Of the NHS's many 'reforms', the setting up of primary care groups has to rank high among the most chaotic. The minimal piloting and lack of specific guidance means that many PCGs are afraid to press ahead with setting up basic management processes - with none more uncertain than the information technology they will need.
The first IT guidance for PCGs did not appear until mid-March, two weeks before PCGs were officially launched.1 Essentially, it said: 'Install as little IT as possible until we have a clearer idea how your organisations will work.'
And yet only six months earlier, the new NHS IT strategy had instructed health authorities' local user groups to produce costed proposals for new systems 'to support both the HA and PCGs in their commissioning role as these develop over the next five years'.2
It is far from clear how PCGs are to manage the data they need to back up this role. It may come from a variety of sources, including trusts, HAs, GP records and fundholding systems. But PCGs do not yet know how easy it will be to get hold of data from each of these sources, how accurate it will be, and how to pull it together.
The NHS Executive says it will not produce any specifications for PCG systems. Even if it knew how to it would not: it is up to PCGs themselves.
Yet at the same time PCGs have the year 2000 bug to worry about - and the target of connecting all GPs to NHSnet by the end of the year. The recent NHSnet guidance, issued in April, with a deadline of 14 May to submit costed plans to region, produced a flurry of activity both locally and nationally.3 It has thrown into sharp relief the tensions between medium-term strategy (the local groups set up to implement Information for Health) and the immediate PCG implementation plans. Many PCG board members agree that obtaining activity and cost data for commissioning, implementing office systems (perhaps with an intranet), and improving data collection from primary care are at least as high a priority as getting GPs on NHSnet. But they are floundering in the recent deluge of circulars.
'There is a definite risk that the focus on the NHSnet target will upset the balance of priorities for IT development in PCGs,' says one GP closely involved in the guidance. 'On the ground we're struggling to implement anything at all, since developing the local implementation strategy was a major distraction for the IM&T people at the health authority. Plenty of PCG chief executives do not yet have a computer, let alone a PCG system.'
Generic software tools like Excel could well see PCGs through until the water is clearer, according to Mike Sowerby, head of primary care computing at the NHS Executive's general medical services branch. 'Some suppliers are already offering so-called integrated PCG solutions, but we believe that in many cases these are the wrong systems. Anyone who signs up for them today may find that in a year they have to discard them as not fit- for-purpose. I'm not saying don't buy anything - just consider very carefully before you do.'
One encouraging point is that some HAs and trusts have been much more open about their data sources since the PCGs went live. PCGs are beginning to get some big spreadsheet files to play with. For example, Ealing, Hounslow and Hammersmith HA is providing analyses based on secondary care data sets to its PCGs to give them an idea about what is available and how it can be used. Already some intriguing patterns are emerging, say Excel aficionados.
Currently, it is mostly finance data that is made available, and it seems to be reasonably accurate, they say. Eventually, this sort of data should be distributed wholesale by the NHS-wide clearing service, but in the short-term it is providing some useful baseline information to work with. Experimenting with the spreadsheets could help PCGs to define exactly what they need to get from trust systems, how this can be verified, and how it should be fed back to GPs.
More than 20 HAs and PCGs have recently participated in a pilot to analyse data from GP computer systems, using the MIQUEST reporting tools and techniques developed by the NHS Executive Collection of Health Data from General Practice (CHDGP) project. 'The opportunities for PCG use are enormous,' says Jan Hoogewerf of First Consulting Group, which led the national evaluation of the pilot project. They include improving data quality, clinical audit (for example, of prescribing) and setting up chronic disease registers. One or two places, such as Calderdale and Kirklees, are also starting to use the data to support health needs assessment within PCGs. Some areas, including east London, Somerset and Birmingham, are planning to appoint informatics staff to PCG or multi-PCG level to help practices within the PCGs take this agenda forward.
What to do is one headache, but there is also much disaffection over the funding being provided to do it.
Mike Sowerby believes that, over the next two years, the average PCG should expect to spend up to£30,000 on new systems specific to its role - for example, every GP system must be included in a PCG-wide local area network. It may need to set up servers that 'mirror' the HA database. It will involve providing office kit for PCG staff and, possibly, their NHSnet connection, although according to the guidance, this is supposed to be funded separately (see below). At the same time they need to upgrade GP systems to make them comply with the latest accreditations (RFA4+), plus year 2000 compliance, standardised data collection (MIQUEST) and prescribing decision support (PRODIGY).To cover this, the NHS Executive is handing out£20m from the modernisation fund; at least£20,000 to each PCG. But because there has been an enormous range in the amount committed by HAs to IT spending over the past two financial years, those HAs which have spent less than average on GP systems in the past two years will get up to£20,000 extra per PCG, to help them catch up. The variation is huge: 17 HAs received the minimum of£20,000 per PCG, while the biggest winner, Bexley and Greenwich HA, collected an extra£83,000. Even so, the NHS PCG Alliance is complaining that the amount of 'catch-up' funding is not enough to target money towards the historically disadvantaged areas with many non-fundholding practices.
Yet other GPs claim that money previously spent by HAs on GP computing gives no advantages to PCGs, whose IT requirements are quite different, making 'catch-up' an inappropriate method of sharing out the funds.
The next round of guidance on the local implementation strategies and PCGs (and primary care trusts) is expected to be much more closely co- ordinated. 'Information systems are beginning to move up the agenda, but there is still a long way to go,' says Ian Trimble, the GP who wrote the national IT guidance for PCGs. There is not much time to waste: established PCGs need to draft primary care investment plans - including IM&T investments over the next three years - by September.
But can PCG systems development be achieved while the GPnet project - connecting GPs to NHSnet and providing pathology links - has to be completed nationally within 1999? According to Jan Hoogewerf, given the timescales and the limited funding, many practices are likely to end up with a standalone 'PC in the corner' - probably with Internet SMTP e-mail rather than the X.400 preferred by NHSnet, plus the promise of something more exciting when funds are available.
'The ability to do more than this seems to be related primarily to the amount of funding allocated per practice, together with the current infrastructure available within the practice,' she says.
Each practice will have an ISDN/router connection to the NHS bought via the framework contracts with BT or Cable and Wireless. Other proposed solutions will have to be cleared by regional NHS Executive offices, says HSC 1999/094.
All practices must have multiple e-mail accounts and web browsing installed on at least one desktop - ready for the launch of the first National Electronic Library of Health sources in autumn. This is optimistic. 'To deliver e- mail to the GP's desktop, you need local area networks, which most practices still do not have,' says Ms Hoogewerf. But the central funding is not intended to provide this internal infrastructure, so, for many practices 'box in the corner' is the only option.
Extending pathology links and migrating away from the established Racal Healthlink will simply have to wait, though HSC 1999/094 says all GPs should be off Healthlink by March 2001 at the latest, when Racal is scheduled to pull the plug.
1 Working Paper - IM&T Requirements to support PCGs. NHS Executive, March 1999.
2 Information for Health. NHS Executive, September 1998.
3 Connecting General Practices to NHSnet. Health Service Circular 1999/094, 13 April, 1999.