UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 422-iv

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

 

 

THE ELECTRONIC PATIENT RECORD

 

 

Thursday 14 June 2007

PROFESSOR JOHN FEEHALLY, DR GILL MARKHAM and MR FRANK BURNS

LORD HUNT OF KINGS HEATH, MR RICHARD GRANGER and DR SIMON ECCLES

Evidence heard in Public Questions 499 - 641

 

 

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Oral Evidence

Taken before the Health Committee

on Thursday 14 June 2007

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Mr Ronnie Campbell

Jim Dowd

Dr Doug Naysmith

Dr Howard Stoate

Dr Richard Taylor

________________

Witnesses: Professor John Feehally, President, The Renal Association, Dr Gill Markham, Vice President, The Royal College of Radiologists, and Mr Frank Burns, Former CEO, Wirral Hospital NHS Trust, gave evidence.

Q499 Chairman: Good morning. Can I welcome you to what is our fourth evidence session on our inquiry into the Electronic Patient Record? I wonder, for the sake of the record, if I could ask you to introduce yourselves and to tell us what position you hold? Could I start with you, Mr Burns?

Mr Burns: My name is Frank Burns. I am a recently retired chief executive of a large general hospital on the Wirral where I was chief executive for 17 years. During the course of my employment at the Wirral I was seconded for 18 months to draft an Information Strategy for the National Health Service which was published in 1998 under the title of Information for Health, and which has been subsequently superseded in terms of the implementation model by the National Programme for Information Technology.

Dr Markham: My name is Dr Gill Markham. I am a consultant radiologist now in North West Thames, I was previously in Liverpool for about 25 years, and I am Vice President of the College, who I am representing today.

Professor Feehally: I am John Feehally, I am a kidney doctor. I work as a consultant in Leicester. I have just completed a three-year term as President of the Renal Association, which is our professional society of kidney specialists in the UK, and I also chair a group called the Renal Information Exchange Group, which is a professional and patient group which has got itself together to try and ensure that the renal health community influences as much as it can and in the best possible way it can the whole information and knowledge agenda within the NHS.

Q500 Chairman: Welcome once again. Could I start by asking a couple of general questions? The aim of introducing electronic patient records is to improve the quality of patient care. To what extent do you think this has been achieved to date?

Mr Burns: By no means as much as it has the potential to improve the quality of patient care, but the fundamental requirement for electronic records, in fact "electronic records" sometimes misdescribes this technology, because the best of this technology is patient care management systems, not simply electronic means of recording what has happened to patients, the best of these systems actually support practising clinicians in their day-to-day work providing better care for patients; and where clinical management systems have been installed, and they have been implemented in various part of the country, not as widely as we need them and not with the urgency with which we need them, there is very serious evidence of the capacity of these systems to improve patient care, but they have to be deployed at the operational level, they have to be functional at the operational level, they have to be tools which are used on a day-to-day basis by clinicians - doctors, nurses, community nurses, specialist nurses - right across the spectrum of care. There are very graphic examples of how information technology deployed in a clinical setting cannot just improve the quality of care but can dramatically improve the safety environment in which patients are cared for.

Dr Markham: My particular remit is the imaging aspect of it, but I also use the Electronic Patient Record in my trust. To give you an example, if I want to have a pathology report, that is immediately available. So, the patient benefit is indirect but it is safer availability, it is instant availability and accurate availability because you can go straight into the record and get it, but, as I say, it is within the trust that I have experience of that and, obviously, the imaging side of it, which we will go into later, I am sure.

Professor Feehally: There is absolutely no doubt about its potential. It is beginning to come in in some places, but in quite a lot of those places it has come in or is coming in, it is quite independent of Connecting for Health, it is initiatives taken locally by others either before Connecting for Health or, indeed, since it began but in spite of. We often think about it within an institution like a hospital, but for me the real gain is across primary, secondary, tertiary care within a network. To give you a single example, I was in my clinic yesterday afternoon. I saw a man in his sixties with diabetes who has kidney disease. He has a complex problem. I see him often. Three days before he was in the diabetes clinic. One week before that he was with his GP. I could not access blood tests from any of those. He is an articulate man who told me what had happened to him, but if he was not I would not have got that right, and that is transformed overnight if you get these things in, but we are not seeing it yet.

Q501 Chairman: Survey evidence has shown that doctors' confidence in the national programme has fallen sharply since 2003. Why do you think this has happened and what can be done about it?

Mr Burns: I think it touches on the points we have all three just made, that what clinicians want is functioning technology that will support the work that they do on a day-to-day basis. I think a lot of clinicians are frustrated, for instance, about the focus of Connecting for Health on the summary care record. The Committee has heard enough evidence already about the delays with this programme. I do not think we need to repeat the fact that there is huge frustration about the fact that, despite the fact that Connecting for Health has been in existence since 2002, if you go round the NHS into the operational clinical services there is very little evidence as yet of the clinical systems that we are describing. There is lots of activity around the implementation and replacement of patient administration systems, but these are not the same thing. Patient administration systems have existed in the NHS for many years. They are administrative systems, they support the processing of patients, they do not support the care of patients, and it is the elements of the technology that support the care of patients which is slowest in coming forward. In many parts of the country, people have begun to despair of it as to whether it will ever arrive and I think a lot of clinicians are very frustrated about the focus on the national summary care record, about the creation of a national approach to sharing information and the lack of priority that is currently being given to the development of the implementation of clinical systems at the clinical level and the sharing of information, in the way that my colleague describes, so that doctors and nurses, when they are treating patients, have a good, up-to-date, reliable, accurate picture of everything that is happening to that patient. Most patients come to harm in the NHS in the course of day-to-day care; they do not come to harm necessarily, to a greater extent, because their records are not available if they happen to turn up at some distant hospital, unconscious with no identification. I think the evidence for the benefit of the summary care record has not been presented, and I think that evidence could easily be obtained. It is not a difficult thing to scope, in terms of the current NHS, how many patients are going to benefit in terms of remote need for emergency care. The real priority for the NHS, for the NP, for Connecting for Health, in my view, and I think it is a view that is supported by most clinicians, is for detailed care records at a local level, and I think it is the absence of progress with that that is creating the frustration you allude to.

Q502 Dr Naysmith: Do you think there has been too much emphasis on this emergency care?

Mr Burns: I do, yes.

Q503 Dr Naysmith: Do you think that is one of the real problems, concentrating on this record being available?

Mr Burns: It is not the only thing that NPfIT are pursuing. NPfIT can list some very general achievements, not least in PACS, which is picture archiving technology for radiologists. I am not here to condemn everything that Connecting for Health is doing, but I do think that the focus on the summary is a misplaced priority. I think it is of less value clinically and less value to patients than the deployment of clinically rich functional technology supporting doctors and nurses on a day-to-day basis, and there is no sign of that being delivered to the NHS any time soon.

Q504 Chairman: Do you have anything to add to that?

Dr Markham: Just to say that Professor Feehally alluded to the fact that much of this had been present before, and we will no doubt come back to PACS in a moment, but an awful lot of PACS was available prior to this and in many ways it has muddied the waters, although it has rolled it out much quicker than it might otherwise have been, but it was in place in many places way before NPfIT.

Professor Feehally: To add to what Frank said, it is lack of progress which frustrates clinicians, but there has also been an appalling communication failure from the beginning. The early attitude was, "We are the computer experts. We will let you know when we need a little something from you, because we will roll this out and it will work", and they have gradually retreated from that as they have realised it is actually difficult, but what they have not done is really listened to clinicians and they have assumed that when we say, "This is difficult", or "This is complex", or, "This is quite sophisticated", we are a bit old fashioned or a bit Luddite or do not understand, rather than assuming we really did understand something very complicated we worked within for a long time, and we have used computers for 20 years in some ways, so it is a communication failure.

Q505 Chairman: Frank, would it be fair to say that out of the detailed care record comes a summary care record?

Mr Burns: Yes.

Q506 Chairman: This is putting the cart before the horse. Would you go as far as to say that?

Mr Burns: Yes, I would. It is true about clinical IT that all of the secondary purposes flow best from focusing on the principal purpose. The principal purpose is to support the care of patients, and if you give total priority to the principal purposes, which is supporting the care for patients, all of your secondary purposes will flow naturally from that. If, for instance, you had good, effective, supported clinical systems in hospitals - you already have them in general practice, it is in hospitals that there is a great black hole in terms of good functioning clinical systems - if you deal with that and focus then on technologies that can integrate the information in those records at a local level so GPs and hospital specialists who work in a partnership on a day-to-day basis can have a shared view and, as my colleague said, even specialists working in the same hospital can have a shared view of what is happening to a patient, I am not a technologist, I am not an IT specialists, but I am very confident that if you had good, local detailed care records, the technologists would not have too many problems in extracting the information that is needed for a national summary care record, if there was a case for a national summary care record. But bearing in mind that most people attend their local hospital if they have an emergency, the occasions when any of us fall over in a distant town and need emergency care are not all that frequent compared with mothers rushing to the local hospital with their sick child because they are not sure why they are crying. Most of this care is delivered locally, not remotely, and that is why the focus should be on delivering this functionality locally.

Q507 Chairman: I do not understand all the technical side of this, but in a sense for that to happen, for my GP to share records that are in my local district general hospital, they have to be compatible, and that is something we have not been very good at. The patient administrative system a decade ago was sharing no discharge notes at all with my local GP service, and I expect that was the case for the whole of the borough. It seems to me there has probably been an emphasis on making sure that, whatever systems are eventually installed, they are compatible systems so that you can deliver that. Has that been one of the major issues, do you think?

Dr Markham: To a degree, but prior to NPfIT there were systems that were set up locally - for instance access to specialist services. If you had a patient coming in with a head injury at night, then you could beam your images off to the local neuro-surgical centre for an opinion, and in some ways that has been made more difficult for NPfIT coming in. I suspect, although, again, I am not obviously a computer expert, these difficulties could have been got round in perhaps a slightly less all-encompassing way. The idea is very good, but I would entirely support what Frank Burns has said that the vast majority of healthcare is done in your local community. In the case of London or any of the conurbations, or even down in the South West, patients go to their local hospital, they may go to a specialist service in a hospital three miles down the road and that is the sort of sharing that we need rather than one end of the country to the other.

Professor Feehally: To repeat the answer in a different way, if at the beginning of this sorry process they had simply given local health networks some resource and said, "You will just simply resolve the question of the primary care computer system talking to the hospital computer system", we would all now be smiling, because there have been many other things we had not yet got, but that alone would have advanced the healthcare system, and that is what we wanted.

Q508 Chairman: John, you were talking earlier about clinical engagement in all this, and we have seen examples of where that has happened certainly for the good in my view. How do you actually get clinical engagement when you have got (I think the national figure is) 700,000 clinicians working inside the National Health Service? What happens? Where this has happened, how many people are really engaged with looking at the system that has been introduced and making sure it does fit their needs and the patients' needs in terms of that locality?

Professor Feehally: You do not need many champions. Where one has seen success there have been a small number of senior clinical leaders who have believed in it and have begun to demonstrate change, and then you take the clinical community with you. What you do not do, to use my specific example, I have on several occasions approached Connecting for Health at several levels saying, "Here I am; I represent the kidney world. We spend 2% of the NHS budget on dialysis and transplant. Chronic kidney disease is very common and it is a cardio-vascular risk marker. We are a big group. Can we please talk to you?", and they have not answered the email, not given me an appointment. I have simply never spoken to anybody. They have not wanted to talk to us. So at that level it is frustrating.

Mr Burns: I think philosophically there are a couple of approaches. The approach that preceded NPfIT where local health communities were, if you like, expected to source, procure, implement systems locally, there is a better opportunity for getting a critical mass. You do not need every clinician, but you need a critical mass of people, the leaders amongst the clinicians, as you do with any endeavour, and you can get a critical mass of local clinicians involved if there is some element of local choice of system. The more you scale that up the more difficult it is to achieve that, and you have to accept, and I accept, that if you accept the argument for national procurement, then there is no practical way you can achieve local clinical engagement. There is no point pretending there is a practical way, because there is not, and if the benefit of national procurement is greater than the need for local high input clinicians, then you make the argument and you go on that basis, and I accept that. But if you do go on that basis, then you have to deliver quickly what it is that you are procuring nationally. If you say to doctors, "There are too many of you to involve you in the choices and the economics defined nationally outweigh the argument for local choice, so we will do it this way because we will get it cheaper, because it is cheaper there will be more of it, because it is cheaper we can give you more sophisticated software, it will be better, then you have to deliver it, you have to come up with that; and if they are still waiting after five years, which is what the case currently is, then you have lost your way of making that particular argument. Then what you have got is not an argument about engagement, you have got a problem of disengagement because clinicians have disengaged because they see no evidence of what was promised in place.

Dr Markham: The way it was done with PACS is a very good example. The sudden cluster, as is now, was almost ready to roll out. People had been agreed, they were going the same way, they were going to connect up, and then it stopped on the basis of a national procurement. In practical terms what happens is you have perhaps a consultant radiologist and a radiographer who have a particular interest in it in a trust or in a group of trusts and they are the ones that develop with the vendors what is required. They say, "This is the problem. This does not work. How can you make this work? This is what we want to do", and the work is very good and there is very close co-operation over a period of probably ten, 15 years as it developed, and that is why it was good.

Q509 Dr Naysmith: Was there any evidence of radiologists being reluctant to use the new system when it was being introduced or just before?

Dr Markham: You mean PACS?

Q510 Dr Naysmith: PACS?

Dr Markham: Absolutely not. That is one of the reasons for its success, because there were such strong drivers as far as PACS was concerned. We were running out of silver films, the disposal of dangerous chemicals was difficult, the paper films or the hard copy films used to get lost, you had to have people carrying them around the hospital in great big bundles, so to have it electronically---

Q511 Dr Naysmith: So there was not any need to convince radiologists that their system was out of date?

Dr Markham: Quite the reverse. We spent a long time trying to convince trusts it was a good idea to have it.

Q512 Dr Naysmith: You had to convince the trusts rather than the radiologists?

Dr Markham: Oh, yes. The radiologists were completely signed up right from the start. We realised the benefits it would bring. It was obviously the financial drivers that we had to convince, because it meant new machines, which, of course, were hugely expensive, but eventually that was gathering speed. Certainly in my own hospital I have been working with PACS for eight years, and two years before that in another hospital, and it was extremely successful.

Mr Burns: It would be almost impossible not to achieve a rapid roll-out of PACS given central funding.

Dr Markham: Absolutely.

