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21 Feb 2008 : Column 153WH—continued
Of course there are genuine concerns and anxieties about confidentiality and security. Those must be taken seriously, but let us not kid ourselves: that problem is not new. Various hon. Members have cited the Royal College of Nursing’s survey of its members. It found that two thirds of its nurses welcomed the introduction of the electronic patient record but, interestingly, 30 per cent. of them said that the security of the system would not be any better than that of the paper records currently
used in health care. They recognise that the present system is not secure. Anyone can access a paper record and leave no calling card. With a proper secure system in place, any access to an electronic record is logged and can be audited and accounted for. However, the public, patients and professionals are right to be concerned about whether proper safeguards will be put in place.
Not enough has been done to explain the benefits of EPR systems. They will deliver much. They will not only improve communication between different health care staff and between staff and patients, but help to reduce the number of errors. We have heard about that already. They will also assist doctors with diagnosis and treatment, which is an increasingly complex issue. We saw at Homerton hospital how having the various options on screen helped doctors to narrow down the alternatives. However, that can happen effectively only if there is sufficient buy-in by health care staff and patients, so increasing local ownership must be a key priority for the programme, and not just in hospitals.
The Health Committee saw how local negotiations with suppliers and the system designers at Homerton hospital paid dividends, with what appeared to be—at least this is what we were told—full buy-in by all professional staff. I appreciate that that will be difficult to replicate country-wide—this was a pilot—but if hospitals, health clinics or GP surgeries are left out of the loop, there will be no incentive or enthusiasm to make the system work, which will have predictably poor results.
The consent arrangements for creating and adding information to the summary care record and for patients to restrict access to particularly sensitive information in the so-called “sealed envelopes” have not been well handled. Concern about recent private information data losses have made that even more difficult, because everyone recognises that maintaining the security of patient records is a significant challenge, but as we have heard, that has been done in the banking sector. Of course there have been mistakes and some elements of fraud, but we must recognise the need to make progress. Although paper records are no more secure, I recognise that the potential for the loss of large numbers of patient records is much greater under any EPR system. Clearly, people will be worried about that. That has to be recognised. It is important that we address the difficult balance between the need to protect patient privacy and the opportunities for beneficial health research. In that situation, patient privacy must always be the greatest priority; secondary uses must come second to patient confidentiality.
We all want to see the end of the delays in the introduction of the EPR system, but we must ensure that any move forward is not made by cutting corners on procedures and on clinical and technical standards. Those must be absolutely paramount. Unless we can prove that patient confidentiality and the security of patient records will be the No. 1 priority, patients will not buy into the system and then it will not be as effective. That said, we must recognise the huge benefits that will come from the EPR eventually.
In the ePolitix selection of responses to the debate, the responses of two organisations—Help the Hospices and Homeless Link, one of which has been mentioned by the Chairman of the Committee—jumped out at me because they helpfully identified two vulnerable groups that will particularly benefit from the EPR. Help the Hospices stated:
“One of the key barriers to providing good care which meets the needs and desires of patients who are dying is the availability and continuity of records which clearly record their condition and their wishes. Without these there is an unnecessary burden on the patient and carer to repeat their history to every new care provider, to keep professionals up to date with changes in care and condition and to ensure that the wishes of the patient are met. These challenges are particularly acute towards the very end of life when conditions deteriorate rapidly and can occur out of normal working hours. It is vital that all those involved in care can access the right information.
The Electronic Patient Record system has the potential to make a significant difference to the appropriateness of care that individuals receive and will help more people to die in their place of choice.”
Similarly, Homeless Link stated:
“The low level of registration with GPs, particularly amongst street homeless people, consequently means that they have a higher usage of A&E for primary care purposes than the general population...Electronic records do offer the real potential to give homeless people a better continuity of care, can mean that records are less likely to be lost for people moving frequently and that street homeless people in particular can receive better more informed emergency treatment.”
We owe it to them and, indeed, to all patients to ensure that we get the EPR right. That will allow us to ensure that vulnerable people in particular get the benefits of that system. We must ensure that we have a 21st-century NHS, not a 20th-century one.
3.58 pm
Dr. John Pugh (Southport) (LD): May I start by saying that this is an excellent report? I do not say that simply to ingratiate myself with the members of the Committee assembled here, although that is worth doing, but because it is true. The report is very balanced in tone, well researched and clear. It follows another very good report on the same subject by the Public Accounts Committee, which in turn followed a report by the National Audit Office. The PAC report focused on four problem areas: the delays, the failure to quantify benefits, the lack of capacity among suppliers and the lack of genuine clinical engagement. All those matters were taken up by the Health Committee, so I think it is fair that I concentrate on them.
