHS numbers, demographic details, drug allergies, medications and significant diagnoses or problems. It will also point clinicians to where more detailed information is held, including contacts of care providers.2,12
- Choose and Book—an electronic booking service that provides people requiring specialist referral with a choice of at least four hospitals or clinics commissioned by their primary care trust. People are able to book initial outpatient appointments at a time, date and place that suits them. Using the directory of services better enables consultants to ensure the right person is booked into the right clinic. This will reduce the lengthy wait between a person's visit to the general practitioner and the hospital appointment, as well as reducing the number of ‘did not attends’.2,13
- Electronic Prescriptions Service (EPS)—this service allows a prescription to be sent directly from the general practitioner or hospital doctor to the pharmacy, making prescribing and dispensing safer, easier and more convenient for patients.2,11,14
- Picture Archiving and Communication System (PACS)—images such as X-rays and scans will be captured, stored and displayed electronically rather than being printed on film. Healthcare professionals will be able to assess these images without any delay, resulting in faster diagnosis and treatment.2,15
- Quality Management and Analysis System (QMAS)—provides general practitioners and primary care trusts with feedback on the quality of care delivered. This service also enables an efficient method of transferring health records when a person changes their general practice.2,16
- NHSmail—a central email and directory service for the NHS, which is secure enough to enable efficient transfer and exchange of patient information.2 NHSmail email addresses (name@nhs.net) remain constant throughout NHS employment.
- Secondary Uses Service (SUS)—this provides anonymous patient data for purposes other than direct clinical use, including studying public health trends, efficacy of treatment and planning NHS needs, such as numbers of hospital beds and members of staff. This will provide useful information for other NHS initiatives, such as Payment by Results, which will dictate how money is distributed within the NHS.17
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Engagement with clinicians
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Engaging clinicians and NHS management in planning and preparation for the successful implementation of the national programme is an important priority.
While more than 4000 clinicians have been involved with the development of the programme, the Medix survey18 of 1329 doctors revealed that only 5% of respondents thought they had received adequate personal consultation about the NPfIT. More than half claimed to have received little or no information and 6% had never heard of the programme. Hendy et al.19 identified that one of the biggest challenges is to make the NHS staff feel optimistic and embrace the IT changes with enthusiasm. So far, morale amongst front-line staff has been low because of lack of communication between the NPfIT headquarters, Local Service Providers and Trust managers. There is also an unrealistic timetable for implementation: staff must cope with disruption and uncertainty without being able to perceive the long-term future benefits.
In Autumn 2004, a team of national clinical leads were appointed to engage with the Medical Royal Colleges, professional bodies and other clinicians to communicate between the programme and the NHS, as well as liaise closely with the Care Record Development Board (CRDB).20,21 One of the mechanisms they use to engage and consult with the Medical Royal Colleges (including the RCOG) and professional bodies is the National Advisory Group (NAG). Its members represent the medical profession, nurses and midwives, allied health professionals and healthcare scientists. These representatives meet quarterly to feed back, review and discuss key elements of the programme, such as role based access control.22 This enables healthcare professionals to be involved with the development of national standards and the design of software and computer systems.
The RCOG has not stated a view on the NPfIT programme but by way of representation is clearly engaged in the process. To date, the National Advisory Group has provided a structure for NHS Connecting for Health to begin to engage with clinicians and seek their views at a high level within the programme. This has involved a series of presentations, workshops and constructive debates. Although this is informative to the clinicians involved in this process, it is how this information is cascaded down to RCOG Fellows and Members that is important. A hierarchical structure to the clinical input of the programme is not what is wanted. However, through the new NPfIT Local Ownership Programme (NLOP), the situation may change. As of 1 April 2007, strategic health authorities are now responsible for delivering the programme into their local Trusts, so there is more impetus for clinicians to get involved with the design, building and testing of software at every level. The hope is that this will result in software better suited to local clinical need.
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The Do Once and Share (DOAS) programme
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In addition, the Do Once and Share programme was set up to enable clinicians to share their knowledge, skills and experience.23 The aim, through action teams based in local health communities, was to produce the best approach to care for people with a particular medical condition. This was intended to minimise duplication of work and optimise the use of new IT systems and services delivered by NHS Connecting for Health. For example, a maternity Do Once and Share programme looked specifically at the needs of maternity units and clinicians in the UK over an 18-month period. The team developed a large stakeholder network that will soon communicate electronically through the Connecting for Maternal Health website (see Websites). They were also involved with the development of electronic care pathways and dataset development that fed back to NHS Connecting for Health. This latter aspect proved difficult because of the lack of an agreed national maternity dataset, despite previous efforts over the years. Other achievements included the production of an evidence-based guideline database, an implementation handbook for maternity units and a mapping of the current maternity information systems in use throughout England.24
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Benefits of NPfIT
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There are certainly many benefits to patients, clinicians and the NHS with the introduction of this programme. Easier access to comprehensive patient details will enable a link between community or primary health care and secondary care to be set up. This will improve communication between healthcare professionals and promote a multidisciplinary approach, speeding up referrals and handover of patient care. This may reduce the number of hospital admissions and increase the level of care within the community. The programme promotes a patient-centred approach, where people have access to their own health records (with the ability to add personal details and initiate corrections), which helps to educate people and encourage them to assume responsibility for their health.
