Smart Healthcare: Scotland | SmartHealthcare.com

MSPs want to widen telehealth's range

Fri, 12 Mar 2010 10:33:10 GMT

A report from the Scottish Parliament has recommended that telehealth technology is used across the country, rather than just in a few areas

The sheer geographical spread of Scotland, from an array of islands in the west to vast expanses of land in the north, has always made the delivery of healthcare challenging. Internet technology has made that task easier but the message from the Scottish Parliament's Health Committee is that NHS Scotland could do better.

A report published on 8 March 2010 urges the SNP-controlled Scottish Government to improve NHS computing systems to ensure that patients do not miss out on better care and treatment. MSPs criticised the "slow and inconsistent" provision of clinical portals – which allow clinicians and GPs to access medical data on patients across Scotland – and telehealth over the last decade.

Telehealth systems can remove the need for patients to travel to towns and hospitals to receive care and treatment by using broadband or mobile services such as video conferencing, which is of particular benefit in rural areas. Although widely utilised in Aberdeenshire and the Highlands, provision varies between health boards in other parts of Scotland.

To rectify this, the committee wants targets for all health boards to offer telehealth to patients. "It has the potential to release much-needed resources in these economically difficult times for front-line patient services," said committee convener Christine Grahame. "The Scottish Government has some serious work to do in encouraging health boards to use and evaluate this technology."

Conservative health spokesperson and committee member Mary Scanlon agreed. "The NHS in Scotland and successive governments in Scotland have been far too slow to embrace new technology," she said. "Telehealth could be used much more extensively, particularly in remote and rural areas, to monitor local conditions."

Scanlon added that the integration of the Aberdeen-based Scottish Centre for Telehealth (SCT) – which has an annual budget of £1m – with NHS24 in April should "lead to more innovative solutions to monitor and complement healthcare in Scotland". The merger was the outcome of a review by the Scottish Government, which is also drafting a telehealth strategy to support the process.

A Scottish Government spokesperson said: "Using the latest technologies has the potential to make a huge difference to healthcare in Scotland. Ministers place great importance on the development of a clinical portal – it is one of the priorities of the eHealth programme and will make a significant contribution to the safety, effectiveness and efficiency of care.

"We welcome the committee's support and good progress is being made in partnership with health boards, although we agree with the committee that progress on telehealth has not been fast enough. That's why a review of progress recommended that the Scottish Centre for Telehealth become part of NHS24, Scotland's provider of national telehealth services."

Richard Simpson, a Labour member of the committee, said: "The committee were clearly very frustrated with the fact that we haven't made more progress. We really have the potential to be a world-leader in telehealth but we're not at the moment because the SCT has been purely advisory and health boards don't have to buy into it, so the most important recommendation is the target for telehealth delivery across all Scottish boards."

Other recommendations include the establishment of safeguards around patient confidentiality and IT systems; value for money being placed at the heart of any NHS telehealth strategy; patients, midwives, nurses and other health representatives to be members of the Clinical Portal Programme Board (which oversees clinical portal projects in Scotland); and the creation of an 'eHealth' professional standards group.

The committee also urged "tackling resistance from medical staff in using technology" but Alan McDevitt, joint deputy chairman of the British Medical Association Scotland's GPs' Committee, said: "We have to remember that for some staff, using telehealth will be quite unusual. But they will ultimately decide whether it genuinely saves time and improves services.

"The more geographically remote an area is then the keener staff will generally be to accept new technology. But it's harder to argue for using telehealth in an urban area. Inevitably it's enthusiasts who advocate more widespread use, but it's important that both clinicians and patients think it represents an improvement on existing services."

Despite these qualifications, a professional and political consensus appears to support wider use, where appropriate, of new technology including telehealth. The health committee, meanwhile, expects to see tangible progress towards making Scotland a smaller country – in virtual terms – by 2014.

