Computerising the NHS

The NHS is major part of British society but often comes under fire for failing to provide the high level of service which its users expect and demand. Most people assume that this is an argument concerning the standard of healthcare provided but in fact the issue runs much deeper and includes the background processes which enable the service to run at all. Like any modern organisation IT has a major role to play within the NHS and it has been claimed that greater use of IT is key to reforming the NHS. (The Economist, 2002) The Wanless Report provided some shocking statistics for everyone involved in the NHS: spending on IT had to immediately double if the NHS was to meet its targets and the NHS was guilty of spending less on IT per employee than any other industry sector. (Wanless Report in The Economist, 2002) It is therefore clear to see that computerising the NHS needs to be taken seriously as in order to regain its status as a 'national treasure' it is necessary to look to the future and consider how this process can best be undertaken in order to add value to the organisation and ultimately improve the level of service provided.

At the centre of the technology employed by the NHS is ‘the spine’. This is made up of a set of Care Record Services (en.wikipedia.org). Key to these care record services are a set of systems: the ‘Choose and Book’ hospital appointment booking system; the electronic prescription service; the personal demographic service and the ‘GP2GP’ records transfer system for family doctors (Shifrin, 2007). It will also allow for information from multiple sources to be available to those with authority to use it (Spronk, 2007).

In terms of controlling access to the spine, the NHS has proposed the use of personal authentication devices which will transmit encrypted passwords to ensure security (Cross, 1995). Further, full access to information will only be granted to those clinicians who need it, while administrative staff will only be allowed access to basic patient information (news.bbc.co.uk). On top of this there are plans for a website called ‘My Health Space’ which can be accessed over the internet by patients. This will allow patients to access their personal details from home through the use of ‘highly secure passwords’ (news.bbc.co.uk).



(Spronk, 2007)

Further, crucial to the spine is the Transaction and Messaging Spine (TMS), see above diagram. This is the master ‘router’ of all the messages between the systems and is based on the HL7 Version 3 XML Messaging Standard. Message flows from local systems are routed to the NCR (see diagram above) and oppositely, if so required (Spronk, 2007).

The network that supports the spine is called ‘N3’. This is said to be a ‘fast and efficient’ network that ensures that the new systems and services run smoothly and quickly (www.connectingforhealth.nhs.uk). This network uses a sufficient band-width to implement these new approaches such as transmitting digital images through the system (www.connectingforhealth.nhs.uk).

Implementing IT has not always gone smoothly in the NHS and in 2004 there were worries over the NHS National Project for IT (NPfIT) which was an ambitious project to computerise the NHS. This was billed as "not just another IT project" and promised that lessons had been learned from previous fiascos such as those witnessed at the Passport Office and air-traffic control. (The Economist, 2004) However, as could be expected problems were quickly identified with this project. Computer Weekly were quick to highlight that the cost of this project could rise to £18.6billion or even a massive £31billion, substantially higher than the budgeted cost of £6.2billion (The Economist, 2002) and surely enough to send shockwaves round those in charge. This illustrates the huge problem of keeping any major project on budget. If the NHS is to be successfully computerised, the people in charge will have to ensure that all projected costs are as accurate as possible and this budget must be adhered to.

A major point for the NHS to consider when implementing a computerised system is the security of the system. The data which will be held on this system is extremely sensitive and people will understandably want assurance that their personal medical records will not fall into the wrong hands. (Cross, M., 1995) Unfortunately this point appeared to have fallen on deaf ears within the NHS as in 2000 there were concerns over the security, or rather the lack of security, in place and it was claimed that the NHS was paying insufficient attention and care to patient privacy and security. (http://en.wikipedia.org/wiki/National_Programme_for_IT#Criticisms_of_the_programme) Furthermore, in 2004 the NPfIT won the "Most Appalling Project" Big Brother Award from Privacy International because of its plans to "computerise patient records without putting in place adequate privacy safeguards". (http://news.bbc.co.uk/1/hi/technology/3933679.stm)