Professor Feehally: And not just radiologists; other clinicians. We had a form of PACS in place for over a decade. It was absolutely fantastic, it works, and so there is never an issue about needing to persuade anybody. It was almost there in a way; it simply had to be rolled out. It was not a magnificent design achievement, I do not think.

Dr Markham: No, and in fact I was at a meeting earlier this week and it was said that PACS roll-out would have happened probably without NPfIT because there were such strong drivers.

Q513 Dr Naysmith: How do we get that sort of enthusiasm there obviously was for PACS to operate for other PAS systems? How do you get clinicians involved in customising their local system?

Dr Markham: We have already talked about the obvious advantages of communicating with general practitioners and within hospitals, but the frustration has been trying to get the software and the hardware to do what you want it to do efficiently, and also a very important point is the actual technical back-up when things are implemented. Inevitably with computers things go wrong, and you need someone who is knowledgeable who is there. Your home PC might crash and you just reboot it, but you cannot quite do that when you have got electronic systems in a hospital.

Q514 Dr Naysmith: You need the experts to talk with the clinicians closely on what is happening and what is required?

Dr Markham: Yes, and that has been in very short supply.

Mr Burns: It is availability and speed of implementation. If you want a PACS system, they are available; you can buy them off the shelf. You can say to clinicians, "Here, I have got some money. You have been asking us to put in PACS systems for the last decade and now we have got some money and you can have it in the next six months", so you get a huge surge of enthusiasm from the radiologists and the other clinicians because they know the technology is available, they know it has been funded and they know they can have it within the next 12 months. On the other hand, if you are waiting for the clinical management systems that support the work of diagnosis, treatment and therapy, the message to the clinicians is that we will be putting PAS systems in (which are not clinical systems) for the next two, three, four years and we are still developing. At least probably two-thirds of the country is still waiting for the clinical system to be finally developed, and the latest estimation---

Q515 Dr Naysmith: Does the same thing apply to patient administration systems, or is that a different problem?

Mr Burns: No, the NHS has been putting patient administration systems in for the last 20 years, and most hospitals have already got them and had them and embraced them. What they are getting is new patient administration systems that are compatible with the clinical systems that have been purchased through the national clinical contract which they are compelled to have and must wait for, and that is the source of most of the frustration. The Patient Administration System is not the clinical system.

Q516 Dr Naysmith: But consultants at the Homerton were booking people into out-patient clinics months in advance.

Mr Burns: Yes. A patient administration system can help you book patients, but it does not help the doctors and nurses in terms of their day-to-day care of patients, the real purpose and benefit of this technology ultimately.

Professor Feehally: We have talked about engaging clinicians by giving them something better, but there is another point that some of us are concerned that we might lose what we already had. We have used computer systems in kidney units for 20 years and, although they look a bit clunky, actually they have got all sorts of very bespoke functionality which we need not use. So part of our discussion with Connecting for Health was, "If you are going to give us something wonderfully new, do you understand what we already have so that we will even have that, let alone something better?" and they have never discussed that with us. So, we have been sitting with our so-called Legacy Systems (in the current jargon) thinking, "Are they even going to take this away from us, because it would be unacceptable?" We have never had those discussions.

Dr Markham: That has happened in many areas, that systems that were working have had to be removed.

Mr Burns: Certainly in my hospital we had a very sophisticated, fully functioning clinical system for 17 years. It is still the most sophisticated clinical patient management system in the UK, in my view, and, in my view, what is eventually produced by NPfIT will not be as sophisticated, which is the reason that in my trust, for issues of patient safety, we had to say that the first offering for NPfIT would have been a positive danger in that all our 6,000 staff have become familiar with using a sophisticated clinical patient management system and we have been offered something much less sophisticated.

Q517 Charlotte Atkins: Based on that comment, Mr Burns, I am assuming that you hold to your view in 2002 that contracting out nationally would be a disaster. If that is the case, can you indicate if there have been any successes, in your view, in the national programme?

Mr Burns: Yes, they have secured £12 billion, which is an enormous success, and it is the most fundamentally important thing about the national programme. There is huge resource available that was not previously available and, despite what was said at previous sessions about the lack of progress prior to NPfIT, the biggest obstacle to lack of progress prior to NPfIT was the absence of resources on the scale that are available to NPfIT. They have huge sums of money at their disposal which, if deployed in the right way---. I think there is a proper argument to be had for contracting nationally, but I think there is a way of contracting nationally using all the economies of scale and using all the purse-string muscle that comes from contracting nationally. I absolutely agree with that. I think they did a super job. I think what they might have done was contracted nationally a catalogue of products which could then have been picked from locally and the prices could have related to how much penetration the different suppliers achieved across the NHS. That would, if you like, combine the benefits of national contracting with---. It is a framework contract. It has been done in many areas. You contract nationally with a range of providers but they then have to compete in terms of how they present their products to potential users to determine what share of the market they get. I think that would have been a much more successful model, and I think we would be much further on if we had adopted that sort of model.

Q518 Charlotte Atkins: I think you argued that you wanted to make local chief executives accountable for delivering the new systems.

Mr Burns: Yes.

Q519 Charlotte Atkins: Do you think that would have resolved many of the delays we are experiencing now?

Mr Burns: From where I sit, and I have been a chief executive for a long time, the introduction of NPfIT and the central contracting and the contracting with local service providers to be responsible for implementation, for taking all the risk of implementation, completely removed from operational chief executives any sense of accountability for delivering this programme. Poor old Richard Granger gets blamed for everything to do with the failures of this programme, but that is because there is no other accountability in the system.

Q520 Charlotte Atkins: Is it too late to turn the clock back and bring in that accountability?

Mr Burns: No, I do not think it is, but it would require---. Everybody wants NPfIT to succeed. The goals and aims of NPfIT, my goals and aims in relation to rolling out functional clinical IT to the NHS, Richard Granger himself has said that you could not possibly embark on a ten-year programme on this scale without having to change tack over the course of the decade and I entirely agree with him. I think there needs to be some decisions made as to how to change tack to deal with some of the delays that they are currently experiencing, and one way they might do that is to use this current OJ tender that they are involved in. They are currently involved in a tender process with the IT supply industry to the NHS to identify a range of products that might supplement what they are currently contracted for, and if they found a way to make the best of those products available as a choice within the NHS (and that presumably would need some tweaking of the contract), then I think that might help move things forward. I will say one final thing and then shut up. If there was more focus on---. You could give accountability to the primary care trust, for instance. Primary care trusts are responsible for the health of their resident population. They are a stable part of the structure of the NHS these days. They could be made responsible for the commissioning arrangements that will bring about the sharing of information from systems that are already in place, because there are many systems that are already in place that could share information and there is no focus or requirement or accountability for bringing information on GP and hospital systems into a single view at the local level, and you could stipulate that as an objective so people could be getting on with what they could be getting on with whilst they are waiting for the delivery of the products that would come via the national programme.

Q521 Charlotte Atkins: We certainly hope that PCTs are now a stable part of the system?

Mr Burns: I am sure they do.

Q522 Charlotte Atkins: And I am sure that one of the advantages is that, of course, they are closely in touch with GPs, and I think that is one of the issues that we have been picking up along the way. Does anyone else want to come in on this issue?

Dr Markham: On the issue of the ambitiousness of the thing, I entirely agree that the roll-out certainly of PACS has been much quicker than it might otherwise have been. It was happening, and it would have happened, and it has certainly happened much quicker, but to give great big contracts to a small number of suppliers was always going to be a problem because not only do they have to supply the machines and the software but they have also got to supply the personnel for the back-up of the installation, and that was always going to be challenging. One thing that we have not mentioned yet but has been a challenge is the fact we have no unique identifier in England, and that is a huge difficulty because we have to be terribly careful, and this is one of the reasons why at the moment we cannot share images across the borders, because we have not got that unique identifier. They have in Scotland, I understand, but not in England.

Q523 Dr Stoate: Surely, we all have an NHS number. Why cannot we use that? That is a unique identifier: you are given it at birth; you keep it until you are dead.

Dr Markham: Apparently the technicalities of issuing them are too challenging at the moment.

Q524 Dr Stoate: One number per person up to 60 million. Can they not count to 60 million?

Dr Markham: If you have someone coming into A & E at night, for instance, badly mangled in a road traffic accident, you have to have that number issued instantly before you could image them - that is the challenge; it has to be like that - and you can get your NHS number, if they have not been imaged before, because it would be a bit like a grandfather clause. Babies could have it but people that are not in the system at the moment may or may not have it, particularly in my area of the country which has a high immigrant population. So the actual technicalities of getting it at two in the morning would be a problem, and there are other minor technical difficulties. I gather there is a push to get it approved, but, of course, all trusts have had their own numbers which they have used and they are reluctant, unless they have a central directive, to change to a new identifier.

Q525 Dr Stoate: Can you briefly explain how Scotland has managed to achieve it and we have not?

Dr Markham: I am not in Scotland, but apparently they have. It is called the Community Health Index. The Chief Medical Officer, so I understand, has decreed in the middle of last year that this is what should be used, and I understand it is working well from my Scottish colleagues.

Q526 Dr Stoate: I just do not understand what the difference is between a Scottish unique identifier based on a patient and an English unique identifier.

Dr Markham: What they have used in Scotland is the date of birth with four digits after it, and they are assured that that is unique. What is more, when England does get one, which we sincerely hope it will, then it will not overlap, so there will not be a conflict of people who go across border for healthcare, but that, I understand, is the problem.

Q527 Chairman: Can I ask a question, Mr Burns. You said earlier that PCTs are a stable part of the structure these days. NPfIT has been around for quite a while now, and we have had not just the restructure of primary care trusts but particularly the restructure of SHAs. We have now got the LSPs that are delivering in the new restructured SHAs. In your view has that been one of the problems of getting cohesion with in terms of the national programme, that there has been this restructuring inside the National Health Service, particularly at SHA level, or it did not matter?

Mr Burns: I do not think so. I think the reasons for the slow progress are the reasons that have been discussed. It is to do with the national contracting model. My point is that I have a fundamental view that there needs to be a genuinely local approach to the development of clinical IT, because that is where most healthcare occurs. There needs to be some local accountability for ensuring that patients have reliable records and for ensuring---. PCTs at the end of the day are responsible for commissioning healthcare. They are responsible for commissioning healthcare from providers who are competent, who employ competent staff and who have competent and up-to-date systems running their organisations. If it was the PCT, for instance, that was responsible for managing the public debate about information sharing, as I have said in my evidence, this Committee has spent a lot of time discussing security and I think it has spent so much time discussing security because of the plan to build a clinical database at national level; I think that is the only reason you have been having the debate, because they have gone for a national model with the summary care record. If they pursue a local approach to development of a detailed care record, which would resolve the problem of local access for emergency records, I think the local debate would be entirely different because you would be able to explain to people why their own GP needs to share information with a specialist at the hospital to which they are being referred and why those two individuals need to share information with the Macmillan nurse, the nurse specialist, the respiratory care nurse, whatever the professional, because they can understand the context, because the context is for their own care in the local healthcare system, and in that context I think the public would be much less concerned. In fact, our experience is that the public expect that we do that and they are quite appalled that we do not, and the one thing that the public do constantly get absolutely sick and tired of is ricocheting around the local healthcare system from the specialist hospital to the general hospital to the GP to the nurse specialist telling them the same story time and time again and finding doctors relying on them, as was evidenced before, to give them information about what happened the last time they saw a doctor. It is a complete indictment of the lack of progress with support in the clinical process with information technology. So, I think if the discussion about access to records out of hours, shared records was all in a real world context of a local healthcare system, I do not think you would have had the debate that you have had about security. It is because somebody is wanting to do this through a national debate that you then have to have a national debate about security, and if you have a national debate about security, then you find yourself talking to national experts on security who, in my view, could spend 20 years in a locked room and never come up with a solution to perfect security.

Professor Feehally: Two comments on local accountability if I could. Firstly, I am not sure PCT is the right level. What it has to be is a local health community which is big enough to reflect where people with chronic conditions are looked after, which is primary care and often a number of hospitals over quite a wide patch - that is where you need to get the accountability that they will work together to solve that - but I absolutely agree with the point about people's understanding of the necessity of this as opposed to the risks of this. I will leave you a single example. In Salford, where I know they have put in a clinical management system, which they have done themselves, nothing to do with Connecting for Health, they started in diabetes and they now have a system across the whole of primary and secondary care for everyone on the diabetes register, everyone on the coronary heart disease register, everyone on the chronic kidney disease register. They had patient engagement while they designed it, they asked everybody on those registers if they were willing for their data to be in and there were no refusals; so that makes the point exactly. If people understand this is about their local healthcare, it is completely self-evident that they would want to be on that record, whereas if they think their data is going to some vague national space where somebody they do not know might use it, they get sometimes anxious. That is a very important point.

Q528 Chairman: I assume, on that basis, that you are largely in favour of using information technology for chronic disease management. That is one of its great potentials.

Mr Burns: Absolutely. Given the amount the NHS has to spend on chronic conditions, in that sense it is its greatest gain, both at the individual clinical level and in terms of the use of NHS resources, by far the greatest gain.

Q529 Mr Campbell: Mr Burns, you have touched on detailed care records, but can I press you a little bit further. You said, instead of having electronic patients record, we should have detailed electronic patient care management systems. Can you explain what that actually means?

Mr Burns: Yes. I will try and give you an example. In my own hospital, for instance, my own former hospital - I was there a long time - we had a system whereby, for instance, if a radiologist reported something sinister on an X-ray she could use the system to automatically alert the relevant clinical nurse specialist, who would then take steps to make sure that patient was seen in the chest clinic. So, this is the technology actually not just recording what has occurred but helping in a proactive and positive way the proper management of that patient. Another area, if you said to me, "Which is the single biggest clinical benefit in my view of proper clinical management systems?", I would say electronic prescribing systems in hospitals, which are as rare as hen's teeth at the moment in the NHS, but the department's own evidence to you gives you some very graphic statistics about the amount of harm that comes to patients from prescribing errors or poor prescribing or prescribing where there are contraindications for prescribing. When you have paper systems the doctor literally, with what is in his own or her own head, writes a prescription. If you have got an electronic prescribing system that has some intelligence attached to it and you write a prescription for something and that system knows that the patient has got diagnostic results that suggest that that prescription might be contraindicated, then the system will tell the doctor, or can tell the doctor, or the system can say, "This medicine should not be prescribed to patients with these contraindications", or the prescribing system will automatically compute the dose for prescribing for children where body mass is important and many, many errors are made. I wish more people would spend more time looking at the website of the National Patient Safety Agency and look at the detail of the adverse incidents that occur in the NHS, a huge number of which, in my view, relate to poor sharing of information, the absence of information, the misreading of information. A huge amount of that could be eliminated by the use of proper clinical management technology. All that is different from simply providing a record of something that happened historically.