Scotland plans health protection IT system

Tue, 09 Mar 2010 12:59:57 GMT

NHS National Services Scotland (NSS) is hoping to use a commercial off the shelf system to support health protection work

In a pre-tender notice in the Official Journal of the European Union on 9 March 2010, NSS said that it is "considering options" for its planned Scottish Health Protection Information Management Solution.

The system, ideally a commercial off the shelf product, will be used across organisational boundaries to support the health protection activities of NHS boards.

The functionality of the system will be expected to cover the case management of incidents and of patients involved in investigations. For scientific users the system will cover national surveillance, analysis and reporting.

NSS intends to begin the process within the next 12- 18 months, depending on funding available.

The pre-tender notice contained no mention of cost. A spokesperson said this was "partly because we will find out from the responses we get back how much a system of this type will cost".

Separately, Scotland's phone and online health advice service NHS24 has announced a contract extension for its customer relationship management system. Its deal with Clinical Solutions, originally signed in March 2007, will now run until 2012.

Scotland plans mobile kit for patient transport

Thu, 04 Mar 2010 16:32:23 GMT

The Scottish Ambulance Service expects to purchase mobile data equipment for its patient transport service

The organisation has published a tender for hardware, application development, system interfacing, installation and maintenance for about 625 vehicles based throughout Scotland.

The patient transport service is used by patients for pre-arranged hospital appointments, or admission and discharge from hospital, rather than for 999 emergency calls.

The tender, published in the Official Journal of the European Union on 2 March 2010, did not provide an estimate of the deal's cost.

In 2009, the Scottish Ambulance Service started a pilot of remote access to the country's Emergency Care Summary records from its emergency ambulances in the Lothian health board area. According to its ICT strategy, it plans to develop this access for frontline ambulances and emergency medical dispatch centres in 2010.

Scotland puts care information for elderly online

Wed, 03 Mar 2010 14:36:16 GMT

The Scottish Government will spend £500,000 annually on a national online and telephone information provider on care services for older people

The website and enquiry line aim to provide a single source of information on the care available for elderly people in Scotland, including services provided by local authorities, the private sector and voluntary organisations.

Scotland's public health minister Shona Robison, opening Care Information Scotland on 2 March 2010, said: "It will make life much easier for anyone seeking information - in what can often be a crisis situation for a family - on care and support for themselves or for older relatives."

The service, which has a budget of £500,000 annually for three years, uses specially trained staff from NHS24, Scotland's health phone service. NHS24 commissioned Conscia to develop and build the website, with involvement from the Leith Agency.

The service was piloted in the Tayside area from mid-October to mid-February. A spokesperson for the Scottish Government said that the trial had seen strong interest online, with 1,500 unique users spending an average of eight minutes on the site and viewing about 10 pages each. Meanwhile, the telephone service received just 150 calls.

The move follows the Welsh Assembly Government's announcement that it is piloting a service for all enquiries on health and social services in the Cwm Taf health board area.

Freeing health's data: opening access to government information

Michael Cross — Wed, 03 Mar 2010 09:00:00 GMT

Politicians are trying to open access to government data, but this may expose problems with the accuracy of NHS information

Even before the Francis report into mortality at Mid Staffordshire trust, the quality of NHS data was emerging as a hot political topic. Over the past year, the government and the Conservatives (but, surprisingly, not the Liberal Democrats) have been trying to outdo each other with promises to empower patients with openly available data about the NHS. As yet, however, there are few signs of the promised consumer revolution.

The centrepiece of the government's efforts is the website www.data.gov.uk, launched last November by worldwide web inventor Sir Tim Berners-Lee and Professor Nigel Shadbolt of Southampton University in their roles as the prime minister's cheerleaders for opening up the vast resource of public sector information (PSI).

The idea, originally floated by the Cabinet Office in its 2007 Power of Information programme, is to create a central clearing house for access to PSI data sets and information about what use is being made of them. The site emulates a similar effort launched in May 2009 by the Obama administration in the US, where there is a long-held assumption that federal government data should be freely available for re-use. It is too early to say whether the same culture will take off in the UK.

