England: big enough to fail

Provincial England's health service suffers from its size when trying to develop informatics

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- SA Mathieson
- Smart Healthcare, Wednesday 25 November 2009 09.00 GMT

The Holy Grail?: Herefordshire's primary care trust and council share a boss, offices and processes. Photo of Hereford Cathedral: jiunlimited.com

Last week's Queen's Speech included a pledge for further devolution from Westminster to Scotland and Wales. This was quickly dismissed as inadequate by the Scottish Nationalist Party, which plans to unveil its plans for a referendum on independence next week.

But the Scottish and Welsh health services have no need of further devolution: they have been independent of England for a decade. As a result of the significant differences between their political natures and Westminster's, significant gaps are starting to show – and in general, on informatics, they are doing better than England.

England is probably too big to run as a single health service. Elsewhere in Europe, health is usually run by regional government, or on an insurance basis with many organisations providing services. Only in England does one parliament – which currently has Scots in the two most important jobs – manage the public sector healthcare of 50m people.

Both Scotland (5m) and Wales (3m) face specific challenges. Scots suffer from high rates of heart attacks, Wales has to serve its people in two languages, and both countries have a legacy of older and retired manual workers with work related complaints, along with many patients living in remote locations.

But Scotland has made the greatest general progress in the UK in developing health informatics, with its Emergency Care Summary patient record system covering all but 1,400 refuseniks and celebrating four years of existence. It now plans to develop this system into new areas such as patients' end-of-life wishes. Wales is moving more slowly, but expects to have common systems running across the country by 2011.

Meanwhile, England's National Programme for IT is notorious for its failure to deliver. This reputation is somewhat unfair – it has established several national systems, such as the N3 high capacity network (shared by Scotland) and email. But on patient record and administration systems, progress has been slow.

England's progress has not just been hampered by scale. Tony Blair and his government mistakenly pursued a one-size approach for the National Programme, pushing all kinds of trusts to use the same systems to get economies of scale.

England also undermined public and professional trust in its Care Record Service patient records through making the scheme opt out, getting it bracketed with 'surveillance state' projects such as identity cards. (Scottish practitioners asks permission to access patients' records on every occasion, except if someone is unconscious or incapable.)

On both counts, policy has been softened, with more localisation and changes to policies on privacy.* But it takes a long time to turn around a supertanker.

Capital idea

It is notable that one part of England seems to be doing better than the rest. NHS London, the capital's strategic health authority, is taking a distinctive path for its 7m population. It has its own local service provider under the National Programme (BT), is planning a move to polyclinics and is going to introduce the Care Record Service across the capital. But such regional management looks unlikely to work outside the M25.

The answer for the rest of England might draw on the other part of the UK: Northern Ireland, where health and social care delivery are combined for the 2m residents. The last reconfiguration of England's NHS bodies left most primary care trusts contiguous with county and unitary authorities. Local authorities run social care, as well as other services complementary to health such as education.

The Conservatives, who look likely to win the next Westminster election, say they are keen on localism, and dominate England's local councils. So why not bring PCTs and councils closer together, or even merge them?

The (current) government's Total Place programme is already encouraging cooperation across the state sector in an area. Herefordshire Council's chief executive Chris Bull also runs the area's primary care trust, and the two are saving money by merging their offices and back office processes.

People in England often identify with their council area, particularly if it is a county or a city, far more than their region. Merging PCTs into councils could result in organisations with a holistic view of health and well-being in their areas. They could give provincial England health organisations big enough to function, but small enough to innovate – and with local democratic accountability.

* Illustrating how the NHS in England has moved on privacy of patient records, a Department of Health spokesperson emailed after publication with the following comments: "The consent model for Summary Care Records in England was revised in September 2008 so that permission is sought from patients when a clinician has a need to utilise records from outside their own organisation.

"Patients have the choice of saying they do not want to be asked in every situation in which the record might be viewed. Otherwise they will be asked for their consent in every situation. In cases of an emergency where a patient is unconscious or incapacitated, clinicians will access their record if safe treatment requires it."