Q530 Mr Campbell: That is all local stuff, and I understand where you are coming from, but then again, if we look at the element of NPfIT which is furthest from even getting started along with the local, they are not on the planet at the minute. How do you get them brought together?

Mr Burns: Yes. What I have just described, very inadequately, because I am not a doctor, and I am sure my colleagues could give better examples, is exactly what the clinical staff in the NHS are looking for - systems which actively support their care of the patient, not just things that passively record what they have done to the patient. But even the passive recording and the instantaneous availability of what has been done to a patient to everybody else that is looking after that patient is part of the process of providing safe care, but it is the absence of those systems at the moment, especially in the hospital setting, that is creating the clinical cynicism and disengagement, in my view, but I defer to my medical colleagues here.

Dr Markham: Perhaps another example is, for instance, if I do an ultrasound scan I see a liver which looks abnormal. Now, this actually might be normal for the patient. If I had access to a blood test, or if I knew something in the past history, I could instantly look at that and say, "Yes, okay, that is relevant. This does need further investigation", or I could say, "Oh, that is because the patient is slightly obese." I would have access to the information that would tell me that. In other words, it is information that is there that might not originally have been thought to be relevant but I can get access to the information that way. Does that answer your question?

Professor Feehally: Let me give you another example, a simple one. It would be great if I could access the GP system and when the patient sits in my clinic know what medicines they are actually taking and know about the blood test result from last week, but even better would be the patient sees me in the clinic, I need to adjust the blood pressure medicine, I make the dose change on the computer so it is immediately in the GP's surgery, but, further more, that patient needs a blood test in two weeks to ensure that the change in blood pressure medicine does not upset the kidneys. I put that on the computer. At the GP's surgery when they open up the system the following morning there is a flag that says, "Mr Smith: blood test 14 December". It will happen. It is moving from information through to clinical management. That is what you are after.

Q531 Mr Campbell: That is what we are hoping for and we are hoping at the end of the day we can work locally and nationally, but the indications are that it is not quite happening at the moment. I do not know whether it is teething problems. Will it happen?

Professor Feehally: It will happen more quickly with local accountability. I am absolutely sure of that. If the local health community for the last five years had known they had some opportunity for resource to do the things they were wanting to do anyway, as Frank said, and were not resourced, if we had seen a bit of the 12 billion, I think there would have been real local progress already. Not to the level I have described perhaps, but something which generated momentum and excitement and expectation amongst the clinical community.

Mr Burns: There is no doubt that the contracts that NPfIT have led have the intention to deliver those sorts of systems, but whether they will be as sophisticated by the time they are delivered, because they are being delivered over an extended period of time and requirements will change in the meantime. I think the real fear is that there is a frustration that what we have described is not yet available and looks to be many years away in some parts of the country, and that is not an overstatement, and there is a secondary fear that when it arrives, because it is being provided to hundreds of organisations - it has to be a common system for hundreds of organisations - if it is not quite what people want, it will take another three years to get any fundamental changes made to the configuration or functionality because it is being implemented over such a large-scale.

Q532 Mr Campbell: Is that the problem? It is such a large scale. It is too big?

Mr Burns: Yes, I think so. There is a counter view, and they have the counter view, there are many other people and it is laced through all the evidence you have that many people think that the schedule of it was too ambitious. It is an impractical scale on which to implement something as complex as supporting clinicians in their day-to-day work. That is a common view. It is not the only view; there are other views that if contracts on a national scale---. I think that is a legitimate view but it is undermined if what you are contracted for is not delivered very quickly and is not very good when it is delivered.

Q533 Dr Naysmith: What sort of conversations do you have with Richard Granger?

Mr Burns: I have never had a direct conversation with Richard Granger.

Dr Naysmith: I think that is a pity.

Q534 Chairman: Can I ask you a related question? You were on this system - you have now retired but it is still your hospital, the Wirral - that your clinicians are very happy with and obviously we have not seen it, or any evidence of it, but it is managing patients, it is good for patients as well as good for the clinical staff who are working there. Did anyone ever ask you whether NPfIT would be compatible with your system or your system compatible with NPfIT?

Mr Burns: No, but given that the model they went for---. The fact is all this conversation started on the basis that they work for a national contractor, which was bound to leave them with huge problems of inter-operability between the large amount of computing capacity that was already in place, despite what is being said to the contrary, and the systems that were secured. That was always inevitably going to be, and they must have known that and they must have factored that into their calculations and timescales and all the rest of it.

Q535 Dr Stoate: I am very interested in looking at the level of detail required for you to do the sort of job you are proposing. You are seeing someone in the renal clinic with diabetes and many other complex health problems and you are suggesting that you have access to a significant chunk of the record. Are you saying you want to see exactly the same record that the GP has in front of him when you see your patient in that clinic? All I am looking at is the level of detail you need.

Professor Feehally: I cannot see any reason not to really, because you merely add complexity by excluding bits, and it will be multi-screened. I will not go to the gynaecology page because it will not be a particular issue for me, but I cannot see why at the local level one should not share all the information. The notion that the primary care would withhold a bit from me would be as odd as the fact that I might not know there was an orthopaedic operation last week on that patient. It seems to me that open sharing of information for those involved in direct clinical care from first principles would be right.

Q536 Dr Stoate: I happen to agree with you. I am a practising GP and I would be delighted for you to get involved in adjusting somebody's dose of medication, because at the moment what happens is that you would write me a letter, I would get that letter probably a fortnight later, by the time it has been typed in your hospital department. It gets scanned in by one of my receptionists and then shredded and ends up on the patient's record as effectively a photograph. I have then got to read that photograph manually, find out what you suggested, enter that manually onto the patient's record and then take the action a fortnight later, which actually is prone to so many steps of error it does not bear thinking about.

Professor Feehally: It is self-evidently the right way to go. I do not think there is any doubt about that.

Q537 Dr Stoate: The question I want to ask now is how close are we realistically to that? Is the programme even heading in that direction or are we miles off course?

Professor Feehally: I think it is heading in that direction. I am aware that, for example, the i-soft clinical manager tool, which is one of the interim solutions, which is the one that has been put in in this Salford application I described, does pretty much most of those things. I have seen it in action just as an observer and you can get that kind of information and you can talk to each other in that kind of electronic way. I think there is the potential to do it, but it is back to this problem of national solution rather than getting people to do things locally: because if we were in the same health community we would self-evidently want to engage and make it happen. At the moment, in so many places, people still have this helpless sense of waiting for the solution to be given to them to then implement. That is the way it is done.

Dr Markham: There is a good example of what is happening at the moment. There is a lot of effort being put in to a common request form for Choose and Book and in this there is an argument about what questions should be filled in by the general practitioner and what will be needed. The good example is MRI imaging. It is becoming clear that we need to have some knowledge of the renal function of a patient. If we had access to the general practitioner's records or, indeed, the records for the local hospital, we could look it up ourselves when we needed it rather than relying on the general practitioner going through his records and putting it down on a national request form. So, that is a good example of where this huge amount of work is going on at a national level for this, which would not be unnecessary.

Mr Burns: There are examples, it depends what degree of integration we are looking for, but we have to work on the basis that a move---. If this is an incremental thing, I suppose it is part of the philosophical debate here about whether you go for big bang national solutions or incremental growth from local systems, but there are places in the country where they are uploading to a different information system from GP systems and the local hospital systems on a 24-hour cycle so that GPs and hospitals in that community can see that integrated information, and there is local agreement amongst the clinicians about what the said clinicians usefully want to see from the record of the general practitioner. There has been a local discussion about what the local GPs would like to see of the hospital record and what the specialists would like to see of the GP's record. Some people would disagree with my colleague about the need to see absolutely everything, and, in fact, it may well be that that would make the debate about confidentiality a bit more problematical if, for instance, social care records or family histories or stuff in the GP record that could usefully stay in the GP record was available outside, but all of that can be agreed locally. The debate could be had locally with the community about what should be on the shared record. It would give the community a greater sense of influence over that process. There are structures in place for those debates at a local level, the Local Overview Scrutiny Committee, where you get some democratic influence on these decisions, and we have done that on the Wirral. There was a debate, the Local Overview Scrutiny Committee was involved, there was an agreement or an explanation about what would be shared and why it was being shared. We did develop a publicity campaign in the local community and virtually nobody objected.

Q538 Dr Stoate: You talk about expert prescribing systems which actually we have been using in general practice for years.

Mr Burns: Indeed you have.

Q539 Dr Stoate: Why is it then so difficult for the hospital simply to replicate what GPs have had on their desks for a long time? What is the problem?

Mr Burns: I do not know. The processes are different.

Q540 Dr Stoate: Why? When I prescribe a drug, lots of menus come up, but one of the menus is the interactions, which you cannot get past - you have to okay the interactions screen before you are allowed to proceed - and if it is a high level interaction, for example, Methotraxate or a complicated drug, you have got to go through several steps before the machine will allow you to prescribe because of the level of interaction. That is not complicated. Why is it different?

Mr Burns: One of the difficulties is that most of the prescribing in hospitals is done by doctors in training, not by fully qualified people, so there are safeguards that you need in place to support that, but electronic prescribing actually provides greater safety. It has always been the most difficult nut to crack.

Q541 Dr Stoate: But why? I still cannot get round why.

Mr Burns: It is partly to do with the leadership, and my two colleagues here might not agree with me, but it is partly to do with the resistance of senior hospital clinicians to the introduction of changes to their working processes that fundamentally affect them directly and require them to, if you like, action the prescription, and understandably so. As you know - you are a doctor and I am not - you can do a lot of harm with trumps, and, therefore, it takes an awful lot of persuading for a community to see its clinicians move away from a tried and trusted system to one where they are relying on a computer.

Q542 Dr Stoate: It has been tried and found wanting, because the current system---

Mr Burns: The current system is a disaster.

Q543 Dr Stoate: The National Patient Safety Agency will tell you that there are hundreds and thousands of mistakes each year.

Mr Burns: I agree.

Q544 Dr Stoate: So, the current system has been tried and found wanting?

Mr Burns: There has not been enough will, either managerially or politically. It is not a priority of NPfIT, and it should be one of the first things that are rolled out across the hospital service (electronic prescribing), but there is not the managerial or political will, and I think there are also issues about the numbers of systems that have cracked the particular way in which hospitals need to prescribe.

Professor Feehally: As you might expect, I am still an enthusiast of such systems, and some of those points may be true in some trusts and also a simple one which comes back to money. There are so many things we would have loved to have done over the last decade in IT development in hospitals for which there was also no resource, and there is still no resource because it is sitting nationally. I have no doubt at all that as to the dispensation of some of that resource locally you would have seen a lot of change in growth.

Mr Burns: It is interesting that the Department of Health evidence in which it extols the importance of using IT and the importance of the work that NPfIT is engaged on quotes directly the benefits of electronic prescribing. As far as the hospital side is concerned, electronic prescribing is the very last in the list of things that are going to be delivered by NPfIT, and there are people who fear they will never ever be delivered?

Dr Markham: Can I come back to one of the problems which I think may be behind this. I have alluded to it before. It is the lack of back-up of IT staff within trusts. The PACS system has just been rolled out across my trust and we have had three people who have been across three different sites with about 20 different consultants, let alone hundreds of radiographers trying to use the new system, and they are extremely stretched; whereas I think in general practice you have got much more direct access to the people that are sorting out the system. Certainly when you sit there and something does not work, you ring them up on their mobile and you find that they are at the trust four miles away, and that has been a big barrier to convincing staff at the hospital that this is definitely the way to go and this is how they should do it. It really is quite frustrating when you know all these wonderful things that you could be doing but your brake is the lack of IT back-up because of the lack of staff and the expertise available, I suspect.

Q545 Dr Taylor: Anybody listening today and reading a lot of our evidence would think that the only good thing NPfIT has done is to produce 12 billion. I want to try and explore the ways in which it has delayed things. Is it fair to say with electronic prescribing in hospitals that many hospitals were on the verge of doing this quite some years ago and that this is one of the things that NPfIT has delayed?

Mr Burns: I would not say that. To be fair to NPfIT, I think introducing electronic prescribing into hospitals - take it from me, I have been there - is a really difficult challenge, because there is so much nervousness around switching prescribing to electronic systems. It is worth the effort in persuading people, because the systems are so much more reliable and safer, but it is very difficult and I do not think it would be fair to say that we would have wall to wall electronic prescribing in hospitals if it had not been for NPfIT. I think that would be unfair.

Q546 Dr Taylor: At Homerton we learned last week that, although they have got a pretty good system, that was the one thing they still did not have. Going on to the radiology front, I know that CT scans have been available at the local neuro-surgical unit for 20 years plus. Did you say that that was being jeopardised or put back by NPfIT in any way?

Dr Markham: There is no doubt there is a difficulty. The arrangement for the clusters, which was NPfIT - these are the areas in the country that have had the providers and they are the areas that have been rolled out - London is one, the south of England is another, the East is another, and that side of things going nationally has jeopardised things that were already in place. For instance, apparently there was a thing before I was in the south of England called the Shire's Consortium, and that was a very co-operative area in the south of England which was ready to go on PACS, communicating between each other, and that was stopped because they had to go on to the NPfIT system. It has rolled out very quickly, and I think parts of the country that were not as well organised as that, I think it has speeded up with the availability of the finance, but there is no doubt there have been instances. For instance, only just now Truro can now communicate with Plymouth and back, whereas before they could not communicate quite as easily, but that has stopped for a while before it has got going again.

Q547 Dr Taylor: Coming back to PACS, because we have talked quite a bit about it, it has been available since the early 1990s.

Dr Markham: Yes.

Q548 Dr Taylor: So where has the delay come on that?

Dr Markham: Part of it was as computer technology. It very much developed in line with computer technology and the storage available, and the acquisition of the images and the storage of the images, if you like, did not roll out as quickly, but it was very much financial and convincing people who had machines that produced hard film that they were going to have to ditch all that and go electronic. That was a big financial investment. Once the advantages were realised, once the radiologists convinced the trust that this would be a great advantage, and the clinicians, because they are now entirely enthusiastic, they have got their work station in the clinic and they can see the images and they can see the reports and that is great, but it took a lot of convincing, I would say it started to roll out towards the middle late nineties really.

Q549 Dr Taylor: I think it was the intention that PACS should be available nationally. Would that have been a good thing?