Officially, of data.gov.uk's 7,500 data sets, 400 relate to healthcare. They provide the basis for a handful of applications already listed on the site, including iPhone apps for finding GPs, pharmacies and dentists from supplier Elbatrop. Another recent offering is Best Care Home, which helps people find the right care home for themselves, family members or clients from Care Quality Commission data. The site includes extracts and the full text of all inspection reports from the regulator, and ranks 18,500 care homes in order of quality performance.

The bulk of NHS datasets listed on data.gov.uk come from England's NHS Information Centre, including hospital episode statistics (HES) and national care quality indicators. The Welsh health service has also contributed data and access to a mapping visualisation system, and Scotland has also released a limited number of datasets on areas including abortions and alcohol interventions.

The launch of data.gov.uk coincided with that of a new licence model for re-using government data by the National Archives, replacing its pioneering, but little used, "click-use" licence. Unlike the click-use licence, the new "non-transactional Creative Commons approach" explicitly allows data to be re-used both for commercial as well as non-commercial purposes.

Right to open data

If the Conservatives form the next government, a sizeable number of new datasets could be made available under these arrangements. David Cameron, who can now count among his advisers Tom Steinberg of the MySociety web activist group (and co-author of the 2007 Power of Information report) is relying heavily on free data as a tool for improving public services.

While decrying the "Google government" tag, he says the web "allows us to make big change in the relationship between government and citizens, giving power to people on an unprecedented scale". Cameron's most eye-catching pledge is to publish in full every government contract worth over £25,000. But he has also promised that health data "currently locked away in vaults" will be published "in an open and standardised format".

The promised explosion in the availability of NHS data raises two interesting problem for the next government. First, if a new generation of commercial and community websites springs up on the back of the new data, what role remains for the NHS's own citizen-facing presence on the web? One pillar of the Power of Information agenda is that the state should not duplicate or compete with independent web-based services. The government has not yet followed this logic through, but a Cameron government might. An obvious way to cut the cost of the NHS Choices website, for example, would be to trim it to a core of essential data feeds and rely on the private and third sector to create citizen-facing applications.

The second problem concerns the quality of information. The more use is made of NHS data sets, the more their accuracy, currency and comparability will come under scrutiny. Commenters at the data.gov.uk website have already observed that the most recent available list of GPs dates from 2006 - and covers only England.

If as simple a list as the up to date GP register is impossible to open up, what hope is there for more sophisticated and controversial data sets? One key finding of the Francis report into the Mid Staffordshire scandal is that a working group led by Professor Sir Bruce Keogh, the NHS's medical director, develop a "single, clearer" measure of hospital mortality ratios for use by the NHS and its patients. The problem is that clarity and simplicity don't always go together with accuracy.

Michael Cross

Implementers claim benefits from mobile projects

Fri, 26 Feb 2010 16:05:51 GMT

Health providers can improve efficiency, reduce errors and improve patient outcomes through mobile technologies, according to those involved in such work

Kirklees Community Healthcare Services has calculated that its introduction of 600 Panasonic Toughbooks for community healthcare staff will save it between £9m and £10m a year from the third year of the project onwards. It reckons at least £4m of this will come from cashable savings.

The calculations, worked out with the project's provider BT, include just over £3m from saving clinicians travel time, £1.85m from avoiding unnecessary admissions and £1.64m from avoiding unnecessary referrals.

Tina Quinn, clinical and operational lead at Kirklees, told the SmartHealthcare.com Mobile and Wireless Healthcare conference in Birmingham on 24 February 2010 that saving money had not been the priority: "When we originally did the business case, it was around patient safety and patient care." Other benefits include improved productivity and better staff communications.

However, she added that the decision was taken more than a year ago, when there was more money available, and that financial savings have moved up the agenda.

