Evidence submitted by Dr Gerard Bulger
I am lead for Practice Based Commissioning in
and a GP in Bovingdon, Hertfordshire, at Archway Surgery,
I am a member of CfH GPSoC Committee
and recently joined the Royal College of General Practitioners
Doctors Working in Secure Environments Group
I worked in East London, as a GP, and in hospitals,
for 20 years. For nine years I was Medical Officer for Redbridge
and Waltham Forest's Unit for Physically Disabled People where
I organised an interface for the severely disabled.
In the 1990s I established the Fundholders' Support Agency
which was partly a data warehouse, carrying data for 350,000 patients.
I also developed the Consultant Provider Agency,
an outpatient and minor surgery service. These were heavily dependent
on IT systems. I have been involved in the design of a clinical
system since 1990. I have installed an IT system within a prison
and have been working part-time in prisons for five years.
1. The UK medical IT industry was effectively
nationalised at the inception of Connecting for Health by using
the Government's monopoly purchasing powers for the NHS, denying
current suppliers of a market.
2. HM Prison Service may have a clinical
IT system imposed on it without any tender or user review process.
3. Access to previous records is designed
to prejudice the care in order to reduce investigation and duplication,
but that can literally prejudice care. We are changing and dying
organic beings, so a previous record or diagnosis can be rendered
wrong or irrelevant the very next day.
4. Deleting an incorrect entry seems to
be impossible when there is a single record collected from different
sources. The only correction possible is for a new correcting
entry to be posted, but negation codes do not exist on most GP
systems. The validity of a record depends on its provenance, but
the very nature of data depends on what it was collected for.
To get round this CfH spine date will be in sections, (GP data,
hospital data) so not really a single record at all.
5. Agreeing how we record drug allergies,
becomes a complex process once we accept that it is a core component
of a central record. To unite us with absolute definitions would
bind us down in such complex data entry coding systems that the
system would become unworkable.
6. Keep data local to where it is collected,
and where its purpose and meaning is understood. A Google type
internal NHS net search engine could find it. There is no need
for a single record. Indeed it is probable that Google Health,
which exists already, could render the core plank of the NHS IT
7. CfH's need to centralise data extends
to GP surgeries. CfH seeks to ban GPs from holding their patients'
clinical data on a server in the practice. ALL GP practice data
is to be held on central servers. GPs could be cut off from their
own patient's records.
8. Few patients know that, under CfH plans,
as soon as a key is pressed in a GP surgery, the data is outside
the surgery building. Indeed all patient data, not just that held
on the spine, is held outside the surgery on a central working
server. Nothing remains in the surgery.
9. A safer approach for doctors and patients
would be for GPs to retain their servers and governance of the
data, and for CfH to run an offsite encrypted backup service.
This would also alleviate the problem of narrow broadband connections
which cannot support off-site serving of clinical systems on a
large scale. Indeed BT has told us that no clinical system should
be dependent on N3/internet connections to function. CfH demands
UK MEDICAL IT INDUSTRY
10. The UK had a vibrant primary care IT
industry, with small innovative competing suppliers developing
systems that had to be able to use common communication and coding
standards for NHS use. These companies had every GP practice as
a potential customer and they needed to sell their product directly
to clinicians. When NPfIT, later CfH, was established in October
2002, that market was taken away. The Primary Care IT companies
were stripped of their customer base and their potential customers.
There was only one customer, the Government. Since then PCTs,
in order to save their costs, have encouraged and bullied GPs
to move to CfH LSP solutions, as the costs of LSP solutions were
"free" to PCTs. Few GPs obliged, but new surgeries have
had to use the LSP "solutions". It is difficult for
existing companies to invest or innovate in this single purchaser
11. The Committee may like to look at the
prison service and IT. Here it makes sense to have a central record
because of the high rate of recidivism; the prison service also
moves prisoners around the prison estate. The size of the system
required is quite small, compared to NHS standards, looking after
80,000 prisoners at a time, with a turnover of about 150,000 prisoners
12. Quantum EDS, which
has the prison service contract, would not allow clinical systems
to use their cables, let alone computers. PCTs have installed
some GP systems with limited NHS connectivity. Many PCTs held
off as it was assumed that the prison service was to have its
own Clinical system, which was in the pipeline. The draft specifications
did state that the system should be based on standard Primary
Care GP systems. It was assumed that CfH would handle it though
the LSPs. But that would have meant that a prisoner in London
would not be able to have the same record when he moved prisons,
say, out of London to Hertfordshire, which is covered by a different
13. CfH is on the brink of awarding the
Prison Service Healthcare contract to one system supplier without
any tender process, simply on the grounds that it is at three
out of the five LSPs. Once again smaller fish have not had any
opportunity to contract for a part of NHS CFH programme.