Dr Markham: You mean connecting up nationally?

Q550 Dr Taylor: Yes?

Dr Markham: Yes. There is no doubt it would be useful. It is a question of where your priorities are, but, as one of my colleague said before, the vast majority of health interactions are relatively local and, yes, you do get people going down to the South West for their holidays and their care is maintained back at base in Newcastle, or wherever, so there will be instances where it is useful, but what has happened at the moment is, largely because of this unique identifier, you cannot transfer images like that; and there is an enormous industry at the moment with people burning CDs, putting the images onto CDs that then get sent to the hospital that might be two miles down the road and then they find they cannot open it because the technologies are not compatible to open it, or there is some problem or other, and then they have to ring up and say, "Can you tell me over the phone what the report was?" All that type of thing is, in my mind, much more important than the relatively small number of people who will be going from one end of the country to the other.

Q551 Dr Taylor: Is the roll-out of PACS pretty well complete now or are there places that still---

Dr Markham: Yes, the North West and the West Midlands is delayed, because there were some contractual problems initially, I believe, but I think about 70/75% of the country is now covered. The full potential is not there just yet. One of the difficulties that was perhaps mistaken at the beginning was that, although the PACS image thing was national, the radiology information systems were not and the interface between those has been challenging. So, although the images were okay, you were trying to interact with your previous films and your previous demographics, and that is still a problem in many places and many places have a radiology infrastructure that does not match.

Q552 Dr Taylor: Have old films been archived digitally?

Dr Markham: Many have, yes.

Q553 Dr Taylor: So the old X-ray departments and stores of X-ray films in the cellars and things are gradually going, are they?

Dr Markham: Gradually going is the way to describe it, yes, absolutely, and the vast majority of previous images are not accessed after about three years; so inevitably we will get less and less.

Q554 Dr Taylor: Obviously PACS has changed the way radiologists work. Has it changed the way other clinicians work?

Dr Markham: We believe so, because they, again, have instant access to the images. A patient can go from A & E, a film is taken and immediately, without the patient having to come back again, the image can be there for the doctor to look at. My colleague will obviously be able to tell you better, but certainly our clinicians are very enthusiastic about it.

Q555 Dr Taylor: Have you got the ready availability of X-rays in all your clinics of any of your patients all the time now?

Professor Feehally: It works. It makes a clear and unequivocal difference. It improves patient care.

Jim Dowd: I would refer to the questions on PACS, but I think they were covered more than adequately in the early part of the session and so I will not delay you any further.

Q556 Chairman: I questioned you (I am talking to Frank Burns now) about the issue of what happened on the national organisation, as it were, versus a local detailed care record in many circumstances. I know you have retired now and I do not wish to upset you in any way, but if you were in charge of Connecting for Health tomorrow what immediate changes would you make to the organisation of the national programme?

Mr Burns: I am not ducking that question, but I think a lot of this depends on the nature of the contract that has been struck. If you are asking me what my wish-list would be, that is a different question to what is practically possible, given that there are contracts in place with the LSPs and with software. I suspect and I hope that it would be possible---. Without that knowledge about what the contracts allow for, certainly in some parts of the country that depended, for instance, on hospital system software that is not yet developed, not yet available, may not be deployed in terms of the clinical functionality until we are into the next decade, if that is the realistic position (and it looks to be the position for some parts of the country), then I would think it absolutely imperative that some options are made available to those parts of the country, that some way is negotiated, either on an interim or on an entirely permanent basis, to give parts of the country with excessive delays in the availability of clinical functionality and resources---. The resources are all locked up in NPfIT, and that is the problem locally. Nobody can do anything because NPfIT has the money. I would look for a way of making resources available in those communities that have got an unacceptably long time to wait for clinical systems and try and find a way of giving them choices of clinical systems. There is a supplementary contracting process going on, as I alluded to before, where NPfIT is identifying IT suppliers with systems that I think are described as "step-in systems", so they have systems, if you like, on the shelf if they have problems with current suppliers. I would move from step-in to alternative in circumstances where the delivery of clinical functionality is unacceptably delayed. I would certainly want to look at why---. There are parts of the country where they have procured a system that is up and running that does have decent clinical functionality but does seem to be taking an age to be implemented, and you would certainly want to have a good hard look at implementation timescales in those parts of the country where potentially decent systems have been procured, and there certainly are parts of the country where that is the case. I think the other thing I would do would be to make PCTs, as they are accountable for the health of their populations, accountable for commissioning arrangements to allow information sharing electronically between the organisations that they contract with for the care of their residents. In other words, I would introduce a local focus on the sharing of information and, if you like, remove any obstacles to the procurement of technology that maximises inter-operability between existing system and allows information sharing between existing systems. I think the structure of the contracts makes that very difficult currently.

Dr Markham: If I had a wish, the unique identifier, because until that is in place---. For instance, there is a trust down the road with extra capacity. They could do some of our reporting if we could send the images. We cannot do that until we have a unique identifier, and also the trust would need to be mandated to use that rather than using something different; so that would be a practical step forward.

Professor Feehally: I think something that has begun to happen which has been almost stealth-like is worth commenting on, because for so long from our perspective we were told that the national programme would deliver everything and we would have a system that would replace everything. Now, as you have heard, within the last few months there is a tender out for so-called additional services capacity, which are effectively interim systems which will be compatible with the final solution, which is a recognition from them that they cannot do everything. That is fine, but they need to be talking to people like us about what are going to be in those interim systems and people like us need to be helping them to get the functionality right. So, I think my single wish really is communication with clinicians over that particular thing but, in general, that they come down from the mountain top and we really engage and they begin to learn to help us understand what they want to do, because we have not got it yet.

Q557 Chairman: Could I thank all three of you very much indeed for coming in and helping us with this inquiry. I am not sure when we will be reporting to the House and the Government, but it I hope it will not be too long.


Memorandum submitted by the Department of Health

Examination of Witnesses

Witnesses: Lord Hunt of Kings Heath, a Member of the House of Lords, Minister of State for Quality, Mr Richard Granger, Director General of IT for the NHS, and Dr Simon Eccles, Department of Health, gave evidence.

Q558 Chairman: Good morning and could I welcome you to what is the second half of our fourth session on taking evidence in relation to the Electronic Patient Record. Could I ask you for the sake of the record if you could introduce yourselves and let us know what position you hold.

Dr Eccles: I am Dr Simon Eccles and I am a Consultant in Emergency Medicine at the Homerton Hospital in Hackney. I am acting Clinical Director for the National Programme for IT which is one of the national clinical leads for secondary care.

Lord Hunt of Kings Heath: I am Philip Hunt and I have ministerial responsibility at the Department of Health for the National Programme for IT.

Mr Granger: I am Richard Granger and I am the NHS IT Director.

Q559 Chairman: Welcome. I have just got a few questions to ask to open this session up in relation to the summary care record. You will have seen no doubt some of the evidence that we have been taking, both written and verbal evidence, in relation to this inquiry and we have heard a number of different answers about what information will be included in the summary care record. Could you tell us definitely what will be included in the summary care record?

Lord Hunt of Kings Heath: Can I ask perhaps Dr Eccles to take that in detail. In basic terms it will start off with information from the GP practice regarding medication, allergies and adverse reactions. The expectation is that it will grow richer in time but I think perhaps Dr Eccles might like to give a more detailed response perhaps about the uses it is put to.

Dr Eccles: The information on the summary care record when it first starts - as you know we are starting in Bolton at the moment - contains centrally held, specific demographic information on the patient, so current address details, date of birth, contact numbers, the NHS number (which means you can uniquely identify individuals), contact preferences, including things like preferred language, and their consent status for the record. The initial upload from the GP summaries of clinical information is medications, allergies and adverse reactions. That upload is by implied consent. The next upload of information, following a discussion with the general practitioners themselves, will be a summary of key medical information - past medical history, important procedures or operations undertaken. What that minimum information set contains is being derived at the moment by a group headed by an A&E consultant up in Bolton using GPs, patients and others to derive what is that most helpful list. That is going to be a part of the evaluation process: Does that work? Is that the right list? The next stage - and we are still in 2008 at this point - is the capacity to take discharge information from hospital settings, whether that is in-patient discharge summaries, clinic discharge letters, or emergency department discharge summaries. So what the GP believes are the most important things wrong with you: medications and allergies; and every time you have been in contact with secondary care the information exchange between GP and secondary care, what we hope, I hope as an A&E consultant, is the most helpful block of summary information. If I have a critically ill patient in front of me that is what I would look for in the notes now, so that is what we are going to provide.

Q560 Chairman: Is it intended to support scheduled care, unplanned care, or both? What is its intention?

Dr Eccles: Its primary role is supporting unscheduled care so when a patient appears at a setting where they are not currently known and their main records do not presently exist - that would be emergency departments for the sake of speed, GP out-of-hours centres where records are currently sketchy (and there has been some recent publicity of some unfortunate occurrences as a result of poor information), walk-in centres; and ambulance personnel and others would have access to this information. I can also see it being used during the transition phase in hospitals where you cannot get the patient's main record. To have access to that summary would be very helpful. And, of course, it would be used where patients transfer via geographical distance, so if they are on holiday somewhere elsewhere in the country that is the only record you may have.

Q561 Chairman: What about the issue of secondary user services and the summary care record?

Lord Hunt of Kings Heath: Clearly the information in anonymised form that becomes available could be extremely helpful in auditing quality and in enabling research to be undertaken into areas of illness. We of course understand that it has huge potential for researchers in the future. It clearly has ethical and practical considerations too, and we have had two working groups, one which has published looking at the scope for potential research in the future, and a second one that will shortly be published on some of the ethical considerations. There is a rich mine of information which, if used appropriately, could have a huge benefit in terms of understanding our knowledge about the quality of care but also in terms of research into future developments, and I think that secondary use is a terminology which I know has been commented upon. It is not a word I am very comfortable with. I think that treatment goes alongside research. One of the great strengths of our National Health Service has been the quality of its research base, it is why so much R&D resource is spent in this country, and I think the potential positive benefits that have been defined under the terminology "secondary use" really do go hand-in-hand with effective treatment and care.

Q562 Chairman: Are patients currently in the early adopter schemes made aware of that?

Dr Eccles: It is indeed referred to within the leaflet on --- I am going to seek confirmation. Unfortunately, I have not got it with me.

Q563 Chairman: It is important to have a leaflet!

Dr Eccles: It is important if I tell you it is in the leaflet to make sure that it is.

Q564 Chairman: I will take your word for that.

Mr Granger: The information in the summary care record is not feeding into the secondary usage service; it is sourced separate. At the moment they are isolated.

Q565 Chairman: Summary records could be used for purposes of research?

Mr Granger: Eventually.

Q566 Chairman: That is why I asked the question. The other thing, Simon, you said earlier about the adverse reactions, prescriptions, allergies and everything that will be in it. All that information will only be added to the record with explicit patient consent and patients will be able to see what is added; is this correct?

Dr Eccles: Let us be clear on what is happening, the implied consent, the automatic update is purely medications, allergies and adverse reactions. The reasons for particularly taking those fields is that it was felt from widespread medical and patient consultation that they are the lifesaving fields. Indeed, according to the National Patient Safety Agency they are the second largest cause of adverse events to patients. The next step, which is the GP-derived summary of important health information, we are recommending is done in consultation with the patient and the patient is shown what is proposed to be sent up and agrees that that is the case. We will be evaluating that model and that is an independent evaluation from University College London: Are we picking the right information? Is the process by which we are gaining patient consent the right one? Is it too cumbersome or is it too stringent or is it too lax? We think it is the right blend.

Q567 Chairman: If you add some information about that patient in that area at a later stage will that have to be consented as well?

Dr Eccles: What we would hope in that early consultation is that patients will usually - and that certainly seems to be the evidence we are getting at the moment - give their express consent, "I am happy for you to continue to add information to this record unless as my GP you think it is clearly of a sensitive nature, and I have outlined to you that for example sexual health issues I wish to keep separate from this, but otherwise if I come in and see you and you diagnose me with diabetes we do not have to have the whole conversation again; I perfectly accept that that goes up to the record." That is how we are expecting those conversations to take place.

Q568 Chairman: Could I ask you what access I will have as a patient to my summary care record if I agree to have one?

Dr Eccles: This is the biggie. This is the purpose of HealthSpace and it is one of the biggest benefits of the summary care record. You as a patient will be able to see your record and everything that is on that summary care record for yourself via a secure website called HealthSpace.

Lord Hunt of Kings Heath: Can I add to that, the great advantage of HealthSpace is alongside having access to your summary care record there will a whole host of information about health, and my own view is that it has huge potential in helping people take control of their own health. More and more people are interested in health issues and we think this HealthSpace has very exciting potential. Having access to your own summary health care record as well will add to the importance of this and I believe the use of it by patients.

Q569 Dr Stoate: I wanted to ask Simon about the logistics. You have talked about effectively sitting face-to-face with patients and there are going to be 2,000 patients on average per GP. You have then got to sit down with the patient, discuss what the implications are about building the record, you have then got to make some judgment as to what gets uploaded, you have then got the logistical problem of actually sifting through the GP record and somehow moving the data from the general GP record into some uploadable form. All this is pretty resource intensive. Have you considered literally the pros and cons of how you are going to do it?

Dr Eccles: My colleague Gillian Braunold thinks of little else on a day-to-day basis I am reliably informed.

Q570 Dr Stoate: She needs to get out more, does she not!

Dr Eccles: We could not do this without her. You are absolutely right that we need to make sure that that logistical process is as straight forward as possible. That is part of the reason for this minimum data set that is being gathered together at the moment by GPs, by patients and by A&E staff in Bolton, in conjunction with all of the early adopter PCTs and the potential early adopter PCTs, so it is not just Bolton, we are asking all of them to give us the list that should automatically pull from the GP record into what we have got on our demonstrator programme. It is quite a clear pane that says this is what we are going to send up, if it is okay with the patient. You print a copy of that out and give it to the patient, "Read this at your leisure and see if you are happy with it," they have a 16-week timespan in which to contemplate that as a patient, approve it and then come back to their GP and say, "Yes, I am happy with what you plan to send up," or, "Take some items out," or, "Why have you not mentioned the back pain ..."

Q571 Dr Stoate: I am just going to stop you there. That is now two consultations with the GP both of which are quite detailed so that is half a year's average GP contact time for a patient just on that one issue. I am very concerned and I would like to know what work you have done on how you are going to say to a GP you have got to do half your annual consultation with that patient on this one issue.