Specifically in obstetrics, community midwives will be able to book women at home with direct access into the maternity database. Using the Picture Archiving and Communication System, images such as obstetric scans requiring advice from a fetal medicine specialist can be transferred electronically from secondary to tertiary care, securely and without delay. In addition, with input of patient information directly into a national maternity database, healthcare professionals can access women's details from any unit in England. This will provide accurate, up-to-date information, while reducing administrative work. When arranging an in utero transfer, for example, the receiving obstetric unit will have access to information regarding care, together with vital details, even before the woman is transferred. The receiving clinician can, therefore, have much more information prior to agreeing transfer.
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Problems with the national programme
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There has been much criticism and scepticism regarding this multibillion pound investment into new information technology by the NHS. Firstly, progress in the NHS Connecting for Health programme is already behind the Government's target in certain areas. One of the key components of the programme, Choose and Book, has missed its target of universal electronic booking by the end of 2005.25,26 It may, therefore, be ambitious of the Government to expect the NHS CRS to be implemented by 2008. Secondly, there is a need to replace existing software in NHS organisation with ‘Spine compliant’ systems, supplied under centrally funded arrangements by Local Service Providers. NHS Connecting for Health is delivering two secondary care software systems: iSoft Lorenzo® and Cerner Millennium®. These need to be interfaced with existing systems in some cases. Different hospital Trusts are at different stages with the NHS Connecting for Health programme, with some Trusts being installed with advanced technology and services whilst others are still waiting.26 In addition, hospital Trusts that are already struggling financially have difficulty devoting resources into training and hardware for the new IT systems.27 Thirdly, delays in the arrival of new software to be installed are forcing some local Trusts to procure new systems outside the NHS Connecting for Health programme. This may result in problems with software compatibility.28
Nevertheless, common user interface computer programs have been written to produce a consistent look and feel so that healthcare professionals working with different computer services and technology will find it easier to navigate through the different systems safely. Finally, the British Computer Society reported that one of the major weaknesses of NHS Connecting for Health is that it lacks business context with policy implementation without associated informatics planning (for an explanation of informatics, please see Box 1). The programme has not taken reforms, such as Payment by Results, the 18-week patient pathway and practice-based commissioning, into consideration. The British Computer Society has recommended that the programme urgently needs to align implementation schedules with the timetable for these NHS reforms. To encourage local implementation, the programme needs to be business-driven rather than IT-led, to demonstrate to Trust management, who have other financial demands, that information technology is vital to improving efficiency and quality of care. Indeed, it is fundamental to service delivery and service reform and to enable NHS Trusts to thrive in a competitive environment.29
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Patient confidentiality and security issues
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Patient confidentiality is a concern with accessibility to electronic health records.30,31 Systems need to be in place to ensure that information is secure and will only allow access to authorised healthcare personnel.32 Different levels of access to the database will depend on the role of the user in relation to the patient. An audit trail to identify healthcare personnel accessing a particular medical record via personalised smartcards with PINs can deter inappropriate access to the database. Any breach in patient confidentiality or misuse of information can be traced.29
People have the right to opt out of having a summary care record and sharing their detailed care record (local health record). They can also choose to have a summary care record and to restrict the information that is available to view through the concept of ‘sealed envelopes’.2 There is concern from clinicians that this could prevent access to crucial information that could affect the quality of patient care and management. Awareness of sexual health information, such as sensitive data on sexual history and partners, sexually transmitted disease and HIV status is important to the clinician.
In addition, with people being able to access their own care records, clinicians may be discouraged from entering particular details into case notes because of the worry of potential litigation or complaints that could be made against them. Examples include social circumstances or information regarding a third party, such as a family member.
Clinicians can also withhold information from the patient by using the ‘sealed envelope’ but this must be balanced against maintaining the doctor–patient relationship. The Care Record Development Board continue to work on several practical issues, for example, sharing information with non-NHS bodies, such as local authority social services, and special issues relating to children and young people.29 Debate concerning the security issues surrounding computerised databases and the concept of sealed envelopes continues. This concern over security issues within the NHS CRS also needs to take into account important women's health issues.
