Select Committee on Health Written Evidence


Evidence submitted by Robin Guenier (EPR 23)

  Guenier is an independent consultant and chairman of the medical online research company, Medix UK plc. In 1996, he was Chief Executive of the Central Computing and Telecommunications Agency reporting to the Cabinet Office. He is a Liveryman of the Information Technologists Company (a City livery company) and is chair of its medicine and health panel. He has written this note in his private capacity, in no way is it intended to represent the views of Medix or of the ITC.

EXECUTIVE SUMMARY

  This evidence is based on findings of surveys of doctors' views of the NHS National Programme for IT (NPfIT) conducted by Medix UK plc. It indicates, in particular, that most doctors are worried about the confidentiality of electronic patient clinical records on the national database. A majority, however, recognises the benefits of such a record with many saying that some additional risk to confidentiality is therefore acceptable. But about 50% say that they will not or are unlikely to upload clinical details to the database unless a patient has given specific consent. Doctors' main concerns are that hackers and public officials from outside health or social care might access the records.

  Unless these concerns are overcome, the successful implementation of the electronic patient record seems likely to be in doubt. Keys to progress, both for NPfIT as a whole and for the electronic record, are (a) considerably better engagement with all users and especially with clinicians and (b) substantial improvement in doctors' confidence regarding the project's implementation. Neither will be easy.

1.  INTRODUCTION

  1.1  This evidence is concerned mainly with doctors' views, in particular, about the data privacy and confidentiality issues associated with the electronic record systems to be introduced under NPfIT and referred to in the inquiry's terms of reference. (Throughout this document this is referred to as "CRS" (the NHS Care Records Service)). It will also consider doctors' views on the CRS concept as a whole, so as to contribute to the Committee's review of its benefits and progress and why its introduction is late. It will examine what conclusions can be drawn regarding actions necessary to ensure that NPfIT, and hence CRS, is successfully implemented.

  1.2  This evidence is based mainly on surveys of doctors' views conducted by Medix UK plc (Medix). There are also references to surveys conducted by Nursix and by Ipsos MORI.

2.  BACKGROUND

  2.1  Medix UK plc has conducted seven major surveys of doctors' views of NPfIT, starting from February 2003. The most recent was carried out in November 2006 and is principally referred to in this evidence. The full results are submitted to the Committee as supplementary material.

  2.2  The survey was commissioned by the British Journal of Healthcare Computing and Information Management, Computer Weekly, E-Health Insider, the Guardian and GP and ran from 7 to 13 November 2006. The objective was to investigate doctors' views about NPfIT and to consider how those views had changed over three years. Respondents were over 1% of the 90,000 or so doctors who practice in England and are therefore affected by NPfIT. They covered a wide and well-balanced range of specialties and, in terms of grade, commitment and decade of qualification, were a good representation of practising doctors on the GMC register (see the demographic details set out in Appendix B to the survey results).[106] That and the large sample achieved are strong indicators that respondents represent the views of the wider population of doctors affected by NPfIT.

  2.3  Respondents were asked six questions relevant to the main focus of the inquiry:

  Q11a Are you aware of when you will be expected to start uploading your patients' clinical details to the national database as part of the Care Records Service (CRS)?

  Q11b Do you agree that the advent of the Care Records Service (CRS) is likely to mean that the confidentiality of patients' records will be more secure than it is today?

  Q11c Do you agree with the following statement: "CRS will benefit patients by enabling clinicians to make better decisions by having easy access to a complete, up-to-date record of clinical information"?

  Q11d If you agreed with the above statement (Q11c), do you agree that some additional risk to patient confidentiality would be acceptable?

  Q11e What are your key concerns about the possible impact of the Care Records Service on patient record confidentiality?

  Q11f To safeguard confidentiality, the DH has published a "Care Record Guarantee". In view of this, are you prepared to upload a patient's clinical details to the national database if that patient has not given their specific consent?

3.  THE CONFIDENTIALITY OF PATIENT RECORDS

  3.1  Respondents were concerned about the security of clinical records uploaded to the national database. 79% of GPs and 55% of non-GPs (largely hospital doctors) said that the advent of CRS is likely to mean that confidentiality will be less secure than it is today. Only 6% of GPs and 16% of non-GPs thought it likely to be more secure.

  3.2  This was the third time that Medix has asked the question. Results from all surveys (January 2005, January 2006 and November 2006) indicate that doctors are becoming less sure about confidentiality. GPs appear to be more concerned than non-GPs. See Table 1.

Table 1

SUMMARY OF FINDINGS RE EFFECT OF CRS ON RECORD CONFIDENTIALITY
Effect of CRS on the confidentiality of patient records? Q647
Jan 2005
Q849
Jan 2006
Q1066
Nov 2006
GPsBetter6% 8%6%
Worse70% 71%79%
Non-GPsBetter18% 15%16%
Worse42% 46%55%


  3.3  That a majority of doctors is increasingly concerned about confidentiality could well prejudice the introduction of CRS. That would have serious consequences for NPfIT as a whole and may be relevant with regard to the third bullet point of the inquiry's terms of reference.