Dr Eccles: I do not think we will, I really do not. The majority of patients will either be given that print-out or will request it from the receptionist staff at the front, who will hand it to them in an envelope without a consultation. For most they will look at it and say, "That's fantastic," and will sign it off again without a consultation.

Lord Hunt of Kings Heath: It is also worth making the point that we have the evaluation being undertaken by UCL and clearly the whole purpose of that is to learn lessons from the early adopter sites so that can then help us feed into the next stage of rolling out the programme.

Dr Eccles: As Gillian just kindly pointed out to me, the reason we are doing it this way is the group we want to get first and most importantly is those patients who have the largest body of disease because they are the ones for whom it will be most helpful for out-of-hours settings where an acute or chronic exacerbation of their existing condition at the moment results in our starting again from scratch and amending a carefully described plan of treatment that the GP and the hospital spend ages getting right and we in A&E through - I would like to point out - no fault of our own adjust that for the emergency and change it for the patient. We will catch them because they have many more than just two consultations a year. We are using diabetic clinics and we are using nurse practitioners who are seeing patients for all of these conditions to have those conversations. I do not think the burden will be that high. I do not know that for certain and that is what we will be evaluating.

Q572 Dr Naysmith: You will be very well aware, I am sure, about the concern there is about iSoft's Lorenzo system. When do you expect it to be widely available.

Lord Hunt of Kings Heath: Perhaps I could ask Mr Granger to answer the details of that.

Mr Granger: We expect within the next couple of weeks the first live running of Lorenzo Version 3 software to be working in Germany in Arkel and we expect the first live secondary care versions of Lorenzo to be available next year in the NHS in England. Also on the topic of iSoft, there has been a lot of speculation regarding the corporate structure that will support iSoft in fulfilling its NHS obligations and the situation at the moment is that the organisation with whom we have a contract, which is not iSoft, it is in fact CFC, are in the latter stages which I hope will conclude satisfactorily, of ensuring appropriate funding and management control to take the now largely completed code and to test it and to get it into a state of readiness for putting it into production. I understand that an associated transaction involving an Australian company, IBA, is also near to satisfactory conclusion with iSoft and IBA and I would hope that those three companies would be making an announcement about that in the next few days. Should that fail, we have third party resource present now to take control of the NHS delivery components on a step-in basis under our contract which will force CFC to step up to the plate of ensuring properly financed and managed completion of the Lorenzo product for the NHS.

Q573 Dr Naysmith: The question was not so much about when you will have a prototype ready but when it would be widely available to those areas which are depending on it?

Mr Granger: It will start to be rolled out next year. One of the challenges in health care IT is it is pretty easy to get a good solution working in one hospital if you throw enough money at it, but when you come to re-tender that solution, it often ends up being unaffordable and the sites of excellence that the NHS had pre-2003 have all faced that challenge. They have run independent tests in many cases and the costs have been unaffordable. One such example is the Wirral where on re-tendering their very good local systems have had to go with a national solution, and indeed one with an American software supplier. In the Homerton their contract was transferred to BT for the same reasons - that it is difficult to sustain excellence even on a limited basis locally. We will start rolling out the Lorenzo product next year. I expect there will be some difficulties with the product in the early sites, and it would be misleading to suggest otherwise, and it will through the last part of 2008 and over the next few years then be rolled out across the rest of the sites that want it.

Q574 Dr Naysmith: Are the on-going delays with Lorenzo your biggest problem? I know you have got lots of other problems.

Mr Granger: I think the biggest problem is finding time to manage a programme which is subjected to so much negative examination.

Q575 Dr Naysmith: Is that not because it is not working?

Mr Granger: No, I think it is because there is a lot of mythology being generated by people who would like to see it fail.

Lord Hunt of Kings Heath: If I could comment on that. Clearly taking over responsibility for this programme at the beginning of this year I have been struck by the degree of negative comment and clearly it is a feature of many IT procurement programmes, but I think if you look at what has been achieved over the last few years, particularly if you look at some of the developments that have had a real impact on quality of patient care such as PACS or the start of the electronic prescription service, or getting broadband connection for the whole of the Health Service, or a quarter of a million staff with their own email address on the NHS system, or the quality management system to enable information in GPs to be properly assessed, or the work we have done on the summary care record, it is a very solid body of achievement. Now you are right, there are also challenges. We know that the summary care record is later than we would wish but that was because of the extensive debate there had to be with clinicians about what should be in it. We know the challenge of patient administration systems, particularly in hospitals with existing systems, as you have inferred, is a particular challenge, and we knew that was going to be the case. However, in terms of where we are, I strongly believe that we have a very strong foundation on which to go forward. If I can look back because, as you know, I have responsibility for IT ---

Q576 Dr Naysmith: I want to ask another question related to this one which will enable you possibly to say something else. The Millennium system seems to be much further advanced and seems to be working much better. If it is successfully implemented and Lorenzo is further delayed, will you allow hospitals outside London and the South to implement the Millennium system instead? Would that be a possibility?

Mr Granger: Yes, definitely. One of the reasons, unlike a number of other organisations, we did not choose a single solution from a single supplier where we were able to have some contingency within our resourcing arrangements was to deal exactly with the risk of supplier failure. Perhaps the best example of that is in the picture archiving arena where we initially chose an innovative product from company called ComMedica to implement in the North West and West Midlands, and unfortunately they missed nine key milestones and their contract was terminated by CSC and they were replaced by the contractor GE that was already serving the south of England. We will by the end of this year have got most hospitals in the NHS running digital imaging systems. It is important to note that when they were being bought locally with 16 different systems being procured locally, most of which were not compliant to the standard that enables images to be read on competitors' systems, Dycon, five per year were being putting in; we do five some weeks now, so the procurement model does work and it does deal with supplier failure.

Q577 Dr Naysmith: It is interesting in the session just prior to this it was said quite clearly that there was a system up and running in the Wirral which is at least as sophisticated as what you are trying to put in nationally now and possibly more sophisticated. That was also happening at the Homerton which we saw last week, so what is happening in this national procurement programme is seeming to be blocking local initiatives which have been working extremely successfully, and perhaps this concentration on the national model and also on the summary patient record, which seems not to necessarily have been the most important thing, seems to be delaying progress rather than making it. Finally, Philip and then I will let you come back, if we have got large areas of the country which are waiting for a system to come in and it is not coming in because it has been consistently delayed and other parts of the country have successfully implemented useful local management systems, which everyone tells us is what is more important than being able to deal with the odd problem that happens when you are on holiday in Cornwall, this is going to be a real disaster for the whole thing, is it not?

Lord Hunt of Kings Heath: I wonder if I could make some general comments and then ask my colleagues to comment on the specifics. The two things I would like to say is that I do not think we should underestimate the potential of the summary care record in everyday clinical practice and not just in the circumstances as you have described. The more general point is that I look back to many years' experience with the NHS's approach to IT and the fact is that at the beginning of this decade, if one looked at what has happened in the NHS, it simply was not making sufficient progress. There were these islands of excellence. I am enormously admiring of Frank Burns's contribution to that in the Wirral but the fact is as a whole the NHS was under-investing, it was developing systems that could not be integrated, it was very patchy in its approach, and I think that national approach that we have taken was absolutely essential in terms of ring-fencing the resource, giving it the priority and ensuring that the NHS did move in step. Clearly there will always be issues that individual organisations will think, yes, we might have done better, but I do think you have to look at the integrity of the NHS as a whole. The way IT had been in the NHS over 20 years simply would not have done the business and that is why I am convinced this approach has been the right one, alongside a contracting regime which does transfer risk to the local service providers, which again is, I believe, a model of what ought to happen in public sector procurements that has not always happened with previous procurements.

Mr Granger: I have just a couple of things to add. The summary care record is going to be the first port of call for the 115.5 hours a week when the GP practice is shut, so I think it is quite a useful instrument to have regardless of whether you stay in one place or move around beyond your immediate place of domicile. In terms of the excellence that has existed in islands in the NHS, I said in 2003 that what we were about was trying to get that implemented in more places, and that remains the challenge. So where we only had 50 sites in the NHS with digital imaging over a ten-year period, we have now probably got less than 50 sites that do not have it, so it is about trying to build off those islands of excellence, all of which have problems with affordability, the standards they use, and the extensibility of what they are doing onto a national basis. So you can do very, very good work with very good clinical engagement at a local level but every time those installations have come up for contract renewal there have been serious affordability problems.

Q578 Dr Naysmith: It is not surprising if all the money is going into a national system.

Mr Granger: If you look at for example the Wirral maybe you should go and look in detail at the cost of replacing that system through local procurement, and it was entirely unaffordable. The same was true of the Shires procurement when that was running on a regional basis, and that was also true in Blackburn and Bradford. So a number of data points show that you cannot afford to buy these rich systems in every NHS site because you do not get any economies of scale from the supplier community. So it is not about all the money being spent nationally. It is about the unit cost being too high if things are bought locally.

Q579 Dr Naysmith: Just finally on this, all the evidence suggests that if you do it locally you can engage the clinicians much better and this is something that is not happening everywhere with the national system. What do you say to that point?

Dr Eccles: You are quite right is the one-line answer to that, but there is the problem we have just heard outlined. I am a committed fan of the idea of a national programme, despite having just agreed with you that a system that a local hospital goes out and buys for itself will always be loved much more than one that is apparently given to them by the government however generous that may apparently seem. Why am I a fan of a national programme therefore? Because we were not getting on with it in the NHS. You have seen what the financial figures for the NHS have been like over the last year. Without a national programme with separate Treasury funding I do not think there is a cat in hell's chance that we would be upgrading the IT systems to the point we needed to get to had we done it on a one-by-one trust-by-trust basis. What I find fascinating working at the Homerton with the Cerner product, and it works and it is part of our day-to-day function (you have come and seen it) is when I bring groups of clinicians from anywhere else in the south of London to have a look at the Homerton system, their answer is: "I want it. I want it right know. When can I have it? That is fine, we will take that product please," and it is a question of trying to get that clinical message back through the management structures of the trusts and then through the strategic health authorities. Do not strip off those clinical functions. Do not see this as an IT project. Do not see this as simply a patient administration problem. This is better patient care and this is saving doctors' time and effort, they do like the product. Give them the whole of that. That is what we thought we were doing, that is what we were trying to do. Understandably, local hospitals reconfigure it to suit themselves and occasionally make a decision that I would regard as flawed that they are going to just take the patient administration system, the pure IT only project and not the much wider clinical benefit programme that I think they should.

Q580 Chairman: Could I just ask, you were the Minister responsible for the national IT programme from 1999 to 2003 and then you have some respite. You are now six months into your second phase, what have been the positives and the negatives coming back in again and looking at the programme over two years on from when you left it?

Lord Hunt of Kings Heath: Respite including heroic stewardship of the Child Support Agency and its IT programme. I think I know a little something about some of the challenges one faces and I would draw a distinction because what it does seem to me in drawing parallels is that the way the national programme has been developed has very much emphasised ensuring that as much of the risk is transferred to the private sector as it ought to be and, secondly, "derisked" in terms of not going for heroic dates when everything has to go live, that it has been very, very carefully planned and executed and I think those are very much to the credit of the IT team. I am absolutely convinced that without that strong national direction the NHS would be nowhere near where it is at the moment in terms of progression. There is nothing to suggest from the history of the NHS that left to its own devices it would have invested sufficiently in IT, nor would it have dealt with the need to ensure that there was integration. It is on integration that so much depends in terms of patient safety and quality. A lot of the programmes are proving to be very successful indeed. I have mentioned them already and I think that they are being used by clinicians on a daily basis. There is a lot of enthusiasm in parts of the NHS in terms of their use and implementation. I would say there are four major challenges. There are the two programmes that we have already discussed, the summary care records and the patient administration systems particularly within hospitals, and clearly those are major challenges. I am sure that it was right to spend more time preparing the ground for the summary care record. We will see the results of the evaluation but I believe that was time well spent. We have seen too many IT programmes in the past where a false target has been set, it has been introduced too quickly, it has not got ownership amongst the people involved, and the technicalities will often not be right. On the patient administration systems, this is a huge challenge. It was never going to be easy for hospitals to change from their current multi-faceted systems, if I could call it that, to the new systems but again it is working through. We are seeing systems delivered quicker and the next two or three years will see a huge advance. The two other areas that I would identify as really major areas for my own attention are the issue of clinical buy-in that Dr Naysmith referred to and the issue of local commitment by the leaders of the NHS. On the clinical buy-in we now have a very good programme. In the National Programme a lot of clinicians are involved. They have an essential role to play. Equally, the Committee may recall that going back to the beginning of the national programme I invited Dr Peter Hutton to chair a group to encourage clinical buy-in and I believe that did very good work at the beginning. I met with the Academy of Royal Colleges a week ago to discuss establishing a joint group which I will co-chair to ensure that we do get buy-in at the senior level. Locally we need individual NHS trusts to do the same and I think that then comes to the issue of getting strong management support for IT and for implementation of the programme. David Nicholson, the newly appointed (some months ago now) Chief Executive of the NHS has made it absolutely clear that IT is to be one of the four top priorities for the NHS over the next few years. We have now given a clear and explicit responsibility to strategic health authorities in terms of their accountability for local implementation. In all the meetings that I have been involved in and David Nicholson has been involved in engagement with chief execs of the local NHS organisations, we have emphasised that this has to be one of the most important areas of responsibility that they are involved in. I think the big change that I have noticed in the four-year gap has been the much stronger buy-in by senior managers, both nationally and locally. We need to make sure that clinicians locally are also brought into the process.

Q581 Chairman: When you look at the whole history of the National Health Service over the last 60 years and its culture as an institution, why was that not one of the things that was done in the early days? It seems to me that would be something that would be so obvious particularly when it was going to be a national programme?

Lord Hunt of Kings Heath: I think that if you look back, one of the problems of IT historically is that many senior managers in the NHS did not give it the priority it deserved. That was one of the reasons why we went for a top-down national programme. I make no apologies for that because I come back to my earlier point, I do not believe that unless it had been driven and driven hard from the centre we would have made the progress that we have. We have moved into a new stage of the programme where it becomes ever more important that there is local ownership, and I think now is the time that we really do need to get the managerial buy-in. I am confident that we are now getting it.

