Essential support

Reform through health informatics - the combined application of information and technology - not only engenders cultural change in the health service, but is shaping the relationship that the industry has with its main customer (albeit often out of sight of the industry itself). It appears as if this programme of works is an industry blind spot - generally out of the sphere of consciousness for most business units. Occasionally, though, a component of health informatics capability brings this reform agenda into the spotlight and affords industry a glimpse of its potential impact.

For example, the emergence of the ScriptSwitch prescribing advice tool in the UK healthcare market has changed the dynamics of prescribing in primary care quite dramatically in some regions. Although a relatively simple concept, it has successfully used information and technology to change habit and enforce policy.

Increasing use of content management is starting to have an impact on market access, as enterprise-wide clinical networks facilitate more centrally-controlled services like electronic formularisation. The output-based specification model, Output Based Specification for Integrated Care Record Service, devised by the Department of Health in 2004, is working on programmes to implement policy at the desktop, an example of which is decision-support-based National Institute for Health and Clinical Excellence (NICE) guidance. The prescribing support unit (PSU), through the NHS Information Centre (IC), has been developing and providing a set of electronically managed and monitored prescribing indicators to the NHS. These are based around the average daily quantities (ADQs) of products to enable organisations like Primary Care Trusts (PCTs) to monitor individual prescribing patterns and detect outliers. Equivalence models or product competitor markets are being defined by informatics policy within the clinical system supply chain through the Dictionary of Medicines and Devices (DM&D). In time, and with planning, programmes of work around outcome-based reimbursement will start to be developed, either centrally or by the informatics service provider network. These projects represent just a cross section of currently influential and consequential health informatics developments affecting the industry. 

It is clear that the NHS and the global healthcare system will be shaped by an increased reliance on information and technology and that these programmes will have growing importance for market access. Far from being a source of fear, however, these changes should be seen as offering a chance for the industry to reform its relationship with customers and to make delivery of its products and services more efficient.

Enabling NHS change
If the NHS were your business, how would you run it? Naturally, you would want a highly skilled, highly motivated and well managed workforce to enable delivery against your targets. To support the workforce, you would require a well structured and well organised infrastructure that enabled the business to function day-to-day. To maintain vision and direction, you would have your business plan for reference and to maximise opportunities, you would ensure that you had access to adequate financial resources. The missing link is performance management; your control, or the measure of your success or failure. If you were managing a pharmaceutical company, you would probably have an enterprise-wide information system to support everything from billing and purchasing to human resources management, as well as a global customer relationship management (CRM) system and a business unit dedicated to business intelligence. 

However, you are not in industry; the NHS is your business. So what do you use to monitor and control your performance?

Sir Derek Wanless, ex-NatWest chief executive, was asked the same question by Gordon Brown when he was chancellor in 2002 and his judgment provides insight into the probable solution. In an excerpt from Securing our Future Health: taking a long term view, published by HM Treasury, Sir Derek said: "Without a major advance in the effective use of information and communications technology, the health service will find it increasingly difficult to deliver the efficient, high quality service that the public will demand. This is a major priority, which will have a crucial impact on the health service over future years."

It is clear that NHS reform and the increased use of information and technology are inextricably linked. If the NHS is to retain its future viability, the use of health informatics is central to the service becoming "fully engaged" with its customer – the patient. The NHS Plan and subsequent sister publications set a direction of travel for the health service to follow to ensure that quality and value are maintained. The vision is of a patient-centred, collaborative environment which learns, develops and implements best practice and that becomes more self critical and self aware. A policy and contractual framework is in place to encourage a cultural change through its contractors and staff and to begin to translate the strategy into tangible outputs.

This emerging culture reflects a vision focused on open communication, flexibility and meritocracy. Control will continue to be divested to regional bases, where service design will be planned around the needs of the local population against a national guideline framework. Individuality and choice will be expressed within the confines of standardisation and benchmarking, with subsequent performance linked to reimbursement and payment. Patients will be empowered as partners of the service, rather than its clients. Knowledge, choice and control will define how patients interact with the service, and by which route. Performance management is at the core of this reformist view, maintaining value in the service and measuring the return on investment.

Connecting for health
To introduce such fundamental re-engineering of workflows, working practices and mindsets, however, requires an equally radical enabler. Presently, this enabler across England and Wales is the DH's IT Directorate, 'Connecting for Health' (CFH). Although the name may change with new leadership or governments, the underlying health informatics principles are here to stay. These programmes focus on using information and technology to translate reform theory into tangible infrastructural, architectural and organisational systems that can be used to manage the service every day.

