With 42 different applications and no national directory, e-mail use in the NHS has become unwieldy and frustrating. Jane Dudman reports on efforts to pull the system together here are two things that make email work properly: the right technical infrastructure and the ability to do useful things, once hooked up. This is a lesson the business world appears to have taken on board so successfully that e-mail is now taken for granted. In the health service, development has been slower.

Only recently has the NHS Information Authority put in the necessary capital investment to develop a centralised, national e-mail system. In March, the organisation put forward its 'holistic' view of developing a national IT infrastructure, but only last month was the business case published to support the first two services to be developed under it:

e-mail and directory services.

The NHS already has a national messaging service, run by Syntegra, but every organisation runs its own e-mail system. This means there are 42 different applications in use, using a mix of underlying messaging technologies and 5,500 different message transfer agents (these are the servers that manage the transfer of e-mail messages across different networks).

'It is a bit messy, ' acknowledges Carrie Armitage, head of delivery, access to information at the NHSIA. 'The legacy of this is that some of the systems are very un-user friendly and many people in the health service find e-mail very frustrating, because the core service just is not very good. Some organisations do have very slick e-mail systems, but many others are struggling.'

In its outline business case for a national e-mail strategy, the NHSIA says use of e-mail within the health service is continuing to rise beyond expectations and the trend will continue with the further implementation of the Information for Health IT strategy.

There are about 250,000 e-mail users in the health service, but the target is to make e-mail available to all NHS staff by the end of 2003. That would push up the numbers to a potential 1 million users.

'Though these represent centrally mandated targets, the experience to date with the take-up of e-mail is that the business drivers outstrip targets, and that these will prove to be conservative estimates, ' says the NHSIA.

The range of different e-mail systems now in use is clearly inefficient and difficult to use, particularly since there is no national directory of staff. The present messaging system is based on the X.400 communications protocol, which has been almost universally superseded by a newer messaging system called SMTP (simple message transfer protocol).

'The service has a very poor reputation within the NHS and contains anomalies such as organisationdependent e-mail addressing, ' says the NHSIA.

This means that as staff move from NHS job to NHS job, they have to switch e-mail addresses. It is an inefficient way to run things, particularly when commercial e-mail companies like Freeserve can provide their system to more than 2 million users from a single mail server farm. Commercial e-mail systems also provide useful facilities such as web access to mail and integration with tools such as virus checkers and other software.

At the same time, the way e-mail is used within the health service is starting to change. As more clinicians are connected, they will start to communicate clinical details over e-mail. So a secure service is needed. By centralising onto a nationalised, secure system, health service e-mail will become more efficient.

The addition of a central directory of NHS staff should make it much easier to track e-mail addresses and provide high levels of security within the system, based on a public key infrastructure. A simple address book service is already provided by Syntegra, but the proposed central directory would hold far more information as part of the new HR and payroll system.

Around 97 per cent of GPs already have e-mail, through the Project Connect programme, and the aim is to get all clinical staff connected by March 2002. After that comes the potentially more difficult task of rolling out e-mails to all administrative and community-based staff around the health service.

'It is not just about rolling out the connections, because people have to be able to do things with it once they have it, such as GP referrals and discharges, ' says Ms Armitage.

The business case for the new e-mail and directory systems was approved at the beginning of September and will now go out to tender. This doesn't give the NHSIA long to procure a system and get it up and running, particularly given the technical requirements, such as web-based access to mail. 'It will be tough to get it in by the end of the financial year, ' acknowledges Ms Armitage.

But it is not just implementing the system that will be tough; once in place, the real challenge will be maintaining and constantly updating the directory.

In future, that should mean staff being able to hang onto a single e-mail address as they move around the health service, rather than having to re-register with each new position. This has major implications in terms of both running a core e-mail system, and also for the national HR and payroll system.

There is real eagerness for an efficient service (see box). Graham Spearing, e-mail project manager at Trent regional office, welcomes the latest moves. It recently called in Esteem Systems to carry out a three-month audit of all its e-mail services, mainly from a technical viewpoint, but also looking at some of the cultural issues involved.

Like many other large health service organisations, Trent has accumulated a range of systems over the years. There are 8,300 registered e-mail addresses within the Trent region - a number that is expected to rise sharply.

'The main technical issues are whether organisations have a robust enough connection to NHSnet, whether they have enough band width, where they store their back-ups, whether they have resilient servers and so on, 'Mr Spearing says.

The aim is to establish what work needs to be done to improve these services as services scale up to a growing number of staff. But, says Mr Spearing, 'It is basic stuff; it is not rocket science.'

Mr Spearing believes the task of improving existing e-mail services will be helped by the move towards a centralised national e-mail system, based on standard industry software, and he welcomes the extra capital expenditure on software and hardware to underpin the new system.

Beyond that, though, there are cultural and organisational issues. 'The question post-March is whether these systems will be used. If we have the infrastructure, the real agenda is not the technical stuff but building e-mail into the information culture, ' says Mr Spearing.

On the whole, despite some frustration that change has not taken place more quickly, the move towards a national e-mail service is being welcomed.As Mark Knight, IMT project and development manager at North Manchester Health Care trust, points out:

'The bits of the jigsaw are being put together.'

Setting up a standardised e-mail service North Manchester Health Care trust won an award earlier this year for effective use of e-mail.But Mark Knight, IMT project and development manager, says it can be frustrating for users and administrators alike to have to make do with what he describes as 'halfway solutions'.

The trust already has more than 1,000 live e-mail accounts and the final target is about 1,500.It runs Microsoft Exchange software, and one of the reasons for the trust's success, says Mr Knight, is that it is standardised, so every PC runs the same software.

The trust tackled that issue by starting at the top - providing first its executive board and then about 100 senior managers with e-mail, before moving quickly down the clinical line.

'Training and culture are important because a lot of this is about how to use e-mail, and that may mean changing work processes, 'Mr Knight says.

Having got staff used to the basics of e-mail, the trust then moved on to putting standard work forms on the system, so it now has almost an internal order communication system, enabling junior doctors, for instance, to carry out internal referrals by e-mail.

This is just an interim point for the trust, though, as it moves towards implementing its full electronic patient record system next year.

Mr Knight welcomes both the national e-mail system and, in particular, the centralised directory system.'We run a tight ship internally, but one of our biggest problems is when staff need to exchange information externally, 'he says.

'The existing address book service is not a complete picture and the national address service will be a great deal better.'

Similarly welcome is the idea of secure, encrypted e-mail which will enable, for instance, consultants to provide discharge letters and other clinical information to GPs.