Mr Granger: The programme was initially led by a doctor - Professor Sir John Patterson - the clinical aspects of the programme were then led by another doctor - Dr Ray Halligan (?) - we then set up a panel of national clinical leads including three doctors. The specification exercise involved hundreds of doctors whose names were in fact made available and the organisations they represented to the PAC last year, so it is not the case that there has not been clinical and medical leadership of the programme. The challenge has been getting people locally interested in something which was in the future. They get most interested in it when it becomes disruptive when a product is about to be delivered, when training is required and when staff rosters need to be altered and so on. The challenge is getting them interested early enough. I think one of the pieces of evidence you received contains a complaint from a specific group of doctors that it is impractical to make seven days available over a two-month period for input to design. The continuous paradox that we face is getting people that are caring for patients involved early enough with the disruption that causes to their lists. I think it is difficult. Undoubtedly, at a small scale you can achieve that more readily with local installations. What you cannot then achieve is ubiquity of local installations because you only get installations in a limited number of sites, so the 105 community hospital and community HAS systems we have put in you do not hear a lot about. What you hear about are the difficulties we have in the acute sector getting that level of clinical engagement. You do not hear about 10% of GP systems replaced. You do not hear about the dozens of sites every month we roll out for picture archiving systems. You only ever hear about the problems and those problems are most severe where the clinicians are most busy managing against their whole set of targetry. Getting those people involved early enough is going to be an on-going problem.

Q582 Ms Atkins: When we visited Homerton Hospital last week I think what we were very impressed by was the clinical engagement, but that was clearly developed very much on an incremental basis because this has been developed over a number of years. I think the other thing was that clearly the trust had been contracting directly with the system supplier so there was much more of a management buy-in and also development of a system which would reflect local needs. How is that going to be replicated when you have the national programme because inevitably there is going to be one-size-fits-all kind of approach?

Mr Granger: You saw two systems at the hospital Simon works at. You have also seen a PACS system.

Q583 Ms Atkins: Yes.

Mr Granger: So it is interesting that you can put a PACS system in on a standard product in every single site in London now and you have a PAS system which was bought locally, and the same would be true of University College Hospital, but both those contracts now in fact are run by BT, so you come back to this paradox of the necessity of strong local leadership and management ownership, which David Nicholson is addressing through the NLOP programme of putting targets for this activity on to trust and strategic health authority chief execs with a necessity of buying things at a higher level in the NHS in order to make them affordable. So we have to do both; it is not an either/or. The Homerton has now transferred its contract to BT so that it can get some economies of scale and have the systems managed on a professional basis with the relevant levels of resilience and so on, which is also part of the problem of doing thing locally, as those trusts that endured the Buncefield Oil Depot fire and no IT systems for two weeks through a locally procured systems (with significant data loss) can probably testify to you.

Dr Eccles: The big thing I hope you saw at the Homerton was that this was seen as a clinical project. It was led by their clinical staff. It was chief executive level decision. This was not run by the finance director and the IT department as an IT project for cost savings.

Q584 Dr Naysmith: This is what we are particularly worried about because Mr Granger was saying that the other two areas we were talking about - the Wirral and so on - were unaffordable and what worries me is this very issue that it is was not finance driven, that it was clinically driven, and therefore you have got a system that actually works with clinicians being involved on a hands-on basis with the system. I am worried that with a national programme you will get a one-size-fits-all which means therefore you will not get a clinical buy-in and you will also not get the hands-on approach which we saw at the Homerton.

Lord Hunt of Kings Heath: Of course you probably will not get the systems because you hit then the unaffordability issue which we faced back at the start of the programme. Mr Granger has already referred to the Shires and the programme in the West Midlands where there was clinical engagement. I met many of the clinicians involved and they were very enthusiastic but you ended up with a situation where it simply was not affordable. There is no easy answer to this. There has clearly got to be a balance between the benefits of a national programme in terms of the value for money but also the strength of a national contracting process aligned with doing as much as possible to get local buy-in to it. There is bound to be a tension there.

Q585 Dr Naysmith: There is bound to be a tension but are we learning the lessons from Homerton, not just in terms of the clinical buy-in at a hospital level but also clinical buy-in at the GP level, because what we saw there was that they could not work electronically with the GPs?

Dr Eccles: With regard to the first of those, yes, I think we have been learning the lessons, as you rightly point out, from the Homerton both within London on its patch and indeed across the whole of the South where that particular Cerner product will be deployed. Myself and Michael Thick, the Chief Clinical Officer, have been round many of the live sites with Cerner having those discussions and what we have seen is where there have been elements of that that have not gone as well as they could have done, that is usually because those lessons were not followed even though they had been very well-described. The second point I want to make is you described the one-size-fits-all. I do not want the impression that the product simply arrives in a box and that is exactly what it looks like and there you are. That is not how it works. There is a huge degree of local tailorability to it. What matters is underlying it the architecture of how tests are ordered and patients' details are moved around the hospital and the coding that applies to the disease process is stored in a very clear, logical way is then compatible with GP systems at the Spine and elsewhere. However, on top the layer that you look at can be tailored hospital-by-hospital and eventually group of clinicians by group of clinicians to the sort of view that they wish to have. That is true both of the Lorenzo product and of the Cerner Millennium product.

Q586 Dr Naysmith: But each of the hospitals under the national system will be working through a local service provider rather than dealing with the systems people direct. Will that lead to a lack of buy-in and also a system which is not as well-tailored to their needs as we have seen with Homerton and other hospitals? Clearly we want a national programme which is cost-effective but there is no point it being cost-effective if it does not work properly.

Mr Granger: I think we have some hard choices to make and I think you have been to see the Veterans' Administration. Did you have a discussion with them about the degree of variability they allowed between sites? Because the answer was none.

Q587 Dr Naysmith: Absolutely and what is more there is no option but to buy in.

Mr Granger: But that has given them a system which has a lot of very useful clinical information at the point at which decisions are made. If we would like to indulge ourselves with 200 rich local systems across the NHS we not only cannot afford them, we will forever be locked into information not being moveable between locations, so there has to be a balance struck between standardisation and localisation, and unfortunately some of the desired variability is simply not affordable. When we computerised Social Security in this country the 600 or so local offices in the DSS many of them did things differently. There is now one national Social Security system in fact for the UK not just for England. It is quite interesting to imagine that we are going to allow every group of clinicians and every group of managers in every NHS trust to do everything as they so choose.

Q588 Dr Naysmith: No, I do not think we are saying that at all. I think what we are actually saying is if this is going to work we have to have proper clinical buy-in and we all know, do we not, that doctors can be pretty difficult characters and doctors have a huge amount of power in the NHS, and if we are not going to get them buying in then it is not going to work properly. You mentioned the Veterans' Administration. Yes, of course we saw the system but I do think the Veterans' Administration is somewhat different to the National Health Service one because being ex Services they are more likely to be compliant around their records so I do not think there is a direct comparison there. What we are concerned about in the Committee, given that we are putting so much money into this national programme, is that it works. That means we have to have proper clinical buy-in and we cannot cut those corners.

Dr Eccles: And we are hitting the tipping point that I think will make the critical difference. Lord Hunt and Richard Granger have made the point that it is extremely hard to get good clinical engagement with a piece of paper talking about an IT system. It is exceedingly hard. It is very hard for the NHS to release people. . It is very hard to get people excited about it. What you tend to get is the people who are very interested in IT, which is fine, but the people I want to get engaged are the people who loath IT because if it works for them it will work for everybody else. As soon as you have begun to get the systems rolled out in the enthusiastic early hospitals, at that point everybody switches on that this is real, it is going it affect them, they can go and see it, they can see it at a neighbouring institution and at that point if that is going to come to my hospital I want to get involved in the committee that is designing it for my hospital and tailoring it and I want to be part of it. We have to get past the point of disability to get the bulk of clinicians engaged. It has been my job for the last couple of years to try and get doctors engaged with an idea. They are very enthusiastic about the idea. They are not necessarily enthusiastic about giving up huge amounts of their time to fine-detail Excel spreadsheets to make it work. Now that they can see it, it is much, much easier to get people enthusiastically engaged, and they are enthusiastic, in secondary care we have overwhelming support for getting this in. People want it but they want it to work for them, and you are quite right on that.

Q589 Dr Naysmith: With Dr Eccles involved I hope that we have some chance of making it work.

Lord Hunt of Kings Heath: If I can comment on that. Clearly one of the strengths we need to develop is we have a huge network of clinicians who are involved. I do not disagree at all with what you are saying about the need for local clinical engagement, I understand it fully. I just think that in terms of the history of the National Health Service that experience shows that the best way to do it is to start with a national programme, get the investment in, get the clinical engagement. I am convinced that we have got the architecture right. If you are saying we need to do more with clinicians, I agree with you. I do believe that the renewed drive, the priority, the targets that have been set for strategic health authorities will absolutely require chief executives to do that. I also think that, as Dr Eccles has said, the more clinicians are using some aspects of the new system the more champions we have. Of course there is this question of where do you reach the tipping point, where do you get the momentum that really does get that critical buy-in.

Q590 Dr Stoate: As a practising doctor I know exactly how clinicians think. Clinicians are all in favour of progress; it is change they cannot stand! You might think that that is facetious but actually it is true. You will get buy-in to the point where it starts to disrupt the way they do things and that is when it starts to clash. Choose and Book is a great example. I think most GPs in principle are very happy with Choose and Book. If it interferes with the way they do their work and if it clunks along and causes them problems, they get angry with it. It is not the principle; it is the practice they have got problems with, and those are the issues we have to smooth out. What I wanted to talk about was this dichotomy between central and local buy-in, if you like. I understand the point you are making, Lord Hunt, about the fact that we have to with economies of scale use a central system to drive progress, that is fine, and we also know that clinicians like local systems. GP systems now have been decentralised to the point where GPs can choose their own supplier. How much further do you intend to go as part of this programme in decentralising as much as you possibly can? Do you have anything in mind that you are going to further decentralise?

Mr Granger: One of the interesting things about the decentralised GP systems is the paradox of the excellent support that they give to you as a GP in the building in which you deliver care and how incredibly useless they are in all other contexts. So they are not very useful for you as a GP in the patient's home. They are not very useful for you as a GP when you are doing a session for an out-of-hours service provider and they are not very useful for your patient when they are anywhere else and they are not very useful for 3.3 million patients when they change GP a year.

Q591 Dr Stoate: So why have you let GPs have different systems?

Mr Granger: We have been trying to walk a difficult path between real inter-operability between competing suppliers who talk the talk about information exchange between their systems and then deliver systems which are fundamentally incompatible with the previous versions of their systems and with their competitors' systems.

Q592 Dr Stoate: I was going to ask you about that because you have put in this RFA compliance that they all have to meet the specifications, and presumably they all do, and yet the point is that none of them is compatible with each other and if you migrate from one GP system to another you lose unacceptably high levels of data.

Mr Granger: I think we are coming to a point with a variety of key information around the issuing of prescriptions, around the making of bookings, around the verification of demographic data where we are using HL7 Version 3 standards which means that if the other countries in the UK want to step on to the arrangements we have they will be able to because these are international standards, they are not English standards, so that is dealing with a number of real-time information exchanges. We are also at a point now where the GP-to-GP record transfer programme, which along with RFA pre-dates the establishment of a national programme, we are getting to a point where we are getting good information transfer between competitor heterogeneous GP systems. We had some difficulties with the GP contract in 2003 and the national programme running in parallel and the interpretation of the words "choice of system" where we bought a choice of system but we did not buy the fact a GP could have any system they so chose. I think we are finally getting to the end of that problem by having a number of compliant systems, but it is no different to the hospital sector where the greater variability of systems and the cost of testing those systems militates against serving the interests of people who want information to move between GP practices.

Q593 Dr Stoate: I am not disagreeing with you; the point is why have you allowed this to develop knowing, as you do, that you will cause yourself some more problems?

Mr Granger: We are trying to strike a balance. We recognise that a lot of GPs do not want to change the system they have got because it supports them very well, delivered by people who understand what they do, at the same time as we want systems which support their patients in multiple locations.

Q594 Dr Stoate: You have not got that, so how will you get that?

Mr Granger: We are getting there with that. If you look at the work that TPP have been doing, for example, where we have now got 10% of GP practices properly hosted in professionally run data centres ---

Q595 Dr Stoate: Is that your vision then, to have hosted data for GPs?

Mr Granger: Yes, and that is exactly what EEMIS are also pushing towards.

Q596 Dr Stoate: That is your vision for the future, is it, for GPs?

Mr Granger: Yes. I do not think having servers sat in GP practices with a whole pile of maintenance problems and difficulties accessing information on them out of hours serves the way people wish to be cared for.

Q597 Dr Stoate: Are you confident that will actually work because the connectivity between GP practices and anything outside the building is not very reliable at the moment?

Mr Granger: Is it not?

Q598 Dr Stoate: No. At the moment, for example, Choose and Book is, to say the least, slow. If I had to run my entire clinical system using some sort of broadband connection as they currently are, I would have real difficulties.

Mr Granger: 10% of GPs in the country now do that and I do not hear them complaining about the speed of performance of their TPP applications or their network connection. If you take some of the legacy GP applications there are some problems with the way they have configured their system to operate Choose and Book, which is not a Choose and Book problem and not a network problem, it is a legacy application configuration problem.

Q599 Dr Stoate: In summary, you want to go down the route of more uniformity eventually so that these systems have effectively less choice but more compatibility, is that what you are aiming for?

Mr Granger: Yes.

Lord Hunt of Kings Heath: What you have really described is the same discussion that we have had before, the trade-offs here. There have had to be some trade-offs with the GP community and you see some of the downsides of that, which is the variability. I think it very clearly illustrates the debates that we are seeing but in the end we have to have a system that really works together rather than the problems that you have described.

Q600 Jim Dowd: By nature, I am slightly more optimistic than some of my colleagues. I want to look at the position when the system is in and working and obviously it must then become a permanent feature forever more beyond that. The contracts only have a ten year lifespan. What do you imagine will emerge after that? The system will obviously need upgrading, it will need improvement, it will need software new releases, et cetera, who is going to be responsible for that and how is that going to work?

Mr Granger: I would say we will be in quite good shape because we have based the core national applications on the dominant global database supplier, Oracle, and we have based the applications on standards which are becoming dominant global standards. In terms of local provision we continue to have contestability there so we should not have the problem of having to effectively bribe the market to compete because we will not have a monolithic national standard. With the central systems where we have got one supplier there have already been numerous upgrades and that is just business as usual. Because we are operating to international standards in terms of the messaging structures and applications and so on, we should well be able to run healthy competition there. Because of the adoption of these standards and, whilst it is not without pain having had to set up an international standards body for data standards, for example, SNOMED CT, we will be in a position where the systems we are using will be similar to the systems being used in other jurisdictions. If you look at what is going on with the regional health organisations in the States, which are effectively pilot operations at the moment, they are going to step up to those standards when they start doing things on a more robust and industrial scale.