14. LSPs do not need to house the system
at all. Under GP Systems of Choice all the major clinical suppliers
are developing their own data centres. Any of the GP clinical
suppliers could tender for the Prison Contract but they are not
being allowed to do so.
15. Why have a single medical record?
The assumption is that a single record is a good thing. All medicines
and procedures have their side-effects, some of which can be dangerous.
The balance of risk over benefit is never discussed by CfH. A
single record is held to be a good thing.
16. At a CfH conference "Your Care
Your Record", on 23 November 2006
professional actors, at NHS cost, demonstrated the advantages
of having a single record. Little did they know that their little
play, unchanged, demonstrated the risk of having a single medical
17. The scene was of a patient at a bus
stop becoming ill. The ambulance arrives and attaches the new
technology to the patient, such that the details are sent to the
hospital in the town. The habit of crews in writing down essential
readings on the back of their gloves was ridiculed at the CfH
conference, implying IT systems would automatically be as reliable
and as useable in an emergency.
18. At the hospital the main advantage of
a single care record was described by the acted scene in which
the patient holding his chest and breathless was assured "we
have your full record here and see that you have chest problems".
All further discussion was stopped. The implication was that the
single record would represent a huge saving to the NHS and save
19. The trouble is with this scenario that
the patient could still have a new condition and could well be
having his first heart attack. The doctors would be biased by
instant access to his records, and the data will allow the staff
to be lazy.
20. To be safe you need to take a history
and examine the patient from scratch. Humans are changing biological
beings and a fresh look is needed in an emergency presentation.
The information in the record may be neither accurate nor relevant
as the patient's condition has changed. Digging out the records
or asking the GP a few days later is reasonable. You do not need
it at midnight. Instant access to records may deny patients that
valuable second opinion.
21. My relative was admitted to hospital
last year. He could not swallow. Why not? The hospital staff replied
that it was because of his dementia. That was a surprise to us.
22. It seems that the GP team or coder had
accepted his wife's statement "he is demented" and placed
the read code "F110" (Alzheimer's Disease) on the computer.
In fact it was the wife who was fragile of mind and intolerant
of her husband's Charles Bonnet syndrome (visual hallucinations).
The condition was caused by blindness from glaucoma. He was not
demented and could name the time, date, and place, the name of
the PMand the entire cabinet.
23. Instant access to the GP's full record
got in the way of managing that man's condition. He was not investigated
on arrival because the access to the GP's record distorted the
management during those vital first few days of his admission.
After that it was too late. He died 12 days later with no diagnosis.
24. It will be a complex process to delete
data. Say a hospital assumes that a patient has penicillin allergy,
but as GPs we know that the patient has not (as we have given
it many times before). It seems that the GP would have to add
another entry countermanding the first. Our current Read coding
system does not allow for negating codes. We would not be able
to delete the incorrect entry, just add another. A search would
still find the "allergic to penicillin" line and would
deny the patient the most potent range of antibiotics, most of
which are still based on that molecule. Similarly it is not clear
how my relative's incorrect diagnosis of dementia would be corrected,
once it was on the spine. Someone's impression that he was demented
could be seen forever and continue to prejudice care.
25. On current GP systems incorrect data
like that can be deleted; we often do just that. There is an audit
trail to say what was done and by whom but it is seldom referred
to. Sharing data on a single platform amongst different organisations,
whilst making sure it is correct, is too complex to contemplate.
CfH seems to have backtracked and the record would be subdivided
such that a GP will have to ask a hospital trust to correct the
hospital's incorrect entry. The single care record is going to
be divided up into sections according to who put it there, in
which case I ask why does the data have to be centralised in the
26. Definitions of disease vary and can
be arbitrary. For example the diagnosis of diabetes is not as
absolute as one might think. Each piece of data, if drilled down
onto it, opens up like a fractual. The complications increase
the closer you getjust as the UK coastline is not 7,760
miles, if you were to count the edge of every rock and inlet at
low tide. Medical data is similar.
27. The central recording of Allergy has
been heralded as a major safety advance of the single record.
But allergy recording becomes complex once it is to be shared.
The nature of data depends on the provenance of the record and
what you originally collected it for. CfH attempts to bring together
information collected for different purposes (and their different
meanings) into a single place for a new purpose.
28. GP clinical systems allow one to mark
a patient as being allergic to a particular drug. The computer
gives warnings if you attempt to give that drug, or any drug of
the same family, if known to give similar reactions. The GP, for
his purposes, will mark a patient record should the patient complain
about a drug. The reaction could be a true dangerous allergy and
collapse, or it could simply be intolerance to the drug, or a
mild rash. It requires a pocketful of coding to describe exactly
the patient's reaction, from a code for a profound dislike of
anything coloured blue, through to intolerance (cough with ramipril
or stomach pains with an antibiotic). The GP wants to remind himself
not to give that again, and upset his patient, so codes the allergy.
