Jeremy Hunt

Time for less pulp fiction on ‘paperless’ NHS

On the first anniversary of health secretary Jeremy Hunt’s groundbreaking speech on NHS IT, EHI editor Jon Hoeksma asks whether the ‘paperless’ NHS needs to start a new chapter. (article first published in EHI 16 Jan http://www.ehi.co.uk/insight/analysis/1240/insider-view

A year ago, health secretary Jeremy Hunt announced that he wanted to see a ‘paperless’ NHS by 2018.

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Twelve months on, the idea remains an important clarion call to action, without a huge amount of clarity on what paperless means, why it should be achieved, or how it will be taken forward.

Literally paperless a pipe dream

Almost nobody working in NHS IT believes in the objective in a literal sense. There is not a chance the NHS will have ceased to use paper within four years.  Stationers and printers across the land can sleep a little easier.

Instead, at the top level, a ‘paperless NHS’ is a national policy initiative that succinctly conveys the urgent need to digitise England’s hugely complex, fragmented national health and care services, to help to achieve a host of pressing productivity, efficiency and clinical safety challenges.

The big question is how this can this be achieved when the NHS is facing a historic squeeze on budgets. Where are the priorities?

Or, to put it another way, what are the main business objectives of a drive to a paperless NHS? Many different and sometimes contradictory answers have been offered over the past 12-months.

Paper mash-up

Is ‘paperless’ primarily about clinical systems; replacing paper records with a drive to integrated digital health and social care records?

This was the clear direction provided by NHS England, when it published its ‘Safer Hospitals, Safer Wards: Achieving an Integrated Digital Care Record’ guidance last July. But the term has been used much more loosely, and for a much wider range of initiatives, even within the acute sector.

Or, is paperless really about catalysing a fundamental shift to online digital services, as seen in many other industries?

Is it meant to dramatically change the way in which many NHS services are delivered, create genuinely patient centred services, challenge many current professional roles, and drive productivity by eliminating a lot of jobs?

That’s the way that NHS England’s director of patients and information, Tim Kelsey, talks (except for the bit about eliminating jobs); and he clearly has Hunt’s ear – meeting him once a fortnight.

However, it has yet to be translated into working projects at a national level, never mind at a local one.

There is a growing air of frustration coming out of NHS England that numerous, brilliantly conceived websites and open data initiatives aren’t being realised and don’t seem to be solving knotty problems like A&E.

Tensions are also mounting between NHS England and the Health and Social Care Information Centre.

Which brings us to: is paperless really about marshaling, linking together and analysing the data resources of the NHS for the benefit of patients, but also public health statisticians, researchers and the life sciences industry – and, in so doing, save UK Plc?

Certainly, this seems to be the HSCIC agenda, and one that is put forward when presenting to ministers – including the prime minister, who has made several references to it at international conferences.
Papering over the cracks

Coming in the wake of the era of the National Programme for IT in the NHS, Hunt’s emphatic re-affirmation of the vital importance of information technology was both succinct and important.

But as a basis for formulating coherent strategy, it has so far proved of limited explanatory value. It has been extremely difficult to translate it into a set of clearly articulated national priorities that local organisations can then translate into local business plans and strategies.

This has not been helped by the different dates that have been put on the milestones on the digital journey, or by the handling of the Safer Hospitals, Safer Wards: Technology Fund that is supposed to fund them.

Although Hunt set out his vision last January, the first mention of paperless was made three months earlier at a London conference by Kelsey, who said he wanted the NHS to be paperless by 2015.

There followed some quick back-tracking, suggesting the focus of his remarks was electronic referrals and discharge letters; but while the new e-referral service will be live by then, the deadline for paperless referrals is now 2017 or 2018.

Hunt himself said that by paperless he meant that all records and communications in the NHS would be paperless by 2018.

As a foundation, he suggested the NHS should have records “that can talk to each other” by 2015; but this date has not found its way into subsequent, national guidance.

Meanwhile, a report by PriceWaterHouseCoopers to support Hunt’s speech suggested that the NHS could save £4 billion if the NHS invested in technologies ranging from records to document scanning to telehealth.

To help create a debate on priorities EHI last April launched the Big EPR Debate.

This was a major online consultation exercise, working with partners including NHS England, that found very strong support for a focus on electronic records and clinical systems that offered clear benefits to patients.

The results helped inform the development of the Clinical Digital Maturity Index, a benchmarking tool developed by EHI Intelligence to measure trust’s progress on installing clinical IT systems, now licensed on behalf of the NHS by NHS England.

