What do the changes to the NHS mean for IT?

Healthcare experts talk about the implications for IT and the informatics agenda across the NHS as it begins a programme of structural change

The cornerstone of the Health and Social Care Act, which has now come into force, saw the transfer of £60bn in funding from the defunct primary care trusts to the newly-created clinical commissioning groups (CCGs).

Chaand Nagpaul, GP and member of the British Medical Association (BMA), said the NHS is now in a period of considerable transition.

“It is difficult to talk about an IT strategy without considering the lack of organisational stability and that the new structures are not yet bedded down," said Chaand Nagpaul.

“CCGs have been advised they will be responsible for the operational delivery of GP IT but most CCGs have only just been advised of notional budgets,” he said. Government has far reaching ambitions on information in its IT strategy, but some of those aims should be subject to a rethink, say experts.

Prudent spending 

“In terms of the technology vision, government has a huge push to the telehealth issue, which is something that needs to be carefully thought through,” said Nagpaul.

But he said, there is reason to question evidence of effectiveness and cost implementation. 

“Government has to learn from the past and not allow ideology and zeal to drive the agenda," he said. "It needs to be slowed down and used in an appropriate way. The IT agenda needs to be rid of ideological targeting approach. There is no logic in the target of three million lives [for telehealth] as a statistic,” he said.

“The new structure has to be based on evidence and responsible use of scant resources, this is not a time for using resources for ideological purposes.” 

The move to give all GP patients access to their records by 2015 and make the NHS paperless by 2018 is not necessarily helpful in the current climate, he says. 

“Online access to patient records is being held hostage to a political timeframe. There are serious issues to be considered if not handled and developed in right way."

Nagpaul believes the challenge for the NHS in terms of delivery of IT is far greater in the current climate of transition. 

The new structure has to be based on evidence and responsible use of scant resources, this is not a time for using resources for ideological purposes

Chaand Nagpaul, GP and member of the British Medical Association

“Even the structures responsible for the delivery of IT do not have clarity and no chance to bed in. There is nothing to be lost in having element of pause while CCG and commissioning support structures are developed. And there is nothing to be lost in slowing down when it comes to broader policy initiatives," he said.

For Nagpaul, there are basic issues that need addressing before wider strategy concerns are driven through. 

“Day-to-day we need to make sure IT is supported and progresses in real-time and make sure the infrastructure is fit for purpose.” 

One such is area is slow connection speeds, which is affecting day-to-day work.

“The N3 speed used in many parts of the country is 2Mbps, about a tenth of the speed of many domestic broadband providers. This is affecting GPs and patients on a daily basis. Speeds are not fit for purpose in many parts of the country," said Nagpaul.

An over reliance on paper, better integration between primary and secondary care and greater functionality in IT need to be tackled before getting into broader political ambitions.

Information assets 

Veena Raleigh, senior fellow of policy at health charity the King's Fund, agrees that there are significant resource and practical implications behind the information strategy in the current period of change.

“The CCGs are new embryonic organisations and there is a lot of anecdotal evidence many are ill-prepared for the new tasks they need to take on. So information may in fact be low down on their priorities, although they can’t even begin to conduct business without it,” she said.

In order for CCGs to be able to provide the necessary provision of services, they need to understand the demographic they serve and its particular health needs – something which is only possible through the proper use of information.

“The NHS cannot do its business without information. That is the oil that makes the machines work, but on the whole the focus is on the machines,” Veena Raleigh said.  

The NHS can’t do its business without information. That is the oil that makes the machines work, but on the whole the focus is on the machines.

Veena Raleigh, senior fellow of policy at health charity the King's Fund

Because of the changes, Raleigh believes it will take a couple of years before the health service is in a position to make changes enabled through a better use of information. “Some of the new organisations won’t have the necessarily information skills at the moment,” she said.

“CCGs will have to develop skills and information, and there is a learning curve to using information and getting the most out of it.”

Under the Act, a divide has been created between local authorities and the NHS in terms of where information sits, with information on areas such as substance misuse now being viewed as a social health issue and falling under the jurisdiction of local authorities.

“So there are some practical issues around information and IT that will become less joined up because of the functional divide," said Raleigh.

“Any reorganisation is problematic, but the boundaries, structures and units in terms of how they function together are going to be quite a challenge.

“A lot of it will depend on local motivations and resource issue, at a time when organisations are all strapped for money and IT being an expensive cost. So I think you will probably get local development happening at different speeds and disparate system happening locally.”

She said one of the strengths of the past was the uniform approach to information standards and policies.

“Now there is more diversity and patchiness. I don’t see radical solutions happening in the short-term, the information strategy was very clear about linking health and social care records, but it also probably underestimated issues around data protection."

It’s unclear at the moment about how all of it will work and how CCGs pay for services from commissioning support.

“This is a period of uncertainty and turmoil. We are likely to see a disruption in the way information flows across local organisations and functions, including public health. It’s likely to be a while before we see the visionary goals identified in the information strategy," said Raleigh.

“The 2015 GP records commitment is something they are trying to push. But that is different from the broader use of information by and for the NHS.”

