Select Committee on Health Written Evidence

Evidence submitted by Mr Frank G Burns (EPR 60)


  It is, frankly, astonishing that a Committee of the House of Commons should, at the beginning of the 21st century feel compelled to undertake an inquiry into the value and mechanics of managing health care records in electronic form.

  This is not a criticism of the Committee which is rightly responding to the ongoing controversy attached to the consistently poor performance of the NHS in convincing the "naysayers" about the importance of electronic records and even poorer performance over the last 20 years in delivering electronic records.


  1.  Healthcare is not a once in a lifetime event. From the moment we are born we begin a process of interaction with healthcare professionals that goes on throughout our life and which becomes increasingly frequent as we get older.

  2.  We see many different healthcare professionals in many different locations and for many different reasons throughout our life.

  3.  Each time we meet a new healthcare professional with a new health problem (or even an ongoing problem) there is a fundamental need to treat the new problem in the context of an accurate picture of our healthcare history.

  4.  A service delivery policy that "divvies up" care between an increasingly wide range of public and private service providers (both local and further afield) makes the task of maintaining a properly integrated health record both more difficult and more important.

  5.  The volume, range and complexity of data items (about us) that our interactions with healthcare professionals generate over our lifetime cannot be properly stored and most definitely cannot be properly retrieved by paper record systems.

  6.  The difference in convenience and access between electronic and paper records is like the difference between using the local Library and an Internet Search Engine to research a given subject. Electronic data capture has literally revolutionised every aspect of our daily lives and the progression of this technology is on an unstoppable evolutionary path.

  7.  Having to make the case for electronic health records is on a par with having to make the case for the telephone, the television, central heating, and the motor car.


What should be held on electronic records?

  8.  A record is a record—the electronic record serves the same purpose as the current paper record. It captures important information that may be important to the care of the patient at a future date. An incomplete record can be dangerous. The vast majority of patients will take for granted that their health record (whether paper or electronic) should contain everything that is relevant to their future care. The real issue of public concern (and even this isn't a regular topic of conversation down the pub) is the adequacy of arrangements to ensure that access to records is confined to bona fide health professionals actively engaged in the care of the individual concerned.

National versus local (and related issues of public confidence)

  9.  If a patient is asked if they object to the creation of an integrated health record at local level for use by the health professionals involved in their care they will generally not object. Not only will they not object to their GP and specialists at the local hospital exchanging relevant information they will be annoyed if failure to do so adversely affects their care (as it often does).

  10.  This tolerant public attitude to a locally created electronic record can be demonstrated by an exercise on the Wirral where just such a proposition was put to the local population (of 350,000 people) with an option to opt out. Only 25 people have asked to opt out over a period of more than two years.

  11.  On the other hand if a patient is asked if they object to their health information being "uploaded" to a "national database", ostensibly for the same purpose, they will form a different perception of what is being created. They will wonder why their personal health information needs to be held and managed on a national database and be concerned about the greater potential for malicious use (whether by government departments or otherwise unauthorised access). The downside of the digital revolution that many ordinary people do understand is the indiscriminate creation of personal databases for commercial use and exploitation. People may well be prepared to put up with the fact that their local supermarket analyses and sells information about their purchasing habits but they will not tolerate even the theoretical possibility of use of their personal health information for other than their own care.

  12.  Public confidence in the development and use of electronic records will be more easily established if it is seen to be an operationally driven process of real-time information sharing and record keeping for the healthcare system in which they reside and in which they get their care.

  13.  The current NPfiT programme has given a huge amount of priority to rolling out a summary electronic record that can be accessed to support out of area emergency care.

  14.  This an enormous distortion of priorities for a number of reasons:

    —  The vast majority of emergency care is provided by the local NHS and as such it follows that clinician access to a fully integrated local record would provide a much more complete context for emergency treatment than will be available through a "thin', incomplete, separately generated summary.

    —  Creating a national summary record before the local systems are in place to properly populate this with up to the minute information is putting the cart before the horse.

    —  The actual frequency with which records need to be accessed "out of area" in an emergency are relatively rare and in many cases adequate information can be got from the patient or by a phone call.

    —  The setting up of a national summary record to support out of hours, out of area care should have waited until the local systems were fully deployed. At that point it might be possible to devise an access protocol that gives remote carefully authorised access to a standardised summary of the local record, via a secure national gateway, as an alternative to creating and maintaining a separate national database for this purpose where failure to update key information immediately and reliably will pose risks to patients.

  15.  The clinical community in the NHS does not see the national summary record as a priority compared with the development of locally integrated electronic records that support the work of local healthcare professionals in the day to day care of their patients. This is particular important for older and other patients with chronic illnesses who are simultaneously accessing many services in tertiary , secondary and primary care and who may, in the future, be receiving some of their care from Non NHS providers.

Can patient confidentiality be adequately protected?

  16.  Where properly devised and implemented, technical access controls to electronic records will be hugely more effective than access controls to paper records.

  17.  A casual walk round any hospital chosen at random will expose the myth that current paper records are secure.

  18.  No doubt the committee will get wheelbarrow loads of evidence from the technical experts on both sides of the argument but the conclusion that has to be reached is that no guarantees can be given that any system of record storage is safe from determined attack by sophisticated criminals with unlimited resources.

  19.  Nonetheless access controls to electronic information does make it more possible to restrict day to day access to patient's records to the people involved in their care and to exclude access by those who are not. A patients name written on a white board at the nurse's station is there for all to see—when the same information is on a computer terminal it requires a password to see and the computer will record the fact when people who don't need to see it are trying access it.

