Published: 17/03/2005, Volume II5, No. 5947 Page 8 9 10
England's national IT programme may have monopolised attention, but Scotland, Wales and Northern Ireland have all been developing their own systems. Steve Mathieson looks at the different approaches being taken
The UK's four national health services are all pursuing major IT programmes. England, of course, has the national programme for IT, worth£6.2bn, which grabs most attention. Scotland has its£357m national e-health/information management and technology strategy, updated last April.
Northern Ireland's equivalent is called the health and personal social services information and communications technology strategy, and Wales has Informing Healthcare.
As one might expect, all four countries have plans for electronic patient records (called the integrated care record in Scotland, the single record in Wales and the electronic care record in Northern Ireland) and for the improved computer networks these will need.
But some divergence is appearing.
Northern Ireland, whose 1.7 million population is equivalent to that of the average English strategic health authority, is taking a relatively centralised approach (see box, opposite). This is less the case in Scotland and Wales, where some health IT projects are being run on collaborative and voluntary lines.
This approach is open to criticism, when compared with England's ruthless standardisation.
In December, former Microsoft director for Scotland Gordon McKenzie told the Scotland on Sunday newspaper that the country's inefficient health IT buying meant it was paying up to four times as much per capita as England.
'NHS Scotland is still operating in a piecemeal way, ' he said, with each region having its own separate email system, and some having more than one. 'To deliver the next generation of healthcare it will need technology not yet funded or designed. They still have to do some things that England did three years ago, ' he said.
The Scottish Executive denied Mr McKenzie's claims. 'Our policy is not decentralisation, ' it says in a statement. 'As part of NHS Scotland's modernisation agenda, the Best Procurement Implementation programme was launched in autumn 2003 to procure nationally. There is an initiative in this programme that will look at the introduction of national e-procurement by all NHS and special health boards.' It says that Scotland has completed national procurements for accident and emergency systems and is buying picture archiving and communication systems, as well as national networks and e-mail systems for the whole of NHS Scotland, which will be mandatory: 'Our Best Procurement Implementation programme is expected to achieve savings for the NHS in Scotland of at least£50m per year by the end of 2006-07.'
Despite these examples of centralised buying, Dundee University professor of general practice Professor Frank Sullivan says Scotland still has 'a more communitarian approach' compared with England. For example, the government gives its General Practice Administration System Scotland (GPASS) software free to GPs, but does not insist on usage, and around a fifth pay for a commercial equivalent.
'[GPASS] always had poor functionality compared to commercial software, ' says Professor Sullivan, as it has often taken a couple of years for new functionality to appear, far slower than in paid-for software. But unlike England's national programme, Scotland's health service is not insisting that GPs adopt certain software.
Professor Sullivan says IT innovation tends to start locally, rather than being imposed from above: 'A lot of Scotland's IM&T is to try to get these local successes through the rest of Scotland.' For example, the country's patient booking system has been developed from work by a GP in Orkney and use of the country's patient identification system, the 10-digit community health index number, was pioneered in the Tayside region.
Plans for patient data focus on regional repositories, rather than England's single NHS spine, although there will be a central database of summary patient information and immunisation data.
Scotland's bottom-up approach is apparent elsewhere, says James Drewer, healthcare programme manager for UK-wide IT trade association Intellect. 'The difference between the national programme in England and what they are trying to achieve in Scotland is that the national programme has decided what IT functionality it wants and has gone to the market to ask a relatively small number of suppliers to deliver it.' In areas such as pharmacy IT, the Scottish NHS has taken a different approach: 'Scotland has set standards, and anyone who can work within these parameters can sell into that market, thereby maintaining a long-term competitive marketplace in which unit price as well as innovative IT solutions will determine a company's success.' Another difference is that the size of contracts for the English national programme, covering nearly 50 million English residents compared with 5 million Scottish and 3 million Welsh residents, has restricted it to larger IT firms. 'The smaller software suppliers were at a disadvantage for the national programme contracts, but That is not the case in Scotland, Wales and Northern Ireland. We will have to wait and see which procurement model works best, ' says Mr Drewer.
Wales' size hasn't stopped its health service from dealing with Oracle, one of the world's largest software firms. Despite this, Wales decided to allow trusts to opt in or out of the project to improve business processes such as procurement and payment processing. This means it covers just 12 of the country's 15 trusts (see box, page 10).
The Welsh national IT strategy, Informing Healthcare, has a similar approach, according to Tony Paget, lecturer for the MSc health informatics course at Swansea University's school of health science.
'One of the key areas is the commitment to stakeholder engagement, involving a lot of groups inside and outside the NHS, ' he says. 'We are starting from a different place on target and goals; they are not quite as rigid as the national programme's.' Another difference is the lack of massive outsourcing deals, although it does share with England the outsourced (and much-delayed) electronic staff record system, run by McKesson: one of the three first pilots to go live was North East Wales trust.
Informing Healthcare's main work is the 'single record', but it is moving ahead in other areas: it has already started staff training, with the aim of all employees taking the European computer driving licence qualification, and has already -10 built its equivalent of the national programme's broadband network N3. 'We had the infrastructure in place some time ago, ' says Mr Paget. 'That was a cracking bit of foresight'.
Overall, he thinks devolution is working well for Welsh healthcare IT. 'It has allowed a lot more people - including clinicians - to have their say than previously. The devolving of power has been quite obvious, ' he says.
Even so, Mr Paget says the national programme for IT is pushing England ahead of Wales in some areas. Murray Bywater, managing director of health IT analyst Silicon Bridge Research, concurs: 'The national programme for IT has put England clearly in the vanguard of innovation for healthcare IT.' He believes the other three countries are considering whether to follow England in its radicalism.
Silicon Bridge is involved in the Health Information Network Europe 2004 European e-hospital census: the full UK results will be presented by the firm at the Healthcare Computing 2005 exhibition next week. But early results show England has made more progress towards 'full electronic prescribing' (the highest level of development in the research, meaning effective use of integrated IT systems including a master patient index, departmental systems, order communications, prescribing and medicines management) than the rest of the UK, although still a long way from the 100 per cent sought by the national programme.
'For the whole of the UK and Ireland, only 1.39 per cent of hospitals interviewed by HINE had implemented full electronic prescribing, some way below the European average, ' says Mr Bywater.
'Of English hospitals interviewed, 2.56 per cent had already accomplished full implementation, reflecting the positive impact of the early NHS electronic patient record pilots.' Across Europe, 2.07 per cent out of 895 hospitals interviewed in 15 different countries have currently achieved this level of implementation.
Given the fast pace of the national programme, Mr Bywater says Scotland, Wales and Northern Ireland may benefit from England's learning experience, as well as enjoying strong competition for their business, given that smaller suppliers less favoured by the national programme are likely to work hard to win other UK business.
Mr Bywater says that each of the four home nations has its own characteristics. 'Northern Ireland has some very clever work in shared infrastructure, concentrating all its hospital systems in two big service centres. They are controlled by the Department of Health, with a very centralised way of working, ' he says.
'Scotland is quite advanced in adopting standard GP systems and patient records components - it has gone further than England.' Mr Bywater adds that Wales' approach is more integrated than Scotland's: 'The control by the Welsh Assembly over IT in hospitals is greater, ' he says.
The differing pace and priorities of the four programmes could cause difficulties in border areas, particularly in the relatively wellpopulated areas either side of the Welsh-English border: for example, 7.3 per cent of inpatients and outpatients treated by North East Wales trust, based in Wrexham, come from England.
However, the trust is confident it can cope. 'I would expect there is going to be sufficient joint working to ensure the two systems [Informing Healthcare and the national programme] can work together, ' says trust corporate affairs manager Andrew Scotson.
In fact, North East Wales trust is more concerned about other aspects of the national programme, particularly the information carried within the choose and book patient booking system. 'It will have a direct impact on patient flows into this trust, ' says Mr Scotson, as Welsh waiting-time requirements differ from those in England.
NORTHERN IRELAND INTEGRATED ICT STRATEGY
Northern Ireland has an advantage in its use of healthcare IT: health and social services are integrated within the same organisation.
In 2001 this allowed it to a launch a single health and personal social services information and communications technology strategy.
'Implementation of new and expanded ICT will facilitate service innovation and development, and make cross-sector cooperation and working possible, ' says a spokesperson for the Department of Health, Social Service and Public Safety.
The programme has two major areas for development: electronic care records and electronic care communications, the latter concerned with joining up communications between the province's health and social services providers.
The work on electronic care records resembles equivalent projects elsewhere in the UK, with the aim of making an individual's information available wherever he or she is treated - except that the individual's unique identifier will serve for both health and social services.
In England, joinedup working can be hampered by local authority staff being unable to connect to NHS systems.
The strategy also covers:
'e-information': providing better information on the range, quality and timeliness of services;
business administration: improving applications including finance, supplies, personnel and payroll;
education: with ICT becoming a core component of all formal training programmes for both students and those already in service;
infrastructure: providing secure networking including identification and authentication of users.
A revised version of the strategy is due in spring.
WALES IN COLLABORATION
Cardiff and Vale trust is the largest in Wales, and one of the largest in the UK. Its neighbour is the country's only undergraduate medical school.
Unsurprisingly, the trust plays a leading role in Welsh NHS IT: it was the first to go live with the Welsh health service's implementation of Oracle software, to improve business processes such as procurement and payment processing, in April 2001.
However, Cardiff and Vale senior assistant director of finance Phil Lansley stresses the collaborative nature of the work. It involves 11 of Wales' 14 NHS trusts, as well as Powys local health board, which provides both acute and primary care.
All volunteered for the project, and all are represented on its strategy board, along with Welsh Health Supplies, which is also connected to the system.
Mr Lansley points out that other trusts have piloted some elements of Oracle's software.
'It is been an excellent example of what you can do by agreement, ' he says, adding of NHS IT in general: 'What I do find in Wales is that It is extremely collaborative.' The three other trusts are considering whether to join the system, and Mr Lansley says there may be future potential to extend it to the other local health boards.
Cardiff and Vale is implementing Oracle's self-service shopping, for more than 1,000 staff in the trust: this allows them to order common goods and services (including those purchased through Welsh Health Supplies) entirely online.
Managers authorise purchases online as well.
Such purchasing allows for economies of scale from large contracts and reduced administration.
The trust is also working on implementing 'business intelligence' software, which should allow managers to monitor financial and administrative performance.
The trust's neighbour, Cardiff University medical school, sends students to all 23 district hospitals in Wales, so its national role is clear.
At any given time, half its students are offcampus around the country. To help keep them in touch with their data and messages, the university linked its own network and Dawn 2, the secure Welsh NHS data network managed by Health Solutions Wales (a division of Velindre trust, responsible for a range of pan-Wales NHS services).
'We had contemplated connecting to one trust then another, but that was very expensive in Wales, given the geography, ' says Cardiff University assistant director of information services Tony Rucinski.
He says using NHS networks for other purposes is possible elsewhere in the UK, but such connections make health service IT staff nervous about security: 'The challenge of achieving this solution was political, as well as technical, ' he says.
Wales' smaller size, as well as the fact the medical school serves all of Wales, helped. 'We could get the people responsible for the decision around a table with relative ease. I am not sure if you would have a big enough table in London.'
Besides some centralised procurement, Scotland's IT programme is being implemented on a bottom-up basis.
Wales has adopted a less rigid approach than England, encouraging stakeholder involvement.