Lord Hunt of Kings Heath: I was just going to say what is really exciting is we are clearly going through the pain barrier at the moment, it certainly feels painful, but, as we know, the more clinicians engage, the more benefits they get and the more enthusiastic they become. By 2010 the health service will have made a significant advance and, of course, the momentum will be there and it will not want to stop there because people will increasingly see the benefits. I believe that alongside the national infrastructure that we clearly will need to develop and take decisions on in due course, we will also get the essential enthusiasm at local level in terms of using these systems. There is not much point in doing this unless we can see at the end of the day improved safety and quality for patients, and patients will increasingly see a really fantastic service as a result of all these changes.

Dr Eccles: I would take a slightly different line from my two colleagues, which is we will have got used to it and in consequence we will be complaining about it bitterly, that it takes up to three seconds to get a CT scan from the neighbouring hospital and you have to sit there and wait for ages looking at the egg timer and how disgraceful is that.

Q601 Jim Dowd: That is irony, is it?

Dr Eccles: As broadband gets faster and faster you still keep complaining it is not quick enough and we are going to be there where the patients will expect their records to be instantly available whenever they change GPs and if it takes two days to do they will be complaining about the two days rather than the three months it takes now. On Dr Stoate's comment of we like progress but we do not like change, we are going to see the innovating hospitals, the innovating individual clinicians, taking the systems we have got and sprinting into the distance with them designing generation after generation ahead and some of their colleagues will be sticking with exactly the core product they have been supplied with and will not change a thing for the next ten years after that.

Q602 Jim Dowd: Is not the danger that that takes us back to exactly the position we are in now and trying to escape from?

Dr Eccles: No, absolutely not. If I take a transport analogy that we are moving everyone to either Mondeos or Vectras, and we will get there in ten years' time and everyone will have them, at the moment some have vintage Bentleys and an awful lot have rickshaws. We have got to get to a common level and that common level is actually world class. There is not another country that will be in the state we will be in at that stage, we will be ahead of the game and the NHS, I think, can genuinely be proud of the change in quality of care it can provide as a result. Moving forward from there is easy, that is a good thing, we have got everybody on to an electronic environment using a common coding set across the whole of the NHS with free movement of patient data with permissions as appropriate. We can do research off that in a way that no-one else, except possibly Sweden, can at the moment. That is absolutely brilliant. If some people start innovating from there others will copy them. Yes, there will be one or two who will stay where they are at that point but that is a hell of a long way ahead from where they are now.

Q603 Jim Dowd: It was put to us today that there is a philosophical divide here as much as anything else insofar as we should have just waited to see what worked elsewhere and utilised that rather than attempting to ---

Dr Eccles: Why would we want to be last?

Q604 Jim Dowd: --- rather than attempting to create the international standard to which others will aspire. I accept there are probably irreconcilable differences and you will not be able to say which is right unless, of course, it does become world leader. Can I just test that for a moment from the taxpayer's point of view. The experience so far has been a reduction in the number of suppliers and participants. You said earlier, Mr Granger, that it is possible - I will not say highly likely, one has to be very careful about this - that as Millennium works and Lorenzo does not we might wind up with simply Millennium everywhere as regards the hospital-based EPR systems. Is there not a danger that we will have a reducing number of participants, people able to supply and support the system and, therefore, the ability for the taxpayer to extract maximum value from any upgrades or changes in the future will diminish?

Mr Granger: That is a risk. Of course, there are no prizes for the NHS not having already fallen into that trap. Nobody says, "Oh, it is quite good actually that you recognised that in January 2003 when you published a procurement strategy that you were not going to immediately become reliant on one supplier for everything". Of course, the Department of Health in 2002 was full of large corporates walking up and down the corridors talking to people, imploring them to just turn the whole lot over to one supplier and, indeed, to TUPE out around 20,000 frontline IT staff from NHS trusts to one supplier. We did not put our head in that particular noose. I do not think we will end up in a situation where we have the Millennium product across the whole country but we do have difficulty attracting the interest of competitor patient record suppliers. One of the other major suppliers has told us that because of the variability in the NHS they are just not willing to supply to us. It is a company called Epic who have some good systems but they say they are not willing to work with the NHS while there is this degree of self-determination amongst frontline clinical groups because their experience with Kaiser Permanente has been you have to have a sufficiency of standardisation in order to be able to put the same software in across multiple institutions or else you end up with incompatibility datasets and an inability to move information to serve patients between primary and secondary care and, indeed, tertiary care. There is a danger there but I think we have mitigated that as much as we can.

Lord Hunt of Kings Heath: To put it bluntly, we are developing a world class system and we need world class suppliers to work with us. The situation ten years ago was that we were doing basically a cottage industry which would not have the capacity or, I suspect, financial strength to be able to support the NHS in the way that we wanted for the national programme. I also think that the contractual arrangements have allowed us to transfer risk to the local service providers and that is a big contrast to many other public sector procurements on IT where the client in the end has accepted the risk and then often had to pay considerably more amounts of money to make fixes to get the system right because they did not get the specification right in the first place. Clearly, I think the contractual arrangements that we have established put us in a much stronger position and we want to continue to do that.

Q605 Chairman: Can I just ask you about the NPfIT Local Ownership Programme. You have given the responsibility for that to the SHAs to implement but the contracts are actually held by Connecting for Health. Is this not responsibility without power?

Lord Hunt of Kings Heath: Mr Granger might want to talk about the details of the contracting process, but I do not think so. Obviously we expect the local service providers and other contractors to work closely with a strategic health authority. They well understand that accountability has been transferred to the chief execs of the strategic health authorities. David Nicholson and I have stressed to the NHS the importance of taking this seriously. If there are problems they will be dealt with. I think it has been a very good thing to have done to get that buy-in at the regional level. It will also ensure at the local level, with the chief executives of the trust, that there will be the absolute right, strong engagement that we need for the next phase of the programme.

Mr Granger: Out in the NHS and the SHAs in the north of England, the Midlands and the east of England, the six SHA CIOs - chief information officers for the strategic health authorities - meet with CSC directly, with procurement contract experts and, indeed, technology experts present. They recently dealt with some contract issues around the achievements and milestones on Lorenzo on a collaborative basis. The same thing has always gone on in London with a CIO for the strategic health authority London - originally there were five SHAs, if I remember rightly, and now one - and in the south the three SHAs recently appointed an individual with responsibility for managing the implementation of key systems there for Fujitsu and she, in fact, is leading the re-planning exercise for release one of the Cerner product with changes to the functionality that have been requested by frontline clinicians. We already have SHA personnel dealing day-to-day with key contractual management issues in collaboration with CFH people and frontline staff from trusts.

Q606 Dr Taylor: Can I go back for a few moments to clinical buy-in because it is marvellous to have enthusiastic national clinical leads, to have enthusiastic local champions and, Lord Hunt, you said huge networks of clinicians involved. We seem to have a knack of picking on the clinicians who do not feel involved. We have had one this morning from the Renal Association who feels distinctly uninvolved in that he has tried to get involved and failed. I would take exception really to Richard's comment that critics want the system to fail; certainly the medical critics do not want it to fail. If I can quote one or two bits out of the Renal Association's evidence: "We are therefore strongly supportive in principle of the development and establishment of electronic patient records" but then they give a litany of complaints: "Connecting for Health has failed to assure the renal community that its strategy respects clinical need as well as technical solutions; failed to develop an understanding of specific IT needs of ours and other specialist health communities; eschewed opportunities of early wins by demonstrating benefit in chronic disease management; and threatened the survival of specialist clinical software suppliers who understand well the needs of the healthcare community". They are not alone, we have had other evidence from groups of clinicians who feel distinctly disengaged with the system.

Lord Hunt of Kings Heath: If I could make a general comment and ask Simon Eccles to comment on the details. Medical organisations are many and varied and they are not backward in coming forwards. Inevitably, in any major programme such as this you are never going to be able to satisfy every specialist group to the degree that they would think necessary. My role as minister back in 1999, 2003 and now is to make sure that the programmes we have established do allow for considerable clinical engagement and the submissions that are put forward are considered and then to make sure with David Nicholson that people out in the service understand the importance of clinical gains at local level. I am not going to say that this is perfect, nor indeed do I think it would ever be possible to meet all the needs that every specialist body produces, but I do think that what has been achieved, starting with the work going back to the start of the programme and more recently with the clinical champions and discussions with various bodies, is a very good foundation. I want to improve on that and that is why I have agreed to establish a high level group with the Academy of Medical Royal Colleges, which I will co-chair, to make sure if there are concerns they are heard by me and we make sure that we do engage as much as possible. Perhaps I could ask Simon Eccles to talk about the specifics of how ---

Q607 Dr Taylor: You have actually answered that and I want to move on to detailed care records. Surely the real priority for improving patient care is to have the detailed care record readily available at local level. We have been looking at security and somebody this morning repeated that security is really only a problem because of the widespread nature of the summary care record. Why have we focused so much on the summary care record, which from our demonstration at Richmond House a week or so ago looked to be merging much more into a detailed care record? Why do we not keep the summary care record as a single field with the demographic, the allergies and the crucial things, and then really work to develop the detailed care record which nobody yet has been able to tell us exactly what it will be? That is what I want to know, what exactly will the detailed care record be? Are you actually working pretty hard to get that available because this is what will improve patient care?

Dr Eccles: Yes, it will. They both will. The summary care record is a subset of the detailed care record, it is not one or the other. All the information in the summary care record will have come from, and be contained in, the detailed care record.

Q608 Dr Taylor: Are you saying the summary care record, by definition, has to come first?

Dr Eccles: No, no, they could come in either order. They do not hinder each other's development. The detailed care records for an individual patient are currently held electronically in over 70% of GP practices and on paper in each of the hospitals in which they have been seen and if they have been seen in the emergency department they will have a separate record, in maternity they will have a separate record, paediatrics has a parent-held record in addition to their own records, sexual health will have their own record and mental health will probably have their own record. Those comprise your and my current detailed care records and, as you will be familiar with, as I am, they do not always appear in front of the clinician who wishes to see them at the time at which they wish to see them. It is those records we are replacing with Cerner Millennium, iSoft Lorenzo and the GP systems of choice. In addition, in London they are using a separate community system and those are being done slightly differently in different areas depending on the needs they are getting from those. We need to ensure they all integrate with each other, that the information contained and entered into a detailed record once can be used many times in other areas for the care of that patient and can cross those boundaries from primary care to community care to hospital care. When relevant an extract goes to the Summary, so if you have only got one bit you have got the most relevant stuff.

Q609 Dr Taylor: Who are you talking to about the design, particularly when one is thinking of common clinical standards so they have got to be all the same and easy to understand? Who are you actually talking to about the design?

Dr Eccles: Lots of clinicians. I mean lots of clinicians.

Q610 Dr Taylor: Specifically, are you talking to the Royal Colleges?

Dr Eccles: Yes. You have taken the lid off that can. Yes, indeed, we are. My colleague, Ian Scott and I, as the national clinical leads for hospital practice, and Gillian Braunold and Mike Pringle for general practice, have met with all of the Royal College presidents, we have met with most of the specialist association presidents and we have a national advisory group to which every specialist association are invited to send members. They do not always come but they are certainly invited. For example, the Choose and Book specialist reference panel has representation from just about all of the specialist associations. We have certainly consulted at a national level as far as we conceivably can. I chair a clinical reference panel representing all of the different types of health professional as well as large numbers of patients, and there are 26 people on there, to make sure we are not just dominated by the medical professional, for example, learned though we are, we have got to make sure this works for allied health professionals, for nursing staff.

Lord Hunt of Kings Heath: That is why I am going to form this group with the Academy to make sure at that senior level they are content with the degree of involvement and buy-in. As you have heard, there is a huge network of discussions that are going on at the moment.

Dr Eccles: We are doing that equally down at local level for the design and tailoring of the product. There are two big products for UK use. They have got large numbers of clinicians, over 2,000 clinicians, involved in the design, the build, the test and so on of those products at that level. You mentioned specialist systems, renal systems for example, and the Chief Clinical Officer, Professor Michael Thick, was due to meet the Renal Association pre-dating this panel, but in some large hospitals in the south of England, for example, there are over 70 databases held by specialist clinicians, in some cases several databases held within one specialty, because individual consultants cannot agree on the right database to use so they are using their own. At some point we are going to have to agree best of breed here in conjunction with those specialist associations, what is the system that we should feed to the manufacturers of that system, to the suppliers: "Here is how to make sure it is compatible with ours so that data will flow out of the national system into your database". What I hope is that our system will be sufficient to manage the day-to-day running of patients with renal disease to a high standard. It may not collect every data field that renal clinicians want because they have got some pretty detailed stuff that is not relevant to others, but we let them know how to get that information out of our system. By doing those two aspects I think we will fit the needs for specialist systems.

Q611 Dr Taylor: So are there enough people like you who are going to engage with all of these specialists, the Royal Colleges?

Dr Eccles: That is a very unfair question to ask me! Some would argue I am unique and I would have to disagree.

Q612 Dr Taylor: Sorry, let us tie it down. How many people are there, and I do not mean just like you but equivalent, who are trying to engage with the specialist associations and the Royal Colleges?

Lord Hunt of Kings Heath: We have got about 250 clinicians who are working with us.

Q613 Dr Taylor: Okay, fine. I will move on.

Lord Hunt of Kings Heath: What I would love to see is more local champions of the programme, that is where it is clear from our discussions we want to see more emphasis given in the future.

Dr Eccles: We need to divide the question in two, not "You have not spoken to me about the design of the system", but "Have you spoken to people like me about the design of the system?" We may not have spoken to each individual renal consultation but have we spoken to a sufficient body of opinion to get it right.

Q614 Mr Campbell: Do the organisations know the names of these people? Are they given the names of these people, the organisations and the health authorities and trusts?

Lord Hunt of Kings Heath: I am not aware that this is anonymous information, it ought not to be. I will certainly check up because clearly they ought to know.

Mr Campbell: They might not know, that is the problem.

Q615 Dr Taylor: We saw very clearly at the Homerton the enormous importance of the enthusiastic senior clinician right at the top. What are you doing via, I do not know, strategic health authorities, whoever, to try to make sure that there is one such figure in every major hospital who will take it under their wing and convert everybody to it?