However, despite the existence of evidence which would suggest that computerised systems within the NHS are lacking in security this does not necessarily mean that the project will be a disaster. If immediate action is taken to correct the problems there is actually the possibility that the new system will be more secure than those used previously as currently patient notes can often be left unattended in hospital wards or consulting rooms. (Cross, M., 1995) A computerised system would therefore solve this problem because all records would be held electronically and would require the use of passwords or other personal authentication devices in order to be viewed.
The security which would be employed should be given careful consideration to ensure that it is as useful as possible. Passwords are likely to be a measure used as they can limit access to information by requiring both a unique user name and password. However, staff must be made aware of basic principles such as never writing down a password and refraining from using words or phrases which can be easily guessed i.e. names of family members or favourite sports teams. (http://en.wikipedia.org/wiki/Password#Security_and_convenience) Another aspect to consider which would make the system more secure would be to time-out after a period of inactivity and require the password to be re-entered. This would be useful because if a computer was accidentally left unattended no unauthorised personnel could gain access to the system under the guise of the original user.

A point to remember is that this is a Government project and these have a long history of failure due to their tendency to be over-ambitious and are often poorly managed. (The Economist, 2002) One only has to consider the air-traffic control NATS system to illustrate this point as this project finished millions of pounds over budget, was years late being delivered (Erskine, R., 2002) and, most worryingly, it was obsolete by the time it was fully implemented. (The Economist, 2002) Most commentators believe that the main reason for this disaster was the fact that it was poorly managed and this can most obviously be highlighted by the fact that the project made use of 3 service providers. (Erskine, R., 2002) This shows a lack of consistency and a complete failure to get the correct people on board from the beginning which ultimately led to its failure. The fact that the same situation took place with the NPfIT is of major concern as it is yet another problem within an already failing project and it is only exaggerated by the fact that the customer is the Government as providers know that this customer is highly unlikely to simply scrap a project as it has used taxpayers' money and will do anything to avoid the negative publicity which would come with such a high profile failure.

Another problem with this project is that unlike a company, for example, the NHS is not a single organisation as it consists of thousands of GP surgeries, hospitals, pharmacies and clinics. (The Economist, 2002) This means that implementation at a local level could prove to be a problem as some practices may choose to resist change and this could lead to a situation where millions of pounds have been wasted as there would still be no unity across the NHS and the level of service available to patients could depend upon their location (a problem which currently exists).

Further, the time scale of the project has also come under scrutiny. At present, the programme is already two years behind schedule with no firm implementation date set (House of Commons, Committee of Public Accounts, 2007). At present almost all acute hospital trusts should have the NPfIT patient administration systems implemented however as of June 2006 this was only the case in 13 hospitals with there being a plan to increase this to 22 by October of that year. However, by February 2007 the number was only 18. Therefore, the House of Commons Public Account Committee feels that the department should enforce a robust timetable to ensure greater confidence in the delivery date (House of Commons, Committee of Public Accounts, 2007).

Additionally, this programme is only set to computerise the 50 million NHS patients in England (www.bbc.co.uk). This could be a problem for patients that regularly travel over the borders as no plan has been made in relation to Scotland and Northern Ireland. Further, Wales is in the process of implementing a programme for service and improvement through the use of IT (en.wikipedia.org). The NHS is supposed to be a National Health Service, not a service solely dedicated to serving England. Therefore, it should not only be patients in England that benefit from the increased efficiency of the system. Further, the fact that there are currently two IT improvement schemes running may make it difficult to integrate one system throughout Britain and it is therefore, possibly a wasted investment on the part of the NHS if one of the programmes needs to be scrapped to allow integration.