The blueprint on which CFH has been designed centres on the output based model necessary to deliver cultural change and reform. A nationwide health information supply chain, or N3 network, has been established, making information more mobile and more accessible. Collaboration across this network is encouraged and invaluable with programmes like the Picture Archiving and Communication System (PACS) facilitating case reviews by a multidisciplinary team in different locations. "Choose and Book" is a pioneer application in the patient choice agenda, allowing patients to nominate their centre of preference. Mandated interoperation facilitates efficient transfer of information around the network, making more content available at more locations to more people. It is this level of greater communication that enables the current Electronic Prescription Service (EPS2) to operate, which, in time, aims to lead to significantly increased levels of efficiency and transparency in the UK's reimbursement function. The Quality Management and Analysis System (QMAS), in conjunction with the Quality and Outcomes Framework (QOF), gives an insight into how the service will use health informatics to benchmark and performance manage against national standards of care.

Pivotal to the extent of this reform is the National Care Records Service (NCRS). The NCRS straddles multiple objectives of NHS reform. In its mobility, it allows more choice and flexibility for the patient interacting with the service and the system becomes more efficient by delivering content at the point of access. Safety is also enhanced by having a patient record available at the point of service contact. In the aggregation of patient data, surveillance and performance against standards can be reviewed and benchmarks set. Longitudinal analysis of patient outcomes becomes a real possibility at different hierarchical levels. Centralised records enable patients to interact directly with their medical notes, empowering them to take more ownership of their own health and shifting the balance of knowledge.

Scepticism
At this point, there may be questions over the wisdom of this approach. How achievable and realistic is this picture and, indeed, how necessary? After all, £12bn is quite a price tag for the CFH business management system. 

A common challenge is that the system will be inefficient, slowing access to information, ultimately to the detriment of patient care.  Further, system crashes and slow connectivity could prohibit ease of use when the patient is in the room. But what is the benchmark, the comparison, the current standard?

The stacks of notes piled high in corridors, in trolleys and behind desks in clinics across the country suggest that the current system is anything but efficient. Additionally, according to health spending projections in 2022-23, the NHS in its traditional mindset would cost the UK an estimated £184bn. If the national health informatics strategy can drive the reform agenda and cultural change, creating a "fully engaged" NHS operating environment, then the cost of running the service reduces by £30bn a year, to £154 bn. So in one year, CFH pays for itself. 

It is true that the track record of IT projects in healthcare is mixed, at best. Large-scale developments have been planned, piloted and abandoned, most notably the Wessex Hospital Information Support Systems initiative (HISS) project collapse in 1990. However, CFH is already well on the way to full implementation.

Choose and Book has been delivered, the N3 network is in place, GP2GP records transfer is live, EPS2 is being rolled out to pharmacies, standards of interoperation have been met, QMAS has been paying GPs for the last few years, the IC is well established, the PACS system is providing imaging facilities in secondary care, and a Secondary Uses Service (SUS) function has been created. The programme is here and already well established. 

Security of information is often cited as a reason for not continuing with the programme of works. Large-scale database projects have a habit of provoking the conspirator theorist in us, but what is this system being judged against? In 2008, Adam Stuart, a postman from Conwy, was jailed for nine months by a judge at Caernarfon Crown Court for dumping 3,100 items of post in woods near his home. In 2006, David Lewis, a retired postman from South Wales, was jailed after he was caught trying to destroy 40,000 items of post. How many referral letters, hospital discharge letters and clinical appointment cards were among them? Written communications between primary and secondary care providers contain many sensitive items of personal information. Every day, thousands of these are entrusted to the Royal Mail and, ultimately, to the local postman.

It is fair to say that a programme of this size, with so many separate components and companies, each with its own responsibility, is going to be difficult to manage. In fact, it is realistic to say that not all the strategy and implementation will be a success; some key components or developments will fail and be seized upon as ill-conceived and poorly planned services; probably quite rightly.

However, this does not mean that the programme is doomed to failure or that it does not represent value for money. Whatever the next government, this programme is too important for the future viability of the NHS to be abandoned. It may be under a different name. It may be delivered in a different way; but the underlying principle of using health informatics to manage performance, create efficiencies and drive reform will remain.

The opportunities that health informatics brings are as real for the industry as they are for the healthcare systems in which they could operate. Industry must strive to understand, accept and embrace the changes brought about by health informatics, as Pandora is well and truly out of the box, with no sign that she is ever getting back in.

The Author
Mark Bailey is managing director of Sciensus