His clinical system reminds him henceforth. That entry collected
for one purpose at a GP's surgery, would now be assumed by a hospital
to mean that the patient was at great danger and would collapse
if given that drug again. To get the NHS to agree on allergy coding
we have to agree a new set of coding and subdivisions, complicating
29. Coding data in this way becomes so complex
that frustrated clinicians end up putting in junk codes. One of
the most common codes used in many practices is £8CB: "had
a chat to patient". If the NHS is too pedantic on coding,
it will develop cumbersome systems and meaningless data.
A GOOGLE WITHIN
30. A clinician at a hospital could, under
CfH, be able to search for records wherever they were held within
the secure NHS Net, and to leave an audit trail and a notice to
the patient that he had done so. That way a record and provenance
of each piece of information could be built up, so that the hospital
clinician could make a new judgment and make up his own record
on the day. He would not be relying on ONE record or any one system.
It would require standards for searching on different systems.
There are already programmes running that can undertake searches
on any GP clinical system; Miquest
and Apollo. 
31. Google, or similar, may well render
the whole of CfH redundant by inventing just such a system on
an international scale. Google already has a department working
on medical data run by Google's Vice President Adam Bosworth.
32. CfH insists that GP data is stored in
data centres. This is still the casedespite the Buncefield
explosion affecting NHS trusts using who were using off-site services.
33. Under CfH's plans GPs are not to have
any clinical servers in their surgery and GPs will be clients
of external servers. That
means all data is external. My patients have worries enough about
having just a fraction of their data going onto the spine. They
are horrified to hear that one day, under CfH, as soon as their
doctor presses a key on the desktop computer, their data will
be on a working server outside the surgery (in our case in Derby).
No matter that it is encryptedall their clinical data will
no longer sit in their doctor's surgery, nor would a copy of the
data, as there is no local server.
34. Those patients who refuse to have their
data outside the surgery will force us to use paper records again,
or to create a new surgery-only clinical computer system.
35. Patients can cope with the idea of an
encrypted dumb back-up file sitting off-site, and indeed even
expect such a thing, as they do not want their records lost. But
in my discussions patients assumed that only their surgery team
had the key to restore the data.
36. Under CfH plans, if anyone accidentally
digs up the cable outside the surgery, there will be NO data whatsoever
for GPs to treat their patients. No patient records would be available
at alla nightmare scenario in a busy surgery.
37. A BT/CfH N3 (broadband) team, made up
of Stuart Hill, Len Chard N3 Project, and Garry Jupp N3 Head of
Service attended my surgery in January 207 after they had read
my blogs about the N3 bandwidth. The
team stated that BT had have pointed out to CFH that no clinical
systems should be dependent on N3 connections to function, because
no communication system could guarantee being up 100%.
N3 CONNECTION BANDWIDTH
38. CfH lacks of bandwidth on N3, the
NHS Intranet. To run systems remotely requires fast upload speeds.
Many practices have only 256k upload speeds and this pipe is simply
not wide enough to transfer the level of data up to a data centre.
It can lead to jerky cursors and fix the GP's eye on the screen
far more than occurs already. The way around this is to have "store
and forward". The data is kept locally and transferred up
when the lines are quieter. Indeed BT protests that its N3 lines
are quiet and that GPs are not using their current lines at anything
like capacity. That underestimates the bursts of activity of any
IT system. A Monday surgery with busy clinics, and data being
scanned in, will be followed by pauses and a quiet night.
39. There are other pressures on bandwidth.
Each machine in a GP's surgery requires windows updates and virus
software updates and NHS Net email.
40. Data should be kept locally. An NHS
Net secure data engine could search for data with a patient's
consent (or in an emergency without it). Both the data holder
and patient are informed of the search and by whom it was made.
There would be no need for a central record.
FREEZING NHS IT IN
41. The NHS is spending £40 million
to develop a common interface for the NHS. Fixing a common interface
may simply set the NHS systems in aspic. The interface with programmes
is the most complex part of software. We are less likely to have
innovative approaches to interfaces if we are to have one interface
imposed upon us. Out there on the internet, new non-windows interfaces
may be developed but will be denied to NHS users.
42. Keep Data local... under the control
and protection of GPs, and search for it if needed, notifying
the GP and the patient that the data have been gathered.
43. Provide reliable offsite live backup
systems rather than demanding the use of hosted systems.
44. Setting standards of medical IT communication
and searching, and applying and developing international standards.
45. Develop and keep a live market in Medical
IT and encourage the smaller firms... one of them could be the
Dr Gerard Bulger
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