Dr Eccles: This is part of the Local Ownership Programme. It cannot be for us centrally to go and start pointing a finger saying, "You are going to be the champion for this hospital" or, indeed, "Send the name of your champion and we will send them files of information". Individual strategic health authorities need to speak to the acute trusts in their patch to identify their champions locally. They must be locally derived champions, if you see what I mean. What we have found is this varies. We have done huge amounts of work centrally to try and encourage leadership. We have a leadership programme being organised by Connecting for Health, we are working with the British Association of Medical Managers to develop leadership here specifically around the programme and we are talking to trusts. When one discovers a trust who, having put in their patient administration system, we ask them, "What was your clinical engagement strategy" and the answer is, "We chose not to tell the doctors", I despair of that.

Lord Hunt of Kings Heath: There are clearly lessons that are being learnt all the time, particularly with the introduction of patient administration systems in hospitals. One of my aims is to ensure that we learn the lessons both good and bad and that is then translated into the roll-out of the programmes. More generally, if you look at where the health service is going, the introduction of much greater patient choice, given that effective IT programmes assist patient choice and the perception of patients as to the value or success of a particular institution, it has got to make sense for senior management to engage the clinicians because if you have an institution where the clinicians have not been involved the one thing you can be sure is that when the patient administration system is introduced it is not going to work very well. Part of the reason for placing responsibility fairly and squarely on the National Health Service is to get that kind of commitment from senior management and it really is a no-brainer that within an NHS trust you want to have a senior respected clinician who is champion of the programme.

Q616 Dr Taylor: What do you say to the critics who say because delivery of the detailed care record is so slow it leads to loss of interest and then loss of engagement?

Dr Eccles: I go back to the answer I gave to Charlotte Atkins earlier. While the product is even visible and coming at some point in the future it is relatively hard to get people enthusiastic. As soon as it is in the neighbouring trust it is much, much easier. Taking a slightly different topic of PFI hospitals, trying to get clinicians involved in the design of a new hospital build, whether it is PFI or anything else, is really, really hard but as soon as the foundations start going in the clinicians all flood in saying, "Well, how is it going to work then?" and it is too late by that stage. What we are hoping is by having some trusts ahead early and by having worked so hard to get clinicians involved in the design up until now, when it is visible we will have no difficulty in its development which we have got carrying on for the next five or six years.

Q617 Dr Taylor: Are you going to insist on more use of the NHS number? Will that go on the summary care record?

Dr Eccles: Yes.

Q618 Dr Taylor: Is that going to be widely used and unique so it can cross boundaries? We have heard there are problems with crossing to Scotland and crossing to Wales at the moment with the NHS number.

Lord Hunt of Kings Heath: If I can make a general point, having the NHS number as the unique identifier is critically important. It is going to be one of the unseen but huge advances that we are going to make. That is not just in terms of administration but also in terms of patient safety.

Q619 Dr Taylor: Is that included in the demographic bit of the summary care record?

Lord Hunt of Kings Heath: That is my understanding, yes.

Dr Eccles: Absolutely, yes.

Lord Hunt of Kings Heath: On the Scotland and Wales issue, would you care to comment on where we have got to?

Mr Granger: It is currently an issue for devolved administrations as to what indexing arrangements they choose to have. We now have, and have in fact had since mid-2004, an online database with demographic details for the NHS in England. That is already accessible to about 7,000 locations. It has been accessed 319 million times since it went live and about 50,000 frontline NHS workers use it every day. The issue is not having a highly robust online database which, unfortunately, had to replace a batch system that was rather quaintly implemented in the late 1990s by somebody who submitted evidence to you in defence of antiques, I think. That is not the issue. The issue is getting the plethora of departmental systems to support that indexing arrangement and, indeed, the GP systems reconciling different demographic information that is held locally and nationally and for the GPs who use the electronic prescription service or Choose and Book they experience that requirement today. We want to know that we have got up-to-date demographic information. We will have to migrate to a properly reconciled unique identifier, it is not something we can do on a big bang basis. Because our demographic information is passing around the NHS in England already on HL7 message standards it is relatively straightforward for other countries in the UK or elsewhere who adopt those international standards to exchange demographic information with us with the appropriate protocols. The challenge is their adoption of the standards rather than our systems.

Q620 Dr Taylor: Will that number be different from the current NHS number?

Mr Granger: No.

Q621 Dr Taylor: How close are we to rolling out electronic prescribing, which seems to me to be the single most important thing to improve safety?

Mr Granger: We are already rolling it out and as of last Friday 4,824, ie 56%, of GP practices and 4,397 community pharmacies, ie 42% ---

Q622 Dr Taylor: It is hospitals I am really aiming at.

Mr Granger: Okay.

Q623 Dr Taylor: We know GPs are doing a lot of it.

Mr Granger: In terms of e-prescribing systems in secondary care, that is going to come in over the next two to three years. The software already exists in the Cerner application. The initial implementation of Cerner has not put e-prescribing in although the software is built and works in hundreds of hospitals.

Q624 Dr Taylor: Are any hospitals doing it already?

Mr Granger: Yes, with local systems.

Q625 Dr Taylor: With their own systems?

Mr Granger: Yes

Q626 Dr Taylor: Will they have to pull those out to put the new in or will they be able to keep those?

Mr Granger: No. The Winchester system is planning to interact with the Cerner system.

Q627 Dr Taylor: Is it just a handful that is doing it now?

Mr Granger: Yes.

Dr Eccles: Part of the reason for going slightly slowly with this was we had huge clinical engagement on e-prescribing, and quite rightly, because it has got to be standardised. It is really an area where we cannot have local variability. We have absolutely clear critical safety. I do not know if you are aware - I was not until I started doing this programme - just how differently pharmacists, general practitioners and hospital-based doctors look at the same prescription for the same medication to the same patient. We have very different ways of describing the same thing. We can all have our unique view but we have got to make absolutely certain that we end up with the same product being taken by the same person with the same expectations on the part of all of those different professionals.

Q628 Dr Taylor: I am fearfully disappointed really because I was involved in trying to implement it about 12 years ago and it was at that time that we did hit on exactly what you have said, the different perspectives from the pharmacists and the prescribers.

Dr Eccles: We will have it sorted.

Lord Hunt of Kings Heath: If one thinks "What is this all about", number one it has got to be about improved patient safety: here is the clear, real winning goal that we must go for.

Q629 Mr Campbell: Just on that point of safety of patients and dependability of the system, we have been told that when clinical records are remotely hosted, the loss of the hosting centre or the network for more than a few minutes could lead to loss of life. so both the hosting and the network need to be available virtually all of the time. Is there any evidence of this?

Mr Granger: Yes, there is lots of evidence of it. Unfortunately, there are some members of the commentariat who seem to have trouble finding their way to the service availability data that we publish on our website. You may have received evidence from people who do not like looking at published service availability data. I think you had Patrick O'Connell from BT come and give evidence. BT run both the network and the core national messaging systems and there is a very strong body of evidence from the published service availability data for both those pieces of national infrastructure that not only do they work but they have the level of reliability and dependability which is appropriate to the task. We have not had any major network outages since we replaced the old NHS network. The last time there was a significant network problem was the Royal Victoria Hospital suffered two routers failing as a consequence of them being plugged into a dirty supply rather than a clean supply during a generator test about two months ago. The last time there were any service problems there were some performance delays, it was taking more seconds than was appropriate to get messages transferred on the Spine infrastructure in January last year, the last time there was a major upgrade, which in fact increased the level of reliability and number of back-up platforms that we used. There is some scaremongering about this which ignores the published data. I think we have been singled out for special treatment here because people do not compare what we have implemented in the NHS with anything else, they just have some abstract "It can't be good enough" set of comments. I would like them to look at the reliability of our core systems and network against other pieces of civil infrastructure. If they have got some evidence that it is wanting on that basis rather than just scaremongering then I would be very happy to go back and review the contracted levels which the suppliers do meet.

Q630 Mr Campbell: Can I just read this out to you: "....a power failure at the CSC centre last year. 80 Trusts (72 PCTs and 8 hospitals) lost access to records systems when servers failed and back-up systems could not be made to work". That is the evidence we have been given. Was that just a one-off or could this happen all the time?

Mr Granger: That is one part of the country, one set of systems, three levels of back-up failed, no data was lost and the back-up systems that the trusts had in place meant that care was not disrupted. This scaremongering that this could have a serious clinical safety issue is completely wrong.

Q631 Mr Campbell: So nobody could lose their life here?

Mr Granger: No, not in that situation.

Q632 Mr Campbell: In what situation would they lose their life if it failed?

Mr Granger: I cannot envisage that situation I do not know if you have received advice from somebody on some strange interaction between a locally run anaesthesia machine, for example, and a patient administration system, but that is a bit of a fantasy because it does not exist, or an intensive care system interfacing to a path system. The critical systems for patient safety that are run off generator backed-up power supplies in hospitals are a different kettle of fish from systems that contain information that is used for administration and care of people generally not on a real-time basis where frontline doctors have work-arounds and can revert to paper and undertake activities that do not necessitate these host systems.

Q633 Mr Campbell: So the view that somebody's life is in danger is scaremongering?

Mr Granger: Yes.

Q634 Mr Campbell: I would accept that.

Dr Eccles: Absolutely people's lives are in danger by lack of information. If we do not know that their potassium is high then we do not know to bring it down and their life is in danger, that is absolutely clear. That is far more prevalent right now than it is in the hospitals that have the systems that we are putting in place.

Lord Hunt of Kings Heath: If you look at the National Audit Office report or the National Reporting and Learning System run by the MPSA, they continually show issues due to medication errors and misidentification of patients. There is no doubt in my mind that the outcome of the national programme for IT will be to have an appreciable reduction in those incidents. Overall I have no doubt whatsoever that this is going to lead to enhanced patient safety.

Q635 Mr Campbell: I just want to nail it and make people aware that they are not going to die. We all know about computer failures, at least MPs do: the Child Support Agency, Child Tax Credits, "Sorry, the system has gone down", and in that case it might be somebody getting mixed up with their money but in your case somebody might die and we need to nail this is not going to be the case before people start to back off from all of this.

Mr Granger: If I can just add a couple of things. The failure that CSC suffered last year led to them being punished to the tune of £3 million. The allocation of that penalty around the NHS in the areas of the country that were affected by that was determined by the strategic health authority CIOs, so that is part of this Local Ownership Process working. Since then CSC have doubled the amount of resilience that they have, so they are now running off four data centres rather than two. The specific difficulty that happened was because there were some engineers in Japan altering some microcode on a back-up platform but they have now ensured that specific failure cannot happen again. The probability of that happening is lower. The thing that is important is recognising the vulnerability - these are civil systems that have been bought on a budget and there can be failures with them - the back-up arrangements that the NHS have locally to deal with this type of failure, people keeping paper copies of things, keeping local electronic copies and having clinical procedures that mean they are not real-time dependent on this information. I will just point out to you that it is estimated by my colleague, Professor Michael Thick, our Chief Clinical Officer, that 40% of patients arrive for outpatients' appointments without their records being present using a paper approach. We have got vulnerabilities with computer systems and their reliability, which are the bane of my life, and we have problems with paper as well. The same is true, for example, of picture archiving systems. Lord Hunt and I visited Basingstoke before Easter and the trust there estimated 20,000-30,000 studies had been re-shot in the year before they put their digital system in. That was 20,000-30,000 sets of radiation and cost applied to patients unnecessarily because the information was not available. There are problems with the analogue world as there are with the digital world.

Q636 Chairman: Do you have a comparator in terms of databases in the UK? I know there are different levels of resilience that evolve but what is the comparator with the one you are implementing for the national patient record?

Mr Granger: We asked CIOs and frontline clinicians in the NHS during the specification process what levels of resilience did they want and they had some degree of tolerance for planning downtime, and I can let you have a note on the details of this, and a low degree of tolerance for unplanned downtime. The computer vendors, frankly, had trouble getting their head around what the NHS wanted because the systems that had been put in nationally in the NHS previously defaulted to not being available when it was dark and all maintenance being done at the weekends. As soon as you started to introduce systems which people have a use for in an A&E department the vendors had to get their heads around the fact that they could not do their upgrade work on a Saturday night because we would quite like the system to be available then. Undoubtedly, if money were no object we would have bought another level of resilience and even lower levels of non-availability. I will let you have a note on the performance over the last year of all the key systems that we run and that is the information which is, indeed, on our website.

Q637 Chairman: The last issue is about patient privacy. We had some evidence given to us that the summary care record and possibly the Secondary Uses Services could be challenged, or are likely to be challenged by European law. Do you think that is a serious risk?

Lord Hunt of Kings Heath: I certainly hope not. We have taken advice from the Information Commissioner and from our own lawyers and we are confident that what we are doing is within the law.

Q638 Chairman: Your lawyers believe that, there is no gap between what laws we have here in the EU and Europe?

Lord Hunt of Kings Heath: Obviously part of their review has been looking at European law as well as domestic law. I am very happy to write a note to you about these aspects if you would like me to. The bottom line is the advice that we have received and the advice from the Information Commissioner is that we are acting within the law.

Q639 Chairman: I would be grateful for that note. Some critical parts of the NHS, clinical IT, are going to start keeping things as images and test results and they are going to be centralised. Of course, individuals can have the right not to have their tests centralised but in any way as you see it now, or in the future, are you likely to turn round and say to these individuals who have not had their tests centralised that the National Health Service cannot treat them because they are not on this system, the non-consent would then say that we cannot do that?

Mr Granger: In particular section 10 of the Data Protection Act and an individual's right due to the level of distress they experience to not have information processed is rather difficult in an environment in which we want to have a health service that is safe and efficient and, therefore, necessarily processes a number of pieces of information electronically. Pathology results and picture archiving are probably the two test cases and friction points around this. If an individual is so distressed that they do not want an x-ray to be conducted electronically, I think ministers would need to decide whether it was indeed in the public interest to maintain wet film processing, a 19th century technology, for these distressed individuals.

Lord Hunt of Kings Heath: Clearly we continue to engage in these kinds of discussions but I think there has to be some reality here and the reality is that we are moving much more into a non-paper based system.

Q640 Chairman: I think that most GP practices now have got records held electronically, have you any evidence that people can opt out of the electronic local record in their GP's surgery and they can tell them they want theirs to be paper based?

Mr Granger: It would be impossible for somebody to be registered with a GP in the NHS without there being an electronic record because we would not be able to pay the GP. Whilst I am sure there are a significant number of philanthropic GPs, there has been very, very good take-up with our payments system under the new GP contract.

Q641 Chairman: In as much as the detailed care record is held in a GP's surgery there is no opt-out there under any circumstances, would that be a fair analysis?

Mr Granger: Yes.

Lord Hunt of Kings Heath: Of course there is a requirement on clinicians to keep records and that is in the public and patient interest.

Chairman: Could I thank you all very much indeed for helping us with today's evidence session.