John Wilson, a consultant gastroenterologist at NHS Fife, told the event that use of mobile technology can reduce medical errors, both improving efficiency and producing better outcomes for patients. This could include use of RFID tracking tags for the likes of sponges, to ensure they are not left inside patients during an operation, and for staff, to keep track of who took part in a procedure, something currently done manually. "Perhaps it would need to stretch out as far as golf courses" to track consultants, he joked.

He added that greater use of videoconferencing for telemedicine should be particularly beneficial for conditions that require "pattern recognition" for diagnosis, such as dermatology and rheumatology, with telediagnosis allowing radiology and other screening, such as of bowel samples, to be carried out by specialists at a remote location.

Wilson also thought that patients with chronic conditions including coronary heart disease, diabetes, respiratory conditions and mental health problems could benefit from remote monitoring, reducing the number of emergency admissions.

However, he warned that clinicians could be resistant to changes, and needed to be engaged to make such projects work. "I'd suggest a good place to start is one on one, not in a group," he said. "Start with their problems, not your solutions."

If an enthusiast can be persuaded to adopt the new technology and make it work to his or her advantage, "a combination of peer pressure and envy will do the rest for you," Wilson added.

Scotland sets £100m ceiling on records deal

Thu, 18 Feb 2010 15:55:01 GMT

NHS National Services Scotland (NSS) has said the value of its patient management system deal with Intersystems will not exceed £100m

The organisation recently announced an initial round of contracts worth £44m under the framework agreement. Under these, Intersystems will provide its TrakCare product to five health boards – Ayrshire and Arran, Borders, Grampian, Greater Glasgow and Clyde and Lanarkshire – for use in acute and mental health.

An NSS spokesperson said the agreement is unlikely to reach £100m, as this would involve all health boards using all the modules offered under the deal. "We're not expecting that to happen, although we are hopeful that as many boards as possible will join," he added.

The system was originally procured for health services in both Scotland and Northern Ireland, but the latter's government has since decided not to take up services under the deal.

NSS made public the £100m upper value through a contract award notice in the Official Journal of the European Union on 18 February 2010.

In another award notice on the same date, it said it will pay Innovation Business Vision £90,000 for a content management system, allowing more than 200 site authors to create websites.

No to SCRs: NO2ID's Phil Booth on Summary Care Records

Wed, 17 Feb 2010 09:00:00 GMT

NO2ID, which has played a major role in the campaign against identity cards, also opposes Summary Care Records

Beneath the headlines about the National Programme for IT – billions wasted, systems underperforming or failing to deliver – lies another story, one that will outlast any particular NHS IT system.

It's the push for control: control of your and your children's medical records – and their children's… and theirs.

This is a fundamental shift, and one that cuts to the heart of the patient-doctor relationship. Putting everything into one pot, no matter what protections you attempt to bolt on, makes compromises inevitable – as both Gordon Brown and Alex Salmond have been unfortunate enough to discover. NHS smartcards are being stolen, lost and abused. It was the same with passwords, and will be with any form of access control.

The creation of centralised systems that make sensitive personal information accessible to many, and not just those directly involved in providing care, undermines the confidence patients can have – must have – if they are to disclose things about themselves for their own treatment and well-being, and for the wider public health.

The myth is that the patient is at the heart of these systems; that they are for our convenience or safety, or purely administrative and not to serve Whitehall's explicit goal to 'overcome current barriers to information sharing' or the interests of a powerful medical research lobby.

In reality the vast majority of patients are highly motivated to look out for their own data and, being the person most likely to be affected, are the smart choice if you're trying to 'join systems up' – especially in the sorts of critical situations being used to sell the Summary Care Record. Those with potentially life-threatening conditions or allergies to particular medicines already wear Medicaid bracelets. Pregnant mothers carry their maternity records.

Like many massive, centralised government IT programmes, NPfIT initiatives are presented as if there were no alternatives. And a huge amount of effort is being expended to manufacture consent.