There is also a need for robust information governance when patient data is used for secondary purposes, including NHS planning, management and research. Data used for the Secondary Uses Service are anonymised. Caldicott principles (see Box 1) would be adhered to, to prevent inappropriate access to patient-identifiable data. Patients and care providers are being informed of the existence of secondary uses of personal data as part of the NHS CRS.29
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The NPfIT database
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The NHS is one of the world's largest employers, with a workforce of over 1.3 million. This means that investment in protected NHS staff time for system training and business change must be factored into the total cost of the NPfIT programme. Otherwise, data entered into the system could be inaccurate, misinterpreted or omitted, which could be dangerous or misleading when managing a patient. The use of patient information for public health research will need accurate coding of medical conditions and interventions, as poor quality data would produce useless information and inappropriate conclusions. A recent qualitative study33 of patients in English general practice found that up to 40% of the summary data derived from the current computer records was inaccurate. This explains some reluctance to share this information with patients. Data has to be comprehensive and accurate, approved by both the patient and the clinician and regularly updated on to the Spine.
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National audit of NPfIT
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In June 2006, the National Audit Office published its evaluation of the programme's cost effectiveness by reviewing the implementation process and the expenditure so far. The positive findings were that the NPfIT programme had strong ministerial and senior management support; it also rapidly procured contracts with suppliers at competitive prices with the principle of only paying when systems are delivered and working. The suppliers have a strong incentive to deliver on time, as they will have to bear the costs associated with any delays. Significant benefits to patients are anticipated, as operational systems have been installed to improve the quality of the services.25
The biggest challenge for the programme is to win the support of NHS staff. The latest survey18 of general practitioners and hospital doctors conducted by Medix showed that 59% of general practitioners and 66% of other doctors expected clinical care to be improved by the programme in the long term. The Ipsos MORI survey34 found that the reasons why NHS staff were unenthusiastic about the programme were that: the implementation process was too slow; target dates were not met; and information updates and deployment plans were often unreliable. The recommendation was that the Department of Health and NHS Connecting for Health improve their communication with local NHS organisations and staff by providing greater clarity and familiarity with the services that the programme was intended to deliver. Maintaining a good partnership with suppliers, NHS management and users, information technologists and patients is essential to overcome the challenges and problems faced. The NPfIT Local Ownership Programme has been introduced to meet this recommendation. It also proposed an annual statement quantifying the benefits delivered by the programme against the expenditures so that this can be opened to public scrutiny.25
A comprehensive national patient database will help healthcare professionals, managers and politicians to understand how the NHS works. They will be able to make decisions based on best practice and individual needs to provide the best possible quality of care. Prospective anonymous data, collected nationally, may provide vital information to help with the allocation of resources, such as identifying bed states in different hospitals, and public health issues such as identifying disease outbreaks. In addition, important statistics for audit and risk management may be provided. However, it is impossible to assess fully the value for money of the programme as the main implementation phase is ongoing and the realisation of benefits will only become apparent in the future. There will, undoubtedly, be immediate benefits in the short term but these may be counterbalanced by the pain of implementation; whether all the long-term benefits will be realised will be up to both clinicians and the national programme.
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Acknowledgements
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The authors would like to thank Adam Gornall, Maternity DOAS team leader and Consultant in Fetomaternal Medicine and Gynaecology, Shrewsbury and Telford Hospital NHS Trust, for his contribution to this article.
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Website addresses
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Connecting for Maternal Health: www.maternity.nhs.uk
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References
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- NHS Connecting for Health. A Guide to the National Programme for Information Technology. Delivering Better Care. London: Department of Health; 2005. p. 3 [www.connectingforhealth.nhs.uk/resources/brochures/npfit_brochure_apr_05_final.pdf].
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- Department of Health. ‘Choose & Book’—Patient's Choice of Hospital and Booked Appointment. Delivery Framework for the Implementation of Choice and Booking at the Point of Referral. London: DH 2003 [www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4112428].
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- Hendy J, Reeves BC, Fulop N, Hutchings A, Masseria C. Challenges to implementing the national programme for information technology (NpfIT): a qualitative study. BMJ 2005;331:331–6. doi:10.1136/bmj.331.7512.331[Abstract/Free Full Text]
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- British Computer Society. The Way Forward for NHS Health Informatics. Where Should NHS Connecting for Health (NHS CFH) Go from Here? Swindon, UK: BCS; 2006. [www.bcs.org/upload/pdf/BCS-HIF-report.pdf].
- NHS Connecting for Health. Health Informatics. Debate over Patient Consent for Electronic Records.
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- MORI Social Research Institute on behalf of NHS Connecting for Health. A Baseline Study on the National Programme for IT. London: MORI 2005 [www.ipsos-mori.com/polls/2006/connectingforhealth.shtml].
- NHS Connecting for Health. Resources for Caldicott Guardians [www.connectingforhealth.nhs.uk/systemsandservices/infogov/caldicott/caldresources].
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Abstract
Introduction