It also appeared to inform and was in tune with the initial priorities for the tech fund. Hunt launched this in May with £260m of unspent capital funds, a figure that would later be increased to £500m, or, as he put it, “£1 billion for NHS IT” over three years, counting in matched funding from trusts.

At this point, it looked as though the Department of Health had decided that e-prescribing – one of the most critical elements of a hospital EPR system, offering measurable patient safety benefits – would be the focus of extra investment.

The move looked extremely shrewd. E-prescribing is a catalyst to driving clinical benefits, but almost impossible to achieve in isolation from a good infrastructure and other clinical information systems. Get one, and you’ll actually get the others.

By July, though, NHS England’s guidance on ICDR indicated that NHS Number, scheduling, and information sharing projects would also be funded.

And as NHS England sought to juggle competing priorities, and the practicalities of getting the first round of hot money spent by the end of the financial year came into view, even this focus was also lost.

The tech fund instead became available for a much wider range of projects including, but not limited to, portals, electronic document management, and mobile initiatives.

At least, that’s to judge from the initial announcements about winning bids that came out in December, many of which appear to be for ‘shovel ready’ projects that trusts had in hand, and might have taken forward in any event.

Time to take a fresh view on paperless priorities

With round two of the tech fund now about to kick off, it makes sense to take stock on ‘paperless’, now both a year old and due to be completed in just four years.

No successful commercial organisation would set ‘paperless’ alone as an objective. It would, instead, have particular business goals that it would aim to harness digital tools and data to deliver. The NHS urgently needs to find a way of adopting the same thinking.

What investments in clinical and business IT will result in ‘meaningful use’ that can deliver the greatest measurable benefits to patients and NHS providers? How can these be turned into a sensible, funded strategy that will make sure those benefits are delivered and can be measured?

And how can the experience of the different parts of the NHS be better shared and learned from, so successes can be scaled up? NHS England is promising that a technology strategy, delayed from December, will now be out in March. A lot may hang on it.

Is it useful to set a 2018 target for a paperless NHS? Vote Now

Secretary of State Jeremy Hunt has set the objective for the NHS to become paper free. Is it a useful target to set? VOTE NOW

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I’ve set up a poll on the CCIO Leaders Network Forum, please do take a minute to vote and say whether you think the target could be helpful, and if so how. Obviously, that’s not the same as saying whether it will be hit.

EHI have published quite a lot already on the new target.  Here’s a selection:

Today’s round up of NHS reaction piece with two current CCIO’s quoted:
http://www.ehi.co.uk/insight/analysis/1023/is-hunt’s-dream-possible_tcq

An analysis of why Hunt is focusing on a digital NHS – and why it will need CCIOs
http://www.ehi.co.uk/insight/analysis/1022/leadership-key-to-paperless-nhs

And EHI’s original news coverage
http://www.ehi.co.uk/news/ehi/8315/hunt-wants-paperless-nhs-in-five-years

Finally, for those who want it from the horses mouth, the video of Hunt’s speech and text of speech (also embedded below)
https://jhoeksma.wordpress.com/2013/01/28/jeremy-hunt-16-jan-paperless-nhs-speech-text/

Jeremy Hunt 16 Jan paperless NHS speech text

EHI has reported on Secretary of State Jeremy Hunt’s 16 January speech at the Policy Exchange, ‘from notepad to iPad: technology and the NHS’, but its worth taking a closer look at the text of the speech.

Video of presentation:

And below is the text published by the DH:

“In 1953, when the NHS was just five years old, two men named Smith took a flight from LA to New York.  They started chatting.

One Mr Smith was the head of American Airlines.  He was having a nightmare coping with the explosion in demand for airline travel.

Back then it could take 3 hours to book a single ticket.  They were dependent on the amount of work that 8 people huddling around a single rolodex could manage and they had reached their limit.  Mr Smith was desperate.

The other Mr Smith worked for IBM.

That chance encounter transformed the industry.

It led to a new computer system that allowed any travel agent anywhere in the country to know which seats were available on any flight, book and issue a ticket all in a matter of minutes.

The implications were massive. Flying went mass-market – and American Airlines became one of the most successful airlines in the world. And we are still using the same system 60 years later – with the internet allowing us all to become our own travel agents.

But think how history would have been different if the man from IBM had been sitting next to a Mr Smith from the NHS.

What they introduced to the airline industry 60 years ago, we still haven’t done for health and social care today.  The revolution that has transformed so much of our daily lives has only just started to touch healthcare.

Today I want to talk about why we need to embrace that revolution with enthusiasm – but also the pitfalls if we get it wrong.

