Come together

e-patient

Although people are getting used to banking or booking airline tickets online, the prospect of picking up hospital test results or booking GP appointments over the web is still several years away.

But if the NHS has been slow to embrace technology, patients have not. 'We are seeing a revolution in the behaviour of the man and woman in the street, ' says Mr Bywater.

'We all say we love our NHS, but when you look at what people do, it is clear we want something completely different. Not just a more responsive service, but one that delivers the sort of quality we get in other areas of our lives. '

Doctors are bearing the brunt of this. The informed patient who walks into the surgery with 'a sheaf of pages off the Internet' has become a staple figure in conference speeches and radio interviews.

This worries clinicians. It also worries ministers, who are trying to spread the idea of using the 'NHS brand' as a seal of quality.

A pilot national electronic library for health (NELH) went live in November as part of this bid to steer patients towards 'accredited' information. NHS Direct Online is being promoted in the same way.

But by far the most significant e-health service so far is the telephone version of NHS Direct.

Launched in March 1998, the service has taken more than 4 million calls.

National project manager Paul Jenkins claims it is the world's leading telephone healthcare service, but it could just be getting started.

Plans are underway to link up NHS Direct's 22 call centres, all of which now use common support software. This would allow calls from Cornwall to be dealt with in Birmingham - or anywhere else - at times of peak demand. But Mr Jenkins told a recent NHS Information Authority conference that NHS Direct was looking at everything from using its databases to spot trends to providing support for the chronically sick.

Although Mr Jenkins denied it, some commentators believe NHS Direct may even be the natural repository of the government's much-vaunted electronic health records (see e-professional).

But NHS Direct is also likely to further fuel consumer demands for much more user-friendly, responsive health services. It is about to launch a major digital TV pilot, 'Nurse in the Home', in 50,000 homes in Birmingham.

This will allow members of the public to dial into NHS Direct Online through a digital TV, and interact with a nurse they can see on screen.

Having glimpsed the service of the future, the public may be far less tolerant of a service based around 1940s technology.

Building the Information Core promises that people will be able to use the Internet to book appointments, view their electronic health record, and have access to e-prescribing and e-pharmacy services by 2005.

Yet as Carrie Armitage, head of access services at the information authority, admits, the service has spent years struggling to get GPs online. That makes providing access to 55 million patients a daunting challenge.

We all have 'a right' to expect high-quality services, says Ms Armitage. 'We have to push the health service that one step further, people want to access it in different ways. If we do not provide these services others will. '

e-professional

While most clinicians use the Internet at home for research, relatively few use it as a tool during the course of their work. This is because they usually work in a variety of locations and rarely have 'desktop' access to information services or e-mail.

Although it has finally gathered momentum, the rollout of NHSnet has been repeatedly delayed, dogged by GPs' concerns about security, service charges and reliability.

The latest target is to connect all computerised practices by March 2002 - two years later than originally planned.

More attention is now being paid to the secondary sector.

Building the Information Core says all trust clinical staff should have 'desktop' access to information services and e-mail by March 2002, and all trust staff should have these basic tools by 2003.

Once connected, the goal is to provide all healthcare professionals with routine access to standardised clinical decision-support systems (CDSS), based on national evidence-based protocols and treatment guidelines.

Such a clinical decision-support system, using standardised algorithms to triage callers, underpins NHS Direct Online.

Last September, a controversial£68m national contract was awarded to private health insurer AXA Assist to provide a common system to all 22 NHS Direct sites.

The same system is to be used in the 36 NHS walk-in centre pilots and increasingly for out-ofhours services.

Peter Dyke, head of marketing for BT Health, describes NHS Direct as the first 'structured IT environment in the NHS' and predicts the concepts of a managed gateway and CDSS will be extended. 'NHS Direct has a lot more potency than a lot of people will admit. '

'We are moving from one-on-one to team medicine, ' says Silicon Bridge's Murray Bywater.

But Dr Paul Cundy, the British Medical Association's GP IT lead, worries that it is a short step from clinical decision-support systems to 'clinician decision-monitoring systems' that require every doctor to justify every minute variation from a national treatment protocol.

There is also concern about the trend towards buying national systems indicated by Building the Information Core and promoted by ministers.

Moves are underway to develop national systems for appointment bookings, 'shared services' for payroll and human resources and possibly for finance and e-commerce as well.

Some industry insiders, like Mr Dyke, predict the government will eventually procure a single system for electronic records. But NHS history suggests IT only works when local users are involved in buying IT systems.

Ellen Pirie, head of healthcare for Microsoft, sees cause for optimism in a shift in staff attitudes.

Where staff used to see IT as a 'distraction' from patient care, they are now starting to see it as something that can deliver better patient care by getting everybody working together, she says.

But major and sustained investments in training will be vital.

e- business

The NHS's back-office systems lack glamour - but ensure that wages are paid, goods ordered and other key services delivered.

Automating and linking together these labyrinthine systems offers huge potential performance improvements.

But the NHS has barely begun. 'I think the NHS has still to get into the basic idea of supply-chain optimisation used in industry, ' says Ellen Pirie, head of healthcare for Microsoft.

The area of greatest potential cost savings is e-commerce. Eric Jackson, NHS Purchasing and Supply Agency head of e-commerce, says: 'We think there are potentially savings of 20 per cent of the NHS's£6bn non-pay spend. ' The agency plans a single integrated finance and e-commerce system for the entire NHS by 2002.

Crucially, the updated IT strategy stresses that the electronic delivery of services must be understood 'as a business, not a technological issue'. The objective is to integrate information across the various parts of health and social care to achieve a single or 'whole' system designed around the individual. But the strategy acknowledges that building a 'networked NHS' entails a major behavioural and cultural challenge.

'Healthcare is the ultimate service industry, and service industries are the ones most reliant on information, ' says Ms Pirie.

'We are only just beginning to see what benefits good information can provide in the NHS. '

Much can be done over the next few years, and web-based technologies provide a range of powerful tools for giving NHS staff and the public easy access to valuable information. But it is only once the routine use of electronic patient records has become a reality that the NHS will be on the way to becoming a genuine ehealth service. EPR remains a huge challenge few trusts have yet delivered on.

Mr Bywater says to achieve EPR 'you first need to have a hospitalwide order communications system, with staff doing everything through their computer'.

No more than 50 hospitals yet have such systems, he believes. Ehealth, then, is a revolution the NHS has only just begun.

'This is not a one-off challenge, ' says Carrie Armitage, head of access services at the NHS Information Authority. 'This is as important as your supply of doctors and nurses. '