The project has also been criticised by civil liberties campaigners such as NO2ID who object to the state having so much personal information held on databases and The Big Opt Out who have provided patients with letters to send to their doctors to ensure that their details are withheld from the system. (en.wikipedia.org) By playing on the "Big Brother State" issue which is a hot topic at the moment such groups can ensure that many people will opt out of the system as they look to create panic and claim that the Government will soon know everything about us. Such criticisms are likely to strike a chord with many people and so it is clear that even if the project can overcome its problems it may still fail as it does not have the confidence or trust of the nation it intends to serve.

As previously mentioned, the NPfIT has only begun to look at computerising the NHS in England. One possibility for the future is that this will be rolled out through the whole of the UK. However, the stakes of the project are high. If it succeeds in its aims, the program could revolutionize the way the NHS uses information, and make significant improvements to the quality of patient care. But if it fails, it could set back IT developments in the NHS for years, and divert money and staff time from front line patient services (House of Commons, Committee of Public Accounts, 2007).

Also, in the future, further innovation in the use of IT in the NHS is inevitable. For example, a new invention of electronic patient tagging is being piloted in a hospital in Birmingham (www.mailonsunday.co.uk). This involves digital photos being taken of patients as the come into the hospital who are then tagged with the information being synchronized with their electronic records. It is said to reduce human error with patients being sure that they are going into the right operation, at the right time, with the right surgeon (www.mailonsunday.co.uk). It is estimated that it could save the NHS thousands in litigation. However, in the implementation of further innovation, the NHS should take on board the criticisms of this vast project and learn from the mistakes that they have encountered.

In sum, one can not comment on the over all conclusion of this project as it is not yet finished. However, they have aimed to implement some key pieces of technology designed to improve efficiency and accuracy within the service they provide. Whilst this is valid and beneficial to all those involved in running the NHS, working for the NHS and those using the service, the criticisms outlined above should be taken into consideration firstly, before the project is finished and also in future projects that the NHS and the government as a whole aim to implement. Key to these criticisms is the security of the systems put in place; the escalating costs of the project and the integration of the network throughout the UK. Further, as in a lot of governmental projects, the management of the project has come under scrutiny which should be able to managed efficiently after the lessons the government has learnt from previous projects. Therefore, although the project has already been 'rolled out' in some areas of England, these points should be considered carefully in the further integration throughout the UK.



REFERENCES

Cross, M, National Health Services I/S Network Takes Shape - UK National Health Information Network, Health Management Technology, January 1995

Erskine, R., At last a silver lining around the troubled NATS Air Traffic Control system, 2002, www.cs.mdx.ac.uk/research/SFC/Reports/TR2002-02.pdf, accessed on 3 December 2007

House of Commons, Committee of Public Accounts, Department of Health: The National Programme for IT in the NHS, March 2007, Accessed from:
http://www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/390/390.pdf

Shirfrin, T, NHS Data Spine will go Off-line for a Major Upgrade, ComputerworldUK.Com, November 2007, Accessed from:
http://www.computerworlduk.com/management/government-law/public-sector/news/index.cfm?newsid=5977

Spronk, R, An English National Programme, Ringholm Whitepaper, March 2007, Accessed from:
http://www.ringholm.de/docs/00970_en.htm

The Economist, Deja vu all over again?, p.36, 2004, http://proquest.umi.com/pqdweb?index=0&did=715018391&SrchMode=1&sid=1&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1196683068&clientId=46002, accessed 19 November 2007

The Economist, The Health Service's IT Problem, p.29, 2002, http://proquest.umi.com/pqdweb?index=1&did=218613561&SrchMode=1&sid=1&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1196683068&clientId=46002, accessed 19 November 2007

http://en.wikipedia.org/wiki/National_Programme-for_IT

http://news.bbc.co.uk/1/hi/health/6454946.stm

http://www.bbc.co.uk/radio4/news/inbusiness/inbusiness-200405135.html

http://www.connectingforhealth.nhs.uk/systemsandservices/n3/background

http://www.mailonsunday.co.uk/pages/live/articles/health/healthmain.html?in_article_id=323718&in_page_id=1774