In the face of high-profile hospital closure disputes, the government has firmly positioned itself behind health services at a local level.But can current technology deliver this vision of integrated care? Sally Whittle reports

Last month, the Department of Health issued a report stressing the value of small, local hospitals to the healthcare system.However, the vision of highly automated, technology-assisted care set out in Keeping the NHS Local could cost billions - and many of the technologies touted are yet to be proven in large-scale deployments.

Releasing the report, health secretary Alan Milburn said new ways of working, coupled with the intelligent use of IT, would enable smaller hospitals to lock into a network of health and social care.

For example, he suggested smaller hospitals could specialise in instant access, day surgery and intermediate care, while using telemedicine and internet technologies to collaborate with acute care units at larger hospitals.

'Patients want more, not fewer local services, ' Mr Milburn said. 'Changing local health services does not necessarily mean centralising services, with fewer, larger super hospitals.'

Keeping the NHS Local follows a series of highprofile disputes over hospital closures. From the present government's point of view, these culminated in the 2001 general election victory of Dr Richard Taylor in Wyre Forest.He claimed a safe Labour seat, protesting against the downgrading of Kidderminster's local hospital.

There is, therefore, a clear political imperative behind the report's message that local hospitals will now be at the heart of the NHS.However, Keeping the NHS Local argues that the NHS faces new healthcare challenges from an ageing population, and unless current trends in obesity are reversed, one with more chronic disease.

At the same time, it argues that the public is taking an increasing interest in health as a consumer issue.

This is being driven by the internet - which is also changing ways of working among clinicians.

Realms of fantasy?

In order to meet the needs of the 21st century patient, the report argues, the government must offer increasingly integrated care. This will give patients access to a far wider range of services than can be provided by a single, struggling hospital.

What does this mean in practice? The report gives the example of Mohammed, a patient who injures his leg in a fall.Mohammed is taken to a local accident treatment centre where a nurse practitioner calls up his electronic patient record to check his history. Finding no previous injuries, an x-ray is taken which shows surgery is necessary.

The nurse practitioner sends the x-ray to the nearest acute trust via a digital imaging link, where the orthopaedic registrar confirms the nurse's diagnosis. The registrar sends the nurse an electronic admission request, and orders transport to take Mohammed from the ATC to the trust.

On arrival, Mohammed is admitted and his EPR updated with all subsequent treatment and observations. The trust registrar uses a handheld computer to access the patient records, and sees that surgery is required.He uses the computer to book a theatre slot for the next morning.While waiting for surgery, the ward staff prescribe Mohammed pain relief using the trust's electronic prescribing system, which ensures the right dosage.

The following morning, consultants review the procedure with Mohammed, using a remote translation software package. Following the operation, the ward administrator puts together an electronic discharge summary with advice for follow-up care using the information that has been stored on the EHR system during Mohammed's stay. It is e-mailed to his GP. Before Mohammed leaves, an outpatient appointment is booked for the following Monday and transport home is arranged.

The Department of Health acknowledges that this is 'futuristic' but believes Mohammed's experience is not in the realms of fantasy.Many technologies used in this scenario (virtual private networks, wireless computing, EPRs, digital imaging) are already being used and tested in the UK and beyond.

For example, the Kaiser Permanente hospital in California uses technology to ensure its most expensive resource - hospital beds - is used efficiently, by monitoring admissions, reducing the length of stay, creating disease management programmes and opening doctors' offices out-ofhours to reduce pressure on accident and emergency departments. The hospital relies on good IT to maintain this system - EPRs, comprehensive and convenient primary care facilities, ambulatory surgery centres and better use ofscarce clinicians, nurses and other staff.

At Brunel University, the health systems department has conducted extensive research into the use of electronic records and other web-based technologies in the NHS.

It argues that investing in any of these technologies without significant research could be a disaster. The Research into Information and Gritty Healthcare Techniques project will bring together a consortium of academic and industry specialists to examine how information and communication technology can be applied to the caredelivery culture.

'Many of the concepts being explored for healthcare have terrific potential but run the risk of being applied simplistically or of failing to be properly connected up, ' says chair Professor Terry Young. 'The danger is that many sound ideas will be swept away without ever having been systematically verified.'

The key concept underlying Keeping the NHS Local is the idea that, while in the past patients had to travel to doctors (or doctors occasionally had to travel to patients), information can now be moved around the system instead. In the long term, it suggests patients in their own homes may communicate directly with clinicians in remote centres. In the short term, doctors based in a large unit can support practitioners in a smaller one.

In a recent major study in Finland, for example, patients in a remote rural area were able to avoid a long trip to hospital through a teleconsultation application, whereby GPs transmitted data to specialists through a secure web-based system.

Remote case conferences were shown to be as effective as face-to-face sessions.

Rapid reform In the UK, telemedicine, digital transmission of x-rays, scanned images of biopsies and other material is well established, allowing remote diagnosis and specialist support to on-site clinicians.

The recent NHS digital TV pilot, meanwhile, explored the potential for services including online appointment booking, call-back services and TVbased appointments with NHS Direct nurses.

Many healthcare professionals welcomed the publication of the report. 'The document provides a vision of rapid reform and modernisation, ' says Royal College of Physicians president Professor Carol Black.However, she adds that the view of technology espoused in the report might be seen as 'optimistic'.

NHS Confederation chief executive Gill Morgan has also welcomed the document. 'We think it avoids trying to set out a single masterplan, and we are particularly pleased that the guidance will allow health communities the scope to work with local people and create appropriate solutions, ' she says.

Through the Future Healthcare Network - an alliance of more than 50 healthcare trusts - the confederation has worked closely with the government on the new framework, and will be heavily involved in its future development.This will be critical in addressing the major challenges of testing and deploying new IT solutions, which need to be addressed quickly, Ms Morgan believes. l One of the best-known telemedicine projects in England, cited as a model for the future in the Keeping the NHS Local report, is the electronic record development and implementation programme demonstrator in Cornwall.

This pan-community electronic health project is based on the development of an integrated community health record, linking community and acute care.The pilot has delivered a range of clinical systems and tested key concepts in implementing electronic records.

'Cornwall set out to continue the development of an electronic health record to support healthcare across Cornwall and the Isles of Scilly, 'explains ERDIP account manager David Freer.

A major first step towards this goal was a 24-hour emergency care record, providing health professionals with instant access to patient information. Implemented in early 2002, it will eventually be extended to all health professionals in Cornwall.

Work on the 24-hour record has focused on the integration of GP practice systems and the local out-of-hours service provider Kernowdoc.A series of condition-specific care modules has also been developed for mental health, coronary heart disease, diabetic care and mental health, to demonstrate the value of the core clinical record to support integrated services.

Other Cornwall-wide systems delivered by the ERDIP project include a single population index, common integration architecture designed to speed implementations and a telemedicine network.

Telemedicine has been introduced for dermatology in GP practices and in minor injuries units, where it facilitates a nurse-led service with links to a remote doctor.