  3.4  However Medix's most recent survey went further than earlier surveys. When asked if some additional risk to confidentiality was acceptable in view of CRS's potential for patient benefit, 55% of the 65% of those respondents who thought there was such benefit (i.e. 36% of all respondents) said either that there was no such risk or that any such risk was acceptable. This indicates that, in practice, some doctors might be willing to accept a lessening of patient record confidentiality. See Tables 2 and 3.

Table 2

  Q11c  Do you agree with the following statement: "CRS will benefit patients by enabling clinicians to make better decisions by having easy access to a complete, up-to-date record of clinical information"?
GPnonGP
Strongly agree718
Agree44%47
Disagree21%14
Strongly disagree8% 5%
Unsure15%10%
Insufficient information to comment5% 7%


Table 3

  Q11d  If you agreed with the above statement (Q11c), do you agree that some additional risk to patient confidentiality would be acceptable?
GPnonGP
I don't think there will be any additional risk 3%8%
Strongly agree3%4%
Agree42% 46%
Disagree29%24%
Strongly disagree12% 8%
Unsure9% 8%
Insufficient information to comment2% 3%

4.  KEY CONCERNS

  4.1  Respondents were asked what concerned them in particular. See Table 4. The greatest concerns were outsiders hacking into the system and access to the system by public officials from outside health or social care. This latter finding may be of interest to the Committee with regard to the second bullet point of the inquiry's terms of reference.

Table 4

  Q11e  What are your key concerns about the possible impact of the Care Records Service on patient record confidentiality? (Select any three—unless first option selected)

GPnonGP
I don't think CRS is likely to make patient records less secure 10%14%
Clinicians not adhering to the rules24% 22%
IT technicians not adhering to the rules 21%17%
Social services staff not adhering to the rules 26%19%
Researchers not adhering to the rules16% 9%
Bribery or blackmail of people with access to the records 34%22%
Outsiders hacking into the system62% 56%
Inadequate access controls48% 42%
Access by public officials outside health or social care 62% 51%
Unsure2%7%
Insufficient information to comment5% 8%
Other4%2%

5.  PATIENT CONSENT

  5.1  Another important new finding was that 51% of GPs and 47% of non-GPs said that they will not or are unlikely to upload a patient's clinical details to the national database unless that patient has given specific consent. Only 13% (GPs) and 18% (non-GPs) said that they would or probably would upload such details in these circumstances. See Table 5.

  5.2  This finding may be of interest to the Committee with regard to the first bullet point of the inquiry's terms of reference. It is a significant finding and, together with the finding about doctors' concerns about confidentiality (3 above), underlines what could be a serious problem for delivery of CRS and thereby of NPfIT.

Table 5

  Q11f  To safeguard confidentiality, the DH has published a "Care Record Guarantee". In view of this, are you prepared to upload a patient's clinical details to the national database if that patient has not given their specific consent?
GPnonGP
Yes5%5%
Probably8%13%
Unsure22%14%
Unlikely13%13%
No38%34%
Insufficient information to comment13% 15%

6.  A WIDER VIEW

  6.1  The survey found that, overall, doctors were positive about NPfIT's potential for patient benefit. For example, 58% of GPs and 69% of non-GPs believe it will improve clinical care in the longer term (see also the Medix/Ipsos MORI comparison submitted as supplementary evidence), although these figures are almost halved when they were asked about the next year or two. This finding reflects some comments by respondents to the survey (see Appendix D to the survey results) that, despite any deficiencies or concerns, the NPfIT concept is vital to the NHS.

  6.2  CRS in particular is supported by a majority of doctors. In its last six surveys, Medix has asked doctors whether they regarded CRS as important and the majority said it was. However, over the years that support has been declining: see Table 6.

Table 6

SUMMARY OF FINDINGS RE SUPPORT FOR CRS
The Care Records Service is important or very important Q354
June 2003
Q476
Feb 2004
Q558
July 2004
Q647
Jan 2005
Q849
Jan 2006
Q1066
Nov 2006
GPs77%81% 79%59%59% 56%
Non-GPs83%82% 88%73%69% 69%


  6.3  This reflects a much harsher deterioration in support for NPfIT as a whole. Since its first survey, Medix has asked doctors if they thought NPfIT was an important priority for the NHS and if they thought it a good use of resources (not asked in July 2004 and January 2005). Since its third survey, Medix has asked doctors if they were enthusiastic about NPfIT. The findings (see Table 7) indicate a serious decline in support.

Table 7

SUMMARY OF FINDINGS RE SUPPORT FOR NPfIT
Q265
Feb 2003
Q354
June 2003
Q476
Feb 2004
Q558
July 2004
Q647
Jan 2005
Q849
Jan 2006
Q1066
Nov 2006
NPfIT is an important priority for the NHS

GPs
67%66%70% 58%41%38% 35%
Non-GPs80%73% 80%73%68% 56%51%
I am fairly/very enthusiastic about NPfIT

GPs
56%45%21% 26%25%
Non-GPs-- 75%65%51% 45%41%
NPfIT is a good use of NHS resources*

All doctors
47%43%31% --17% 11%


  *  Results confirmed in surveys conducted by Ipsos MORI for CfH—see the Medix/Ipsos MORI comparison submitted as supplementary information.