The Health Committee came up with some good suggestions on delays, with which the Government appeared to agree—I emphasise the word “appeared”. One suggestion was that local strategic partnerships should publish detailed timetables for implementation. The Government response states:
“The Government accepts these recommendations”
but, clarifying that acceptance, they say:
“Responsibility for deployment, including planning and timetabling, has now been transferred to the local NHS, who agree the deployments with suppliers in line with the suppliers’ capacity and their local NHS business circumstances and implementation slots...This is therefore removing much of the earlier uncertainty for trusts”.
If only it did so. The response does not actually say that a detailed timetable will be forthcoming.
The Health Committee also made a sensible suggestion on the deadline that should be set for the ill-fated Lorenzo project, which, as we know, has had considerable problems getting off the ground. It is the crucial patient
administration system that we are all waiting for. The Government say that they agree with that, stating:
“Although the delays to the delivery of the Lorenzo system have been disappointing”—
“deployments are scheduled for early adopter sites in the summer of 2008”.
We await that with bated breath. The Government then say:
“The NHS and suppliers are working together to ensure that Lorenzo can be delivered within the terms and life of the contract”.
We would expect no less, frankly, and that is what the NHS and suppliers have been doing for some appreciable time. Of course, there are serious worries because iSOFT, which makes and provides Lorenzo, is being taken over by an Australian firm for which such work is not core business. The sensible recommendations have not been responded to with the vigour that one might expect and hope for, but the Government do not dissent from them.
The second issue that the PAC and Health Committee lighted on was a failure to quantify benefits or to undertake a serious cost-benefit analysis. That point has been dealt with in interventions and comments today, but it is worth repeating the most damning passage in the whole report, which states that there is a perplexing lack of clarity on what Connecting for Health will now deliver. The report also states that it is not clear what will be on secondary care records, how they will be used or in what situations they will be needed. The report states that
“it is not clear what information will be recorded and shared on”
the detailed care record. The Government cannot have a serious cost-benefit analysis if they do not know what they are endeavouring to do in the first place.
I do not want to be picky, because no one can be against the digitalisation of data, or better accessibility to, and sharing of, clinical data. That is a personal point: my last five medical appointments have been with five different doctors, and every time I have had to launch into a narrative as the prelude to sensible consultation with a medic. Nobody is against tele-medicine, a good internal mail service, image transition or electronic prescribing, because it is all good stuff. It is arguable whether we need choose and book or the complexities of the tariff, but I think there is cross-party agreement that the other developments are bound to happen and that that is a good thing.
The choice has always been whether to grow the services, whether to impose or commission them en bloc, or, taking an expression that was used earlier, to have the big bang. Commissioning en bloc has not been demonstrated to be obviously cheaper or technically necessary, if there is wide agreement on IT standards and ways in which data are going to be formulated, expressed and transmitted. The situation will not be helped if the project is, as I have described it, underspecified; if we end up with a high risk of supplier dependence simply because there are few suppliers, which appears to be happening; or if there are high risks for the health bodies, which are basically getting on with looking after patients in the meanwhile. There are serious problems up and down the country while hospitals wait for the perfect patient administration system to come over the horizon. Hospitals have issues about what to do with
their legacy equipment, when to spend money, and how to cope with the other new demands that the NHS imposes on them.
My GPs have a slightly different experience from those cited by some members of the Committee. They say to me that choose and book is fine, even if it is far slower than they would wish. However, some of the appointments that are booked do not stay booked. When one endeavours to book with an hospital, someone phones and asks, “You are trying to choose to book, so what can we do for you?”, and then they go back to the system that they had before. In a sense, there has still been no adequate cost-benefit analysis.
Another criticism made by the PAC and the Health Committee is the lack of capacity among suppliers. No one will disagree with that—only CSC, BT and Fujitsu are really left in the big game, which is not what people want. Only the cash-rich are staying in the game, because they can hide their losses while projects develop. The Health Committee suggested some solutions, which are sensible. The Committee calls for direct local negotiation and a choice from a wider catalogue of suppliers built around common technical standards. That solution could run or fly—it could work and benefit the whole project.
Responding to that suggestion, however, the Government have said:
“There is no intention to change the contractual arrangements”,
and argue that central procurement delivers “value for money” and ensures interoperability. However, everybody agrees that big central procurement is not necessary for interoperability—it might happen that way, but it is not a requirement. Similarly, the case that big central procurement provides value for money has not been made. In the long term, we should look at interoperability that means that I can be seen adequately by a physician who knows something about me if I fall ill in London. If I were to fall ill in Paris, I would in principle like the same kind of expertise to be available—increasing migration across national boundaries is the case for that approach.
I delivered a talk to anaesthetists in Rotherham on that issue. I said that although it would be helpful and nice if whoever was looking after me had details of my record if I were taken ill in Rotherham, it was the first time I had ever been to the town. However, I have been to Paris four or five times, which is why I plead the case for interoperability outside British national procurement boundaries.
Sandra Gidley (Romsey) (LD): I do not know how much of the report my hon. Friend has read—
Sandra Gidley: Excellent! The Committee visited France and looked at the French system, which to a certain extent is web-based. Indeed, it can be accessed from all over the world. Presumably, my hon. Friend would advocate a system such as the French one. I should add that it can be accessed only with the patient’s permission.