  20.  The argument about security can only be sensibly conducted in relation to day to day reality. The arcane debates between the experts about the difficulty of achieving the holy grail of the unhackable database should not get in the way of the beneficial use of new technology in health care. As with all things the balance of advantage has to be carefully weighed. Large numbers of NHS patients come to serious harm on a daily basis through poor access to patient's previous history or test results and poor or non existent communication between health and social care professionals. 10% of NHS patients (one million patients!) suffer harm each year through some sort of error and 2000 of these will die. Many of these errors relate to record keeping and communication. The massive improvements in this area that come with properly integrated electronic records render the technical debate on how to achieve ultimate security completely redundant.

Why the delays with NPfIT?

  21.  The top down approach with centrally procured systems that characterises the current national programme arose from the acknowledged failure of the local implementation approach advocated by the 1998 Strategy Information for Health.

  22.  It is important to note, however, that the clinical emphasis and local approach advocated in Information for Health was universally and enthusiastically supported by all the key professional bodies.

  23.  It was clear at the time of launching Information For Health that the senior management (CEO) community and some of the political advisors would have preferred a more prescriptive approach. This was principally attributable to a desire on the part of CEOs to have this traditionally challenging and difficult agenda delivered by the "centre" as a gift wrapped and imposed solution. Many CEOs, DH officials and advisors simply assumed that clinical IT could be rolled out across the NHS in the same way that "check out" technology could be rolled out by a supermarket chain. This was then, and is now, a grotesquely over simplistic view of the transition from paper records to electronic records in the Health Sector. The problems encountered by the national programme provide graphic and painful evidence of the consequences of underestimating the complexity of implementing clinical IT systems and of trying to impose standard solutions on healthcare professionals.

  24.  In the event the Information for Health strategy failed through lack of financial support and through not being given sufficient priority by local managers (who, to be fair to them, were understandably pre occupied with ever more demanding waiting time and other targets.)

  25.  The government, understandably frustrated with this setback to their modernisation programme accepted the case made by the advocates of a more robust nationally controlled implementation and as a consequence NPfIT was born in 2002.

  26.  A simple summary of the reasons many senior NHS staff would cite for the subsequent problems with the national programme would include the following:

    —  A national procurement process that, by its very nature, couldn't possibly allow sufficient engagement by practising clinicians.

    —  A feeling by many of the clinicians who did get involved in the procurement that in the end their requirements and advice were subordinated to the bottom line cost.

    —  An impression that the most important part of the contract was the penalty clauses for non delivery. Whilst this has properly ensured that the NHS shouldn't pay for what it hasn't had, the better outcome would be if the NHS was in a position to pay up for timely delivery of what was bought.

    —  Covering the whole of England with only 5 LSPs (contracts) created implementation projects of unprecedented size and scale each involving up to 150 NHS organisations. Tackling an agenda already known to be the most difficult change management agenda for the NHS in the manner and on the scale being attempted was always a very tall order.

    —  In many parts of the country, and setting aside the widespread resentment regarding imposed, standardised solutions, there have been mounting delays which have not been helped by the withdrawal of one of the LSPs and 2 of the 5 LSPs changing to a different clinical system supplier some years into the programme.

    —  One major system supplier is currently the subject of takeover discussions and openly acknowledges that its definitive system (ie that which it is contracted to deliver will not be fully developed until at least 2008).

    —  With contracts on this scale any major problem affects large swathes of the NHS simultaneously. Worryingly this has also been found to be true for system failures where these have occurred.

    —  Many in the NHS believe that by the time the systems procured are implemented and taking into account the need to standardise and simplify to allow simultaneous multiple site implementations—what they end up with will not be the sophisticated clinical management systems that they need for modern healthcare.

    —  There has been a serious lack of local management ownership and accountability for ensuring successful local implementation. Setting up a multi £ billion investment in NHS IT with almost no personal accountability for delivery on the part of local NHS CEOs was and remains a monumental error of project management.

    —  NPfIT and IFH before it both addressed the IT needs of an NHS in a position of the monopoly supplier of healthcare. More recent policy is encouraging the entry of private sector providers into the NHS in all sectors of care. These new providers further fragment the treatment pathways and as yet there is no clear view of how NHS clinical data created in non NHS environments is to be integrated into the patient record.

    —  There is a lack of clarity (at least to some) as to how under the national programme the fully integrated local electronic health record is to be created. At one stage it was though this might be done through the national spine but more recently it seems that the programme will only a deliver a summary emergency record through the national spine. As argued previously the more urgent practical requirement for the NHS is not the emergency record but the integrated local record that supports 99.9 % of day to day care.

Where now?

  27.  There have been signs recently that the DH has recognised the urgency of introducing more local ownership and a degree of local freedom around enhancements to the systems that are eventually delivered through the NPfIT process. The more that this is possible (allowing for the limited room for manoeuvre in contracts that have been entered into) the more positive the NHS will become about this agenda.

  28.  The NHS is capable of implementing sophisticated electronic patient management systems. GPs throughout the country have been using their own electronic records for many years and a number of hospitals had installed sophisticated systems before the advent of NPfIT. In some areas of the country local progress has been made in sharing electronically the information in Hospital and GP records. It is important to recognise that in all these cases progress has been made by local clinicians working with local managers and IT staff and focussing on their own local priorities.

  29.  Whatever adjustments are made to current policy these should be made in relation to the most urgent service priorities for better use of IT. These include:

    —  Rapid deployment of functional clinical systems into secondary care.

    —  Rapid deployment of functional clinical systems to support community staff.

    —  Rapid deployment of functional clinical systems to support the work of the many multi site clinical networks (eg cancer networks) that are providing care on a collaborative basis to some of the sickest patients in the service.

    —  An urgent review of the most effective way of accelerating the capture and availability to all health professionals of clinical information about individuals that is spreading over an increasingly wide range of public and private sector providers.

Frank G Burns

Independent Healthcare Consultant

March 2007

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