Examination of Witnesses (Questions 120-139)
20 MAY 2004
RT HON
JOHN HUTTON
MP, MR JOHN
BACON, MS
ANN STEPHENSON
AND MR
GORDON HEXTALL
CB
Q120 Mr Jones: I am sorry to interrupt,
but when you say things will start happening in June, just to
be clear, do you mean that the first phase is on schedule, will
happen in June, or that little bits of it will happen in June?
Mr Hutton: That is the schedule.
It will start with programmes in Yorkshire and in London. A number
of primary care trusts will be involved in that. Then gradually
over the remaining period of this year and the end of 2005, every
GP site will be connected up with e-booking systems so that patients
can be referred into hospital electronically. The thing we have
learned, and I think it is the right thing to have done, about
this programme, which is, you are right, the biggest in the world,
is to try to break it down into manageable component parts; that
is why we have these four key core functional bits to it. We have
then broken that down further in terms of geographic governance
with the five cluster arrangements which we have established.
Finally, we have decided not to do it in one big bang, but to
try to phase it in over time so we can learn lessons of what works
and what does not as we go along. Part of the procurement was
a very extensive proof of solution phase where we tested the technical
side of the kit, hardware, software, application systems and so
on. We are confident in what we have bought and we have a very,
very good state-of-art- system. We do not want to repeat the mistakes
of previous large IT solutions which was big bang, all in one,
monolithic, poor governance, poor control over project and not
enough frontline staff engagement. We are trying to address all
of that. The national programme for IT has come an immense distance
in a very short period of time, now to the point where people
are saying we are going too quickly. Sometimes you cannot win
with any of these programmes.
Q121 Mr Jones: If it is geographically
in phases, does that not mean that you are going to have to maintain
a duplication of systems until everybody is in? If you have London
in and the South East not in, since patients will transfer from
one to the other, until they are all in, you will have to maintain
the two systems, the paper system and the computer system.
Mr Hutton: There will be an element
of that. You have to look at the risks you are trying to manage
here.
Q122 Mr Jones: How is the process of
transferring the paper information onto computer happening? Are
there banks and banks of people doing this, or what? What happens?
Mr Hextall: It is an incremental
roll-out geographically and an incremental roll-out by functionality.
The initial implementation in a small number of locations this
summer will not have any kind of conversion of existing programmes;
it is inputting new data into the system. It is for electronic
bookings for new patients who want to be booked into secondary
care. The full booking of patients into primary care is in a subsequent
release scheduled for the beginning of next year, 2005.
Mr Hutton: In relation to the
care records.
Mr Hextall: Yes, when we get onto
the care records, similarly that is in a subsequent release. Where
hospitals have current patient administration systems with existing
data which is clean and up-to-date relatively speaking, that will
be transferred automatically. If they do not have an electronic
system, where the data can be extracted with a degree of accuracy
or ease, then we shall not be doing that.
Q123 Mr Jones: So hospital information
will largely be on computer anyway and they can just flick a switch
and it goes across.
Mr Hextall: Yes, for those who
have those kinds of electronics.
Q124 Mr Jones: Then how does that happen
in the GPs', where they have these huge files?
Mr Hextall: It builds up over
time, otherwise that would be a huge clerical exercise to go back
and try to do all that data input. That is why this is really
a 10-year programme effectively and phase 3 is 2008 to 2010, by
which time everybody ought to have a record who has visited—
Mr Hutton: And the record is fully
functional as a comprehensive record.
Q125 Mr Jones: I was going to ask you
a question about the financial implications of this transfer,
but there does not appear from your description to be a big financial
implication for this transfer.
Mr Hextall: That is right.
Mr Hutton: What we have tried
to produce for the Committee is what it will actually look like,
what these patient care records would look like and also how the
electronic booking system will appear. This is the sort of information
which someone using the system will see on the screen, to give
you a sense of what is in there, what it looks like and the feel
of it. I hope you find that helpful. I should be very keen to
extend an invitation to the Committee to see a demonstration of
e-booking actually working and how the care record is prepared,
if the Committee have time. We are setting up a ward simulation
scenario in Leicester, where we are trying to train and take people
through the various stages around all of this in a real ward environment.
The critical issue now with the national programme is not procurement
any more; we have done the shopping trip and bought the gear.
It is getting people to recognise that it is useful, that it is
usable and that the information and therefore the rationale behind
it is compelling. That is the really important phase of the exercise
that the national programme is getting into now, which is yes,
we need to make sure the technical side of it is right, we are
getting all of this data migrated and so on, but it is getting
nurses, managers, doctors to say they want to use that, because
that is going to help them improve the case, the care they get
for their patients.
Q126 Mr Jones: When you say that it is
usable, would there be any provision for the patients themselves
to see and use some of this computer information?
Mr Hutton: Yes.
Q127 Mr Jones: There will?
Mr Hutton: Yes, there will be.
Not only that, but they will be able to access their own personal
preferences into their electronic care record as well through
what we call HealthSpace. Obviously we have to govern access to
that, we have to make it secure, but the whole point about this
is not to restrain information, it is to open it up so patients,
clinicians, people can see it. It is your data, it is about your
life, you are entitled to see it.
Q128 Mr Jones: How then do you try to
ensure patient confidentiality with the system?