From 2006, NO2ID has helped campaign for patients' rights over the Summary Care Record. To exercise what control they could. Though the vast majority of GPs and the public opposed the uploading of patients' information without explicit consent, Connecting for Health pushed on regardless, uploading the details of anyone who failed to respond to a single letter.

No-one knows how many of the hundreds of thousands of patients whose details have been uploaded actually received or read the mailshot. No-one knows how many simply binned the envelope, thinking it was yet another mass-mailed circular. No-one knows how many who actually read the leaflet, heavily weighted against opting out, were dissuaded from acting when told they would have to confirm their decision in person.

Connecting for Health is using what are effectively inertia selling techniques, making those who might wish to opt out jump through unnecessary hoops. Which is why, with pre-election "purdah" almost upon us, it's multi-million pound inducement to ramp up the mass roll-out of SCR is all the more extraordinary. Surely the Department is not playing politics with patients' records, in the face of Conservative and Liberal Democrat proposals for more localised or decentralised approaches?

Let us hope that this time every mailout will contain the required opt out form, conveniently absent from previous mailings. Failing to include the form may seem trivial, but it will have significantly reduced the numbers taking action. For the only action patients can take on receiving the information is to opt out. Inaction implies consent.

A radical rethink is long overdue. It's not just about IT – it's never just about IT. But whatever systems get built, it is vital that they provide meaningful mechanisms of informed consent and put doctors and patients back in control.

Scotland tenders for NHS HR system

Thu, 11 Feb 2010 10:24:39 GMT

NHS National Services Scotland is seeking an electronic human resources system for the country's health service

In a tender notice in the Official Journal of the European Union the agency says it intends to buy a suite of software applications. Core elements will include recruitment, training administration, attendance management, employee relations processing and medical staffing.

Initially the contract is expected to run for five years, but there is an option to extend for another two. The value is estimated at between £5m and £10m.

The notice, published on 11 February 2010, says that "a range of complex interfaces" is required to cover payroll, time attendance, expenses and a workforce database. It also outlines optional functions, including an occupational health transferable record, performance management and appraisal, "staff bank" management, and e-rostering.

Hosting of the software could be provided by the agency's IT provider, Atos Origin, but the notice gives bidders the scope to propose alternatives.

The chosen supplier will also have to provide support and development services, training and disaster recovery.

The new system will be used by all the health boards in Scotland and by organisations that work with them.

Scotland signs for patient info system

Mon, 01 Feb 2010 15:05:36 GMT

NHS National Services Scotland (NHS NSS) has struck a framework deal with InterSystems for the supply of a patient management system, but NI has opted out

In an initial round of contracts worth £44m, the company will provide its TrakCare product to a consortium of five health boards – Ayrshire and Arran, Borders, Grampian, Greater Glasgow and Clyde and Lanarkshire – to help manage acute and mental healthcare.

With NHS Lothian already using the system, it will now cover healthcare providers serving 70% of Scotland's population. NHS NSS said that other health boards are in discussions over use of the framework contract.

Health secretary Nicola Sturgeon said of the InterSystems deal: "This contract will enable health boards across Scotland to implement a single, nationally available patient management system that will play a major role in improving patient services.

"Clinicians and patients will both be winners from a system which will track patient journeys from referral to discharge. It means clinicians will have easier and quicker access to medical records and patients will benefit from having more time with healthcare professionals," she added.

The tender notice for the integrated patient management system, published in April 2008, put the deal's value at £30m to £120m, and said the agreement would also be open to healthcare providers in Northern Ireland. NSS said that 73 companies expressed an interest in the original tender.

The notice said the system would include "a core patient administration system (including mental health), complex scheduling, clinical notes, order communications, accident and emergency, theatres, mental health clinical, maternity, clinical support tools, neonatal and the management of drugs including prescribing and administration". However, users are able to choose which of these modules they wish to buy, rather than having to take them all.