Connecting data 

Phil Molyneux, former CIO at NHS Yorkshire and the Humber and policy vice-chair at BCS Health, said the NHS has a logistical challenge on its hands if it is to achieve its ambitions for informatics.

The changes are extremely complex and will involve more organisations working in concert if the perceived benefits of these changes are to result in more effective and better coordinated patient care

Phil Molyneux, former CIO at NHS Yorkshire and the Humber and policy vice-chair at BCS Health

However, he said informatics has an increasingly important role to play, particularly when it comes to passing information across organisational boundaries in order to support more seamless care. This inevitably requires a shift from paper-based systems to electronically-held records of patient care.

“There is now a new set of organisations responsible for driving informatics policy. 

"[National director, patients and information, NHS England] Tim Kelsey, is putting a big emphasis on transparency and engaging the public and patients through greater transparency and giving them a real voice through increasing access to data on health services,” said Molyneux. 

"This is likely to lead to the growth of a market in helping people to interpret data and use it to improve their use of health services as well as their lifestyle choices in some instances.

“There will be a growth in organisations that are adding value around providing information to help patients understand their conditions better and we are already seeing some of this in a way in the development of low-cost apps in this field, but this is an awful lot more to happen in this space," he said.

“The big challenge there is that it’s about a different way of thinking."   

But the BMA’s Nagpaul believes less haste is required in this area: “The public’s trust is paramount. While government promotes the philosophy of ownership of data, at the same time if it’s not treated with safeguards, it could quickly lead to public mistrust. We need to tread carefully with the information agenda and make sure it is not driven by zeal and ideology.”

Gerry McLaughlin, director of IT Contractor, has had extensive experience working in public sector IT and believes that the move to decentralise IT could make it difficult to join up data. 

“If the same data resides on lots of different databases and systems it can be difficult to extract good information," said McLaughlin.

“What they need to do is work out what each data field is, its size and its name and call it that across all their systems. That way they can build a feed from each of the local systems to be able to get aggregated information."

Poor data gives poor information which leads to bad management decisions and it will be difficult for senior management to be able to manage properly without good information.

Orlando Agrippa, associate director of Business Informatics Colchester NHS, said CCGs should look to the best examples already used within the NHS when it comes to purchasing systems and software.

“If you are trying to get efficiencies, you need to ask what is the best tool and get the best practice across the landscape," Orlando Agrippa said.

"We want to make sure that when we provide information through business intelligence (BI) software, such as QlikView, we are using the same tools. Technology can help break boundaries down and it will be important to use technology that is working well within the NHS to make the transition smoother rather than buying something new that has never been used that doesn’t have a track record of success. 

"[CCGs] should look to the best practice from organisations that have been dealing with data for a long time.”

Clear SLAs 

Another key issue for CCGs is ensuring they have the right service level agreements (SLAs) in place with the commissioning support units that will be delivering IT services to their practices, says the BCS’ Molyneux.

“This will again require them to work closely with their providers, helping them to ensure they understand the CCGs' needs and directions of travel,” he said. It will also be incumbent on the commissioning support units (CSUs) to step in and provide services even if SLAs are not fully developed or funding is not entirely clear, to ensure that practice needs continue to be met.

“One of my worries is that the area teams which are charged with overseeing the system, don’t have the expertise to manage IT SLAs and to advise CCGs, and they will have therefore to rely on the four IT leads in the regional teams. The system has lost a significant amount of IT expertise and advice with the inevitable demise of the strategic health authorities. The demands on the regional IT leads, as the whole system adjusts to new relationships and ways of working will therefore be quite challenging," he said.

“Ultimately the challenge is for IT is delivery. It is always a challenge to work across organisational boundaries – even more so now huge amounts of boundaries changing."

Opportunities for change 

Jon Lindberg, head of healthcare at IT trade association Intellect, is positive that the changes could be an opportunity to push the transformation agenda.  

“When the dust settled on the new organisation and delivery from today onwards, we should expect more clarity,” Lindberg said.

He said the CCGs need to get grips with what technology can do for them in terms of commissioning, using things like predictive modeling and commissioning power to influence how technology is being used.

“The decentralised model fits better with incrementalism, which means we can see more clearly examples of good and bad practice across the system. That also means you can reward good and help bad. Having a decentralised approach brings clarity about where progress is going. There needs to be an emphasis on integration across primary and secondary care."

He said a carrot-and-stick approach from the centre will be needed to drive change. 

“From a central NHS England and from an industry point of view, there needs to be a clear strategy. So if bodies don’t meet the information standards, such as every piece of patient information corresponding to an NHS as an identifier, they will be subject to penalties.

“We must have stronger enforcement of standards otherwise thousands of systems will not get joined.”

Time is the upmost concern in setting out a clear strategy for fulfilling the informatics ambitions.

“A strategy needs to be out by the end of summer, or it won’t be able to hit the targets it wants to hit," Lindberg said. "For NHS England, time is the challenge. But many willing people are prepared to help and the department is more open in engaging and seeking advice than in the past."

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