Lighting the way to best practice

Bolton NHS Trust is one of the National Health Service's Beacon sites in a programme designed to encourage the adoption of best...

Bolton NHS Trust is one of the National Health Service's Beacon sites in a programme designed to encourage the adoption of best practices throughout the country. Beacon sites are chosen on the basis of excellence in a specific specialist area.

In Bolton Trust's case it was its Web site, The site provides details of the services run by the trust, along with links to other health-related sites. It also allows access to more general healthcare-related information, for example, advice on nutrition. This general information is also made available to other NHS sites via NHSNet as part of the beacon programme.

Bolton Trust was given extra funding for this and will be responsible for developing NHS-wide content in the designated specialist areas.

"Different trusts are doing different things and the idea is to pick the best and implement it throughout the NHS, rather than doing things centrally," says Malcolm Wilson, system development manager for Bolton NHS Trust. Yet, in some respects, there is more central control, in line with the NHS strategy to establish an information core that has consistent data and standards.

For the first version of the Web site, all information of local interest, such as details of doctors, dentists and chemists in the area, was maintained locally. But under the new NHS IT guidelines, such information that might be duplicated elsewhere is held centrally in a single repository, so that there is one consistent source.

"We now use links to appropriate URLs instead of duplicating information," says Wilson. It is interesting to note, however, that this centralised data-management strategy will not extend to electronic patient records.

Some information is still maintained locally, such as a database of job vacancies within the Trust. "That is actually live data, so the personnel department uses it to create documents that go out to the press," says Wilson. The information can also be browsed through by any member of the public, in the knowledge that it is fully up to date.

As with NHS Direct, the Web site has been kept as simple as possible. For instance, conspicuous screen buttons make it easier for less sophisticated users to access the information. It also allows for slow access. "We have kept pictures to a minimum to make it as quick to load up as possible," says Wilson.

Prescription for long-term health
IT problems in the NHS have been rooted in a reluctance to prescribe from the centre, according to Geoff Rayner, finance director of the health sector supply chain system supplier eHospital. This has led to vast, unnecessary duplication of systems development effort and a lack of a binding infrastructure to facilitate co-operation between systems and processes, especially at an inter-trust level.

On the procurement side, such lack of progress with integration has prevented the health sector from exploiting its massive purchasing power to the full. It has been unable to extract the best deals from suppliers across the spectrum from drugs to dressings, as well as from IT systems themselves.

The ethos of local autonomy has been too strong, with doctors having too much power to specify supplies, without the co-ordination that would make the ordering process more efficient, argues Rayner. "Fortunately, I think the current Government is moving stepwise away from this position," he says.

Rayner alludes to a range initiatives such as the proposals for an information core. There are also initiatives on the procurement side, with plans to move towards national contracts rather than having each Trust, or individual doctors within trusts, doing their own thing. But Rayner admits that this would require cultural changes, and could exacerbate the long-running tensions between senior consultants and managers within parts of the NHS.

Rayner also points out that as with all industry sectors, procurement savings can only be maximised by tackling the entire supply chain.

"The purchaser is only one part of a supply chain, and the NHS should be sharing its materials and inventory budget with suppliers so that they can plan ahead. You want suppliers to see immediately when a cabinet is empty," says Rayner.

There are also great potential benefits in giving suppliers guarantees that certain levels of orders can be maintained. "If you can guarantee that you will buy 80% of your surgical gloves from one supplier, he will give you a better deal, because he knows he is blocking out his competitors.

However, there has to be a balance between the level of choice allowed to doctors and the savings that can be made through preferred supplier deals," says Rayner. He agrees that the issue of electronic patient records (EPRs) is a smoking gun and also suggests that the NHS will have its work cut out to achieve the desired level of integration and establish common standards.

"Integration will never be as easy as people say and it is ongoing. You've got to keep watering the garden," Rayner explains. He also agrees that the NHS is on the right track with unification efforts now under way, citing a contract currently being negotiated for a national human resources system. But he suggests that the biggest challenges in integration, skills development and of course EPR, are yet to come.

"They are taking the low-hanging fruit first and taking a long time to get there, but at least they are doing it. But the biggest problem is long-term under-investment in the past and it will take a decade at least to get back to where we should be," Rayner concludes.

Defining IT events in the NHS

  • Conservative government proposes NHSNet to increase efficiency and ease administration of the then new internal market

  • Contract signed with BT Syntegra to implement and manage NHSNet

  • Labour government announces Information for Health NHS IT strategy with NHSNet as the central enabler

  • In July, Department of Health abandons plans to have all GPs linked to NHSNet by the end of the year and opens discussions to drop the much-criticised X.400 messaging standard

June 2000
  • The NHS Information Management and Technology Procurement Review is published, highlighting the need for a partnership approach with willingness to exploit best practices, combined with national standards to facilitate information and application sharing

August 2000
  • NHS Plan promises 95% of GPs access to NHSNet by 2001 (92% had been achieved by March 2001) and 100% by end of 2002

January 2001
  • Building the Information Core project promises desktop access to e-mail, browsing and directory services for 25% of NHS Trust clinical and support staff by 2001 and for all NHS staff by 2003
  • NHS IT receives one-off £851m extra payment for Building the Information Core project, but must meet new deadlines

  • NHS Direct Online, providing Internet access to databases of common health problems and advice, will be redesigned with a powerful new search engine and additional content including online health encyclopedia, more local information and e-mail enquiry service

  • Components of NHS public key infrastructure (PKI) planned for implementation. PKI will replace existing cryptography solutions within the NHS, and is an essential prerequisite for electronic patient records (EPR)

March 2003
  • Deadline for migration to national standards such as SMTP for e-mail

March 2004
  • Deadline for national payroll and human resource system

  • 500 kiosks to be available for access to NHS Direct and e-pharmacy services. Access via digital TV also planned
  • With NHSNet fully rolled out, the NHS will face its greatest challenge - implementing EPRs. This will pave the way for e-booking and e-prescribing

  • Aim for near-universal e-prescribing, replacing hand written prescriptions, and widespread use of e-booking

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