Mr Hutton: Our current thinking
at the moment around that is that we have a number of portals
into this which we have to be careful about. For staff, we will
do it in a number of ways: smart card, swipe access into the database
coupled with a pin. Once you are in, the system knows that you
are in, it knows who you are and what records you are looking
at. It will also be based essentially on who you are too: are
you a nurse, are you a doctor, are there some aspects of the care
record which you need to see about a person's personal health,
or are you booking in someone for an appointment, do you need
to know more general information about their phone number, their
contact details, where they live, who they are. That is a sensible
way to try to govern the arrangement around confidentiality. It
is partly a technical fix in the software and hardware. I think
we can fix that. It is also a training and people issue around
access, which local NHS trusts will have to engage in as well.
We are trying to do two things. We are trying to make sure the
information is confidential; it has to be, because it is the most
sensitive information about any of us. I do not want anyone looking
at it and I am sure you do not want anyone looking at your information
either, other than those who need to see it. We can build some
protocols in there. The other thing we have to be sure about is
that we allow patients to access that information too. I do not
know whether you want to say anything about patient access to
the record Gordon.
Mr Hextall: That again will build
up over time. HealthSpace is there now; that is up there on the
web, but it is very basic; it is a calendar and you can book your
own appointments and use it as a prompt. The aim is to use that
same means of web based access increasingly to put patient details
on for individual members of the public to access themselves.
These are the same kinds of access security you might have if
you were going into an internet bank account, but nevertheless
you would be able to get in there. That is very much for a later
phase in the national programme.
Q129 Mr Jones: In future, if I received
treatment in St Thomas's or somewhere, automatically the clinician
who treated me would put that treatment onto a database so then
my medical history would be updated when I was treated. Is that
how it is meant to work or will work?
Mr Hextall: Yes and two levels
of care record information will be held. There is what has become
known as the national spine of data, which is a summary of your
NHS care record, but a much lower level of detailed information
will just be held at a local level. The clinicians who have been
involved in helping to design this so far have agreed an amount
of summary record data which is to be held nationally, so that
if you turn up somewhere remote injured, have an accident or are
taken ill, then the clinician there will be able to get a sufficient
level of information to be able to treat you, but it would not
have a very low level of information, like your temperature, blood
pressure readings and what have you.
Q130 Mr Jones: If I continue using myself
as an example, I might have computer information available here
if I were visiting St Thomas's, but as it currently stands I would
not have any when I am in Cardiff. Did you offer the IT system
you are rolling out in England to Scotland, Northern Ireland and
Wales?
Mr Hutton: Yes, we did.
Q131 Mr Jones: And what?
Mr Hutton: They were not able
to proceed on the same timescale we were able to proceed.
Q132 Mr Jones: In the border hospitals,
in particular on the Welsh Marches, Chester hospital for example,
two thirds of the patients are English, one third of the patients
are Welsh and acute treatment for most of the border region on
the Welsh side actually takes place in England. Chester hospital
then will have to have for the foreseeable future an IT-based
appointment system and a duplicate paper-based system. Is that
right?
Mr Hutton: Yes, I think that is
likely.
Q133 Mr Jones: Who is going to pay for
running the two systems?
Mr Hutton: The services which
Chester provides to patients who are Welsh patients is funded
through Welsh NHS resources, so they would be paying for that
service.
Q134 Mr Jones: Yes, but at the moment
they utilise the same administrative system for booking; Chester
only runs one administrative system. When all of England is using
the IT system and Wales is not, then hospitals further away from
the border will presumably not use a paper system, they will just
use the IT system, but hospitals near the border will have to
use two systems.
Mr Hutton: There will have to
be an understanding around all of that. Those services which are
provided for Welsh patients are paid for by Welsh commissioners
and those services we provide to English patients are funded in
this case through the national programme for IT. They will clearly
need to be booking in Welsh patients in whatever ways they are
currently booking. That is an identifiable strand of their activity
which Welsh commissioners will need to handle.
Q135 Mr Jones: Will the other national
groups in Britain eventually be using the same IT system?
Mr Hutton: I hope so.
Q136 Mr Jones: But you do not know.
Mr Hutton: It is devolution.
Q137 Chairman: I set out a scenario about
the care of a dying patient and the ability to offer records in
the home. How far away from that kind of model are we? I shall
not hold you to your estimate, because I shall not be here and
you will not be. Do you have a broad idea as to how far away we
are from having that terminal in the home and the ability to access
the information when the carer or district nurse or whoever comes
in?
Mr Hextall: It is at the end of
this period we have been talking about, the 2008-10, but the preparation
for that and the thinking behind it can take place in advance.
Telemedicine is already quite advanced in some countries and is
very much a part of the thinking of how we are designing these
systems for the future. Enabling the patient to access remotely
is exactly the same technology which would enable that information
to be available.
Q138 Chairman: Probably within the next
10 years we could be seeing that sort of model.
Mr Hextall: Yes.
Q139 Mr Burstow: Just picking up on the
discussion we have had about the open aspect of the record for
the patient, will that provide at some point the ability for a
patient to record an advance direction? At what sort of point
will that sort of functionality be available?
Mr Hextall: I am not really sure
about the detail of your question.
Mr Hutton: I think it is a question
of how much information you can put in now. I shall get back to
you on this, but that is available now through accessing the HealthSpace
part of NHS.co.uk, the website. If you want to specify precisely
those sorts of personal preferences around the core of your treatment,
you will be able to do that.
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