The deal is one of several national contracts recently placed by NSS on behalf of the Scottish health service, reflecting the country's centralisation of its informatics work. In 2009, it awarded Lumension a deal covering information security and Sun Microsystems a £9.5m contract for an identity and access management system.

The organisation is also in the process of tendering for a national GP systems deal, which may also be used by other primary care providers, worth £10m to £50m.

* Update, 5 February: Northern Ireland has chosen not to take up services under this framework contract, an NSS spokesperson said.

Scotland strains to hit e-referral target

Fri, 04 Dec 2009 15:39:27 GMT

NHS Scotland is increasing its rate of electronic management of outpatient referrals, but needs to do so more quickly to hit its target

The chief executive's annual report for 2008-09 says the service is aiming to ensure that 90% of new GP outpatient referrals to consultant led secondary care are managed electronically by December 2010.

While it does not provide the precise figure for this, it does measure the percentage of referrals through the Scottish Care Information (SCI) Gateway – the national system for integrating primary and secondary care – and estimates that if this reaches 95% then it will achieve the 90% figure for new referrals.

At the end of March 2009 the SCI figure was 80.8%, up from 72.7% a year earlier. While this indicates that the service will fall short of the target, the report states: "NHS boards have local delivery plans in place to continue the current rate of increase until December 2010 to achieve this aspect of the target."

NHS information security: what's going wrong?

Wed, 02 Dec 2009 09:00:00 GMT

Data security in the health service has been heavily criticised, following a number of high profile breaches

Mention security to anyone involved in NHS IT and you're likely to elicit more than a few war stories. While the media has reported a stream of data losses and leaks – ranging from Scotland's patient records incident a year ago through to the revelations in late May when NHS London reported 76 "serious untoward incidents" – it could be argued that the sheer size of the NHS means it will always be a source of such incidents.

But the situation could be getting worse. In June of this year, the Information Commissioner's Office (ICO) warned that the personal data of patients is still being compromised by "shocking" examples of poor security. Assistant commissioner Mick Gorrill gave a damning verdict on the NHS's efforts to improve its data security after a series of high profile breaches in recent years.

Gorrill, who spoke at the North East Fraud Forum's annual conference in Gateshead, said: "We have found that lots of organisations, particularly the NHS, aren't up to scratch with the necessary precautions to secure data."

"There is some shocking evidence of poor security in NHS organisations and we are trying to work with them to ensure that there is change," he added.

Citing a recent example of a hospital which left old computers holding data from 2,500 medical records out in the street to be accidentally removed by local refuse collectors, Gorrill painted a bleak picture of IT security understanding within the NHS.

In another recent incident, he said that an NHS representative donated a handbag to a charity shop, unaware that it contained a USB stick used to store patient information.

Has the situation changed? It doesn't look like it because, as reported by Smarthealthcare.com last month, the ICO chastised the NHS over the fact that its operations were responsible for 30% of the security breaches reported to it in the last two years.

Securing the country

The NHS is formed of hundreds of organisations. Clive Peacock, who leads the IT security team for Manchester-based Salford Software and works with more than 40 trusts, says some do a very good job – especially those in rural areas such as in Devon and Cornwall.

"In the city there's a lot more competition for IT staff, so it's natural that, as a major employer nationally, the NHS will attract a higher calibre of staff in more rural areas of the UK," he says.

Other trusts have improved their security through a strong use of identity and access management systems, Peacock adds. "The South London and Maudsley NHS Foundation Trust, for example, now has the capability to provision users on its access management system across the board within 24 hours of its IT services staff being notified about a new member of staff," he said. "This shows what can be done with the right levels of integration between human resources and IT services."

But this can lead to problems when the HR database isn't up to scratch. "We've come across instances where the names, dates of birth and even national insurance numbers do not match up with the ones that employees actually have," he says.

Another potential problem for NHS trusts is the red tape involved in selling them IT security, according to Steve Howes, chief executive of Huntingdon-based company Gridsure, which has developed a pictorial authentication system that can replace passwords and PINs.