  6.4  The surveys do not determine why this deterioration is happening. However one question, asked in January and November 2006, may be a pointer: when asked how they rated NPfIT's progress so far, on both occasions only 1% of all respondents considered it excellent or good and 8% satisfactory. In January 75% of GPs and 63% of non-GPs rated it poor or unacceptable and, by November, these figures had increased to 82% and 72%. These findings illustrate sharply the immense challenge facing Connecting for Health in persuading doctors that it is doing an competent job.

  6.5  Another concern is poor consultation:

  6.5.1  From the outset doctors have complained about their not being engaged with NPfIT: see Table 8.

Table 8

SUMMARY OF FINDINGS RE CONSULTATION (ALL DOCTORS)
Q265
Feb
2003
Q354
June
2003
Q476
Feb
2004
Q558
July
2004
Q647
Jan
2005
Q849
Jan
2006
Q1066
Nov
2006
How much consultation with you about NPfIT? Adequate2%2% 4%5%5% 5%5%
Is consultation with you important?Yes -85%88% 84%86%89% 92%


    6.5.2 An associated finding (Q1) is that, as recently as November 2006, 50% of doctors had little or no information about NPfIT (from any source), with 3% saying that the survey was the first they had heard of it. These findings echo a Nursix survey of 4,451 nurses conducted by Medix in June 2006 that found that 65% of respondents had either inadequate or no information about CRS.

  6.5.3 Also relevant is a survey of doctors conducted by Ipsos MORI for NHS Connecting for Health in February 2006 and published in June which found that 68% of respondents had little or no information about NPfIT, 11% saying they had "no information at all". (A table showing the similarity of key Medix and CfH's Ipsos MORI findings is submitted as supplementary information.)

7.  DEVELOPMENT AND DELIVERY

  7.1  The Medix survey casts light on the matters referred to in the fifth bullet point: when asked (Q11a) if they were aware when they would be uploading patients' clinical details to a national database, a big majority was unsure or didn't know. See Table 9.

Table 9

  Q11a  Are you aware of when you will be expected to start uploading your patients' clinical details to the national database as part of the Care Records Service (CRS)?
GPnon GP
I am already doing so4% 1%
Fully aware4%3%
Slightly aware8%9%
Unaware64%63%
Unsure12%12%
Insufficient information to comment8% 7%
Not appropriate to me1% 7%


  This finding confirms that the development of CRS has a long way to go and contrasts with the then minister in the Department of Health David Lammy's reply to a parliamentary question on 28 February 2003. He said that a target was that, by December 2005, "All primary care trusts, and all NHS trusts (will be) actively implementing elements of electronic patient records". The suggestion in the Committee's terms of reference that the new systems are "up to two years behind schedule" may prove optimistic.

  7.2  The fifth bullet point asks why CRS is late. An Office of Government Commerce / National Audit Office "agreed list of common causes of project failure" (see the Annex to the recent NAO report "Delivering Successful IT-enabled Business Change") had as its third cause (out of eight) "Lack of effective engagement with stakeholders". At least so far as clinicians are concerned, that would appear to be a major obstacle to NPfIT and hence CRS success—see 6.5 above. Unfortunately, most of the remaining seven causes on the OGC/NAO list also raise serious doubts about the overall management of NPfIT.

8.  CONCLUSION

  These findings indicate, in particular, that a lot needs to be done to regain clinicians' support for NPfIT and hence for CRS. An immediate action must be detailed, genuine and widespread consultation: if an electronic patient record, with its attendant advantages, is to be introduced successfully, the above findings make it clear that clinicians have to be consulted and involved. The findings suggest also that doctors have to be persuaded that NPfIT's implementation is sound. It seems likely that the commissioning and publication of an independent review of NPfIT, as recently recommended to the Committee by leading academics, could make an important contribution to achieving that.

  Consultation will be a huge (about 700,000 people would be involved) and expensive task, made particularly difficult by being started so long after the project was announced. Yet it should not be a hopeless task: doctors and nurses have consistently said that the objectives of NPfIT and particularly of CRS are worthwhile. Until it is done, however, it's hard to see how doctors in particular can be persuaded that serious and effective action is being taken to protect the confidentiality of patient records under CRS (see 3, 4 and 5 above). And, until that is done, the overall development and delivery of the service (fifth bullet point) seems likely to be in jeopardy. Giving evidence at a Department of Works and Pensions Select Committee hearing on 2 February 2004, Sir Peter Gershon (then chief executive of the Office of Government Commerce) said, "If the staff are not brought in to new ways of working, new ways of delivering benefits to the population, however successful the technology is the systems will not be successful." If the NPfIT systems are not successful, questions of concern to the Committee about the protection of patient data confidentiality and the benefits of an electronic patient record could be irrelevant.

Robin Guenier

15 March 2007




106   The NHS Plan: A Plan for Investment A Plan for Reform; Department of Health; 2000. Back


 
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