The NHS today

Right now, one of the biggest challenges facing the NHS is the Francis Report about the appalling abuses of care at Stafford Hospital, shortly due to land on my desk.

I am clear that our response to that report must be about getting the culture and values right in the modern NHS as about regulation and systems.

Technology is not the answer to this. It can never replace human interaction, nor the care and compassion that must be at the heart of what the NHS stands for.

But today, I want to argue that it does have a role to play if we are to give doctors and nurses the time and space to deliver on those core NHS values.

The clearest example of this is patient records.

Because they are mainly paper-based, they can only be in one place at a time, only seen by one person at a time.

So they’re no use to a patient on holiday in Gloucester if his file is in a GP surgery in Godalming.

Or to a paramedic picking up a frail elderly woman in an emergency who, if he had her notes, could see she was a diabetic with a heart condition who had a fall last month.

They’re no use to a hospital doctor who might not be aware of a patient’s other medication and prescribe drugs incorrectly – potentially lethally – because the notes have got lost.

Unaware of a patient’s full history, complications arise in surgery.

Diagnostic tests are repeated unnecessarily.

And patients find themselves having to repeat their medical history over and over again, sometimes several times on the same day in the same hospital.

International comparisons

Other countries are making great strides.

In Denmark, people can see all their hospital records online, and this year will be able to see their GP records too.

In America, military veterans, who have their own healthcare system not unlike the NHS, can download their own health records.  Something that almost 20,000 veterans do every month.

In Sweden, over 85% of prescriptions are transferred from doctor to pharmacy online.

Here in the UK we too have some interesting pioneers.

King’s College Hospital, for example, is on track to become fully paperless by the end of this year.

The drive comes from the clinicians who demand to have the right information in the right place at the right time.  They’ve introduced electronic prescribing, and nurses use an iPod Touch to record and monitor a patient’s vital signs at the bedside.

Maudsley Hospital’s ‘MyHealthLocker’, gives their patients online access to their hospital and GP records, a world’s first in mental health.  They can also feed back on their care plan, helping them to take control of their own healthcare.

And Newham University Hospital is piloting using Skype for diabetic outpatient appointments that don’t require an examination.

Missed appointments are down by 11%, patients don’t have to travel and the quality of care is improved.

But today I want to argue that we need to go much further, much faster.

So today I am setting a new ambition for the NHS.

I want it to become paperless by 2018. The most modern digital health service in the world.

Patients will be at the heart of this change – which means allowing for those unable or unwilling to engage in technology.

But between the NHS and social care, there must be total commitment to ensuring that interaction is paperless, and that, with a patient’s consent, their full medical history can follow them around the system seamlessly.

Challenges

This will be a profound change with huge impact, impossible to underestimate. And with profound change come profound challenges.

First, unsurprisingly, is money.

If Labour failed to do this with their billions, how can we hope to do it on a much more limited budget?

We shouldn’t forget that local hospitals and local GP practices spend their own money on technology all the time.  We just need a much more ambitious vision as to how to make that money and that investment count.

Every NHS organisation, including all 266 NHS trusts, has a major incentive to do this because the savings are so enormous – £4.4 billion annually according to today’s PWC report – that money, released to spend on better care, can go a long way towards helping them deliver health services sustainably in a time of real financial pressure.

Second, there is the objection that this should not be a priority because we want nurses talking to patients not looking at iPads.

But how many times do we see a nurse station in a ward with nurses unable to catch your eye because their heads are buried in paperwork?  Proper investment in technology means more contact time with patients – which is why the Prime Minister announced a £100m fund to help nurses take advantage of it.

Then there is the objection that patients don’t want technology. It’s true that only 3% of people book GP appointments online.  But 29% say they want to.

Before online banking became available, were customers marching in the streets, demanding that banks put their accounts online?  Of course not.  But that didn’t stop people going online in droves – with 80% of us, including a third of pensioners, now banking online .  Never let it be said that this is only something of interest to younger generations.

Then there is the critical issue of data security, which Fiona Caldicott is reviewing right now. Clearly we need protocols so that people can be comfortable that their data is only being accessed when necessary and with their permission.

But if the banks can make people confident that their money is safe, we must surely be able to develop a system that keeps medical records safe too.

Then there is the importance of the doctor-patient relationship.  There will be many times when only a face-to-face meeting will do.

But allowing repeat prescriptions to be booked online will free up much more time for such meetings, as well as offering a better and more convenient service for patients.

Finally, people say that we’ve been here before.  That Labour tried it and failed. The truth is that Labour had the right idea but the wrong approach.