Howes says the tendering process usually results in the cheapest option being selected, which may not be the best: "This makes the task of selling IT security into the NHS a lot more expensive than it could be. This undoubtedly puts a lot of vendors off, especially when they invest time and money into the selling process and then fail to secure the contract."

"On the authentication front, it may be easier to look at using mobile phones as devices, as this removes the cost of single sign-on devices from the IT equation," Howes argues, adding that that using a mobile phone for authentication would cut the likelihood of staff sharing passwords and authentication devices.

However, software-based security is always going to be cheaper to implement than hardware, which means Howes' firm is unlikely to make sales to trusts that always go for the cheapest product.

As long as the NHS, whether across a country or in individual trusts, goes for the lowest-cost IT security, there is a danger of data breaches continuing.

But the price issue is something that NHS managers and their suppliers will have to live with for some time to come, owing to the parlous state of the UK's public sector finances.

England: big enough to fail

SA Mathieson — Wed, 25 Nov 2009 09:00:00 GMT

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

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."

SA Mathieson

Scotland prescribes e-counts for health board elections

Wed, 18 Nov 2009 09:00:00 GMT

Electronic counting, which was associated with major problems in Scotland's 2007 parliamentary elections, will be used for its first health board votes

Correction

The article below states that electronic counting was to blame for the large number of rejected ballots. In a review of this election (link), the Electoral Commission recorded several technical problems with the electronic counting system. However, it concluded that legislative delays leading to poor ballot paper design were the main cause of problems, adding that it had "not found any evidence that the electronic count contributed to the number of rejected ballot papers".
___________________________________________________________

May 2007 saw Scotland electing its first Scottish Nationalist Party (SNP) government, but the manner in which that minority administration came to power generated almost as big a story. The election saw some 140,000 votes – about 7% of those cast – going uncounted.

The cause was electronic counting scanners which were meant automatically to count ballot papers and the votes on them. As the number of unprocessed suggests, this did not go to plan. But despite the 2007 experience the technique is about to be used once more, this time in direct elections to health boards in Scotland.

Health board elections were an SNP manifesto pledge, framed in response to controversial plans – later reversed – to close two accident and emergency units in Scottish hospitals.

Direct elections will be piloted in two health board areas, Fife and Dumfries & Galloway, early next year, before nationwide use is considered. Although the relevant bill passed through the Scottish Parliament with Labour support, healthcare professionals have not universally embraced the plan. Nevertheless, Scottish returning officers have already begun the procurement process for an electronic vote, or 'e-counting', system.

The Electoral Commission is acutely aware of the task at hand. Andy O'Neill, its head in Scotland, said: "With electronic counting, it is important that those using it are trained in the processes, and that there is effective on-site technical support to address any problems that may arise. It is also essential to have an external audit mechanism in place, in case the results are queried."

In 2007 a successful joint bid by DRS Data Services and Electoral Reform Services (ERS) ran the show. DRS, which had substantial experience of running e-counts since the 2000 Greater London Authority (GLA) election, acted as the lead system supplier, while ERS, which runs votes for trade unions and political parties, provided the module to perform complex calculations for the Scottish local government vote, which was conducted for the first time under the Single Transferable Vote (STV) system of proportional representation.

The package used this time round, also for elections conducted under STV, is unlikely to be much different, despite the teething troubles of more than two years ago. Ken Ritchie, chief executive of the Electoral Reform Society, says that the DRS/ERS package was essentially sound but suffered from a "capacity problem" in terms of the number of papers that required adjudication.

When it comes to next year's health board pilot elections, however, he is cautious for a different reason. "These health boards have a small electorate and will perhaps have an even smaller turnout," he says. "I would have thought it would have been easier just to do the counts by hand."

From e-counts to e-votes

That is not, however, the inclination of the Scottish Government, which appears content to follow the guidance of both the Electoral Commission and the Arbuthnott Commission that electronic counting should become the norm as soon as possible before 2011 – and that electronic voting should eventually follow.