Dr. Pugh:
I would like to avoid a system whereby medical data cannot be transferred across national boundaries when necessary with the patient’s consent.
In a sense, that means that I wish to back away from any arrangement that involves a lock-in to any particular provider that does not provide fully interoperable software. That is why common technical standards are so important to development. Suppliers can be here today and gone tomorrow, but we need to get the system’s architecture right in the first place.
When talking about diversity, the Government pray in aid GP systems of choice, which, frankly, was a response to the fact that GPs would not put up with what they were offered. I have had some communications with GPs in the Yorkshire area who say that they exercise their choice to have the equipment that they want or to keep their existing equipment, but that puts the strategic health authority under appreciable pressure, because it is locked into a contract whereby it has to buy equipment from a specific provider, whether or not GPs are going to use it.
I shall pass over the issue of clinical engagement—others can speak about that if they so wish. On the PAC’s three main criticisms—delays, cost-benefit analysis, and the paucity of suppliers—the jury is still out, despite this excellent Health Committee report.
4.9 pm
Sandra Gidley (Romsey) (LD): Had I known that so much time would have been available, I would have prepared a longer speech. Thank heaven for small mercies.
Fundamentally, we all agree with the hon. Member for Staffordshire, Moorlands (Charlotte Atkins) that the national patient record is a good idea because access to patient data by the appropriate practitioner at the appropriate time should improve patient health, in the broader sense, and patient outcomes. However, she made a point about it becoming a party political matter. Given that the UK system is large and complex and a number of legitimate concerns have been raised, it is only right that Members on both sides of the House should query what is going on. Had concerns not been expressed about the system, its implementation and the delays, I am sure that the Health Committee would have found something else to occupy its time. After all, we are never short of subjects to investigate.
Any good functional system needs to be reliable and secure, and it should ensure full interoperability. A number of witnesses were concerned that it was well nigh impossible to ensure all three. One could have two of the three—one could perm two of the three—but achieving all three consistently was not possible.
Given the recent outbreak of scandals concerning the loss of data, I shall base my comments on data use and patient confidentiality. It is worth bearing in mind that one witness was fairly convinced that the system as it stands broke European Union data protection rules. Those are all matters that we should take seriously. Indeed, even the Deputy Information Commissioner has raised some concerns.
My first concern is that some people may wish to opt out of the system. I would encourage them to stay within the system, but people have a right to opt out if they wish. In many cases, however, they do not realise that they are able to do so. I was surprised, as a Hampshire Member, to be told by witnesses that a trial
had taken place in Hampshire. It had completely passed most residents by. Dr. Braunold was candid about what had happened. She said,
“I can take you through how we are not happy to do it the way Hampshire did it.”
We were criticised for not listening. Apparently, in Hampshire a leaflet was included with the free newspapers—with the junk mail—and most people threw it away, not realising that it was there. People were opted into the system without knowing whether they had the opportunity to opt in or opt out.
Thankfully, the NHS has learned from those mistakes. Where the system is being rolled out in new areas, positive attempts have been made to ensure awareness by sending addressed letters to individuals; there is a greater chance of them being opened. The information is now being provided in many languages, and those who wish to opt out have the opportunity to discuss the matter with a health professional. I was pleased to see that the vast majority of people were reassured and that relatively few people opted out of the system in those areas.
There is a niggling doubt about how confident citizens should be about who is able to gain access to data. The Committee learned that in many situations, often because of the slowness of the existing system, smartcards can be left in the machine all day, which means that anybody is able to gain access to the data.
Some members of the Committee know that I am a pharmacist by profession, and I know that concerns have been raised about access are data in chemists’ shops. Data in pharmacies are usually kept behind the scenes, but little concern seems to have been raised about GP practices. The right hon. Member for Rother Valley (Mr. Barron) alluded to the problem. For instance, a card could be left in the machine all day long; even the cleaner could gain access to the data, because Dr. Smith had left the card in the system.
The Committee recommended that the sharing of smartcards between users was unacceptable. We also recommended that access times should be improved and that the potential for more sophisticated access systems should be investigated. The Government accepted the first recommendation, claiming that it was work in progress, but they rejected the second.
I believe that some sort of sanction is needed against people who do not use their cards properly. We heard from my hon. Friend the Member for Southport (Dr. Pugh) about the lax procedures if cards are lost. We have learned from other system failures that it is not always the system itself that has failed but the human operators; people do not always understand confidentiality issues and there is little training in that aspect. I recall asking Richard Granger in the early days of his tenure what he would to do ensure that staff were adequately trained in the NHS IT system. His rather brusque reply was that there would not be much need for training because it would be highly intuitive. Time has knocked that one on the head.
The Government rejected the Committee’s second recommendation, but their reason is interesting. Their response states:
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