Labour’s Connecting for Health became the NHS equivalent of ordering an aircraft carrier. A project that became over-centralised, over-specified and ultimately impossible to deliver.

What works – and you can see this everywhere – is local solutions, local decisions and local leadership.

Most systems won’t necessarily need to be replaced, just updated or adapted so they can talk with each other.  A thousand different local solutions linking together using common standards.

If this sounds incredibly complex, it’s actually very  commonplace.  It’s why your Blackberry can talk to my iPhone. It’s why all of those apps on our phones integrate so seamlessly.  It’s why you can use any computer, phone or tablet and log on to the internet to catch up on the latest news or watch a video on YouTube.

Things don’t have to be the same.  They just have to be compatible.

Why do it

Today’s report by PWC confirms what we already know.  That the right sort of technology, used in the right way, can release billions of pounds to be re-invested in better, safer care – and millions of hours of staff time for better patient care.

And it can do something else too.

Over a million people have some form of contact with the NHS every 36 hours and have done so for over 60 years.  This produces mind-boggling amounts of data that, if properly utilised with the right safeguards, can help improve treatments, unlock new cures and transform the face of modern health and social care.

The challenge

The stakes are high.  But already we have made real progress in preparing the NHS for a paperless, digital future.

In November, I announced in the NHS Mandate that by March 2015 everyone who wants it will be able to get online access to their GP record, as well as book appointments with their GP and order repeat prescriptions online.

E-consultations, like those in Newham, will also become much more widely available.

Today I can confirm that the NHS Commissioning Board have agreed that hospitals should be able to share digital data from April 2014, and to adopt paperless referrals from April 2015.  It is currently working on detailed guidance to help local NHS organisations make the leap.

This follows on from other recent steps:

  • Changing the standard NHS contract to insist that providers comply with defined information standards.
  • Setting up ‘care.data’, a service to give local commissioners timely and accurate information on the performance of providers.
  • From this summer, we’ll begin to publish huge amounts of clinical data on a wide range of surgical procedures, everything from vascular surgery to bariatric surgery.  Bringing unprecedented transparency to great swathes of NHS performance.
  • And to drive all of this, from 2013/14, the NHS number will become a patient’s primary means of identification within the health and care system, enabling all of their records, wherever they are held to combine around the individual person.

Conclusion

So, to conclude, technology is not a holy grail or a silver bullet for all the challenges facing the NHS.  It must always be a means to an end and not an end in itself.

But properly adopted, it has the potential to play a central role in facing up to the core challenge of dealing with an ageing society in which patients insist on a more personalised service.

As Bill Gates said, “Never before in history has innovation offered promise of so much to so many in so short a time”.

Well, health needs to be at the front of the queue in taking advantage of that promise – and I am determined it will be.

Thank you.”

Is it time to get smart on health IT targets?

Does it help to have national targets?  I’m thinking here about the latest 2018 target for a paperless NHS announced by Jeremy Hunt last week. It’s a big bold target, but will it deliver any benefit and does it have any chance of being met?  Would the NHS be better served by learning from the US approach.

The big argument in favour of national targets is that it gives focus and gets everyone pointing in the same direction. The big argument against is that 100% targets are so vague as to be meaningless.  The only parts of NHS IT that have reached 100% are primary care IT and PACS where take-up wasn’t driven primarily by a national target, but by a clear demand and measurable set of benefits.

In NHS health IT, particularly for hospitals, we’ve had getting on for 15-years of national targets on EPR roll-out and and digitisation, and its not entirely clear whether targets help.

Are we any further forward on EPR in NHS hospitals because of the national targets set in every NHS IT strategy since Information for Health in 1998?

How many trusts that have made strides towards implementing EPRs -and the NHS still has very few hospitals with advanced EPRs in use – have done so because of the existence of a national target?  Those that have made the most progress have done so  because they recognised this is an essential investment, one necessary to deliver modern safe, high quality healthcare?

It could be argued that setting targets that few believe can be hit, and there is no chance of 2018 being hit from where we stand today – without a sea change that the NPfIT billions failed to deliver, just breeds cynicism.

Rather than focus on blunt national targets, which the DH and Secretary of State have just lost the tools to enforce anyway after the Health and Social Care Act, there is a strong argument to look at the Meaningful Use approach of HITECH in the US which has focused on incentives (and eventually penalties) based on meaningful use of advanced EPRs to deliver clinical benefits. 

Part of the logic is that getting healthcare providers to the point where you have begun the journey to implement complex clinical decision support or electronic prescribing will catalyse them to take the plunge.  

The NHS may not have the HITECH funds available but it could still be a lot smarter on targets that deliver tangible benefits.