Health secretary Nicola Sturgeon is a particular enthusiast, and claims that direct elections are "essential" in order to improve the public accountability of the NHS. Under her scheme, each health board would see local authority councillors and elected public members form a majority on boards, with anyone aged 16 and over eligible to vote. But importantly, opposition parties only backed the pilots on the basis that they would be properly evaluated before being rolled out across the country.

The British Medical Association in Scotland, however, warned money could be wasted and health boards could become politicised, while five of Scotland's 14 health authorities opposed direct health board elections outright. On the other hand Unison Scotland, the union that represents health workers and IT staff, was among the most vociferous supporters of increased accountability.

Dave Watson, Unison's Scottish organiser for policy, said: "The NHS board election pilots in Fife and Dumfries & Galloway are welcome steps on the road to a more accountable and responsive NHS in Scotland. That should mean that boards are more receptive to the needs of patients and staff." And far from being concerned about the potential impact of elected members for those working in informatics and IT on Scottish health boards, Unison sees little or no trouble in store.

The proof, of course, will be in the electoral pudding. Perhaps it will take the smooth running of next year's pilot elections to restore political faith in the e-counting process, while the Scottish Government will be hoping that more democratic health board management will restore public faith in NHS accountability.

Scotland adds resuscitation wishes to care record

Tue, 10 Nov 2009 11:08:19 GMT

National Services Scotland is adding patients' wishes on whether they should be allowed to die to its Emergency Care Summary system

It is piloting palliative care summaries, developed from those used by Macmillan cancer nurses, in the Lothian and Grampian health board areas.

These will include a clause, which is optional for the patient to use, that says whether the patient wishes to be kept alive in various extreme medical circumstances.

NSS is explaining the plan to GPs and has prepared leaflets for patients. The system is technically available across Scotland, but its usage will be rolled out over the next few months.

Dr Libby Morris, chair of the Emergency Care Summary board, said that NSS expects about 20 participants each year for each average 5,000 patient GP practice. The records will be added only with patients' explicit consent, and can include their wishes on the circumstances in which they would or would not want to be resuscitated.

"In my own practice, I feel one of the limits is calling it a palliative care summary," she told an audience at the e-Health Insider conference in Birmingham on 9 November 2009. "They then say, I didn't think it was that bad." An alternative name may be a special summary, she added.

Morris said that Scotland now has 5.4m ECS records, more than its 5.2m population as it retains records for two years after death. The system, which draws data from GP systems twice a day, is shunned by just 1,400 patients, 0.02% of the population.

NHS staff ask patients for permission to access the record on every occasion, unless the patient is unconscious or otherwise incapable. "It's just a matter of politeness and good manners," she said. Patients agree their records can be accessed in 99.3% of requests.

Morris said that the information security breach of paper records in Fife last year had actually boosted the use of ECS, rather than causing patients to opt out. It caused a GP practice that thought it was participating but had accidentally switched off its connection to realise this, and reconnect as a result.

ECS is available to out of hours providers, operators of Scotland's NHS24 health helpline and staff at accident and emergency wards. The Scottish Ambulance Service is piloting ECS access in the Lothian health board area, and access for planned hospital admissions is under consideration: Morris said that at present A&E often gets better data on patients than wards for scheduled care, as referrals from doctors may have been written several months ago.

She said that the system might eventually develop into a central record of all medications, but it currently holds acute prescriptions from the last 30 days and repeat prescriptions from the last year.

Morris said the system has proven its worth through cases such as a 62 year-old woman who was admitted to hospital and had not mentioned she needed insulin – as she was hooked up to a drip, she assumed staff already knew. It also helped a 17 year-old who was taken to A&E unconscious after an overdose. His ECS showed he was not on any medication, but his father who brought him in gave permission for access to his own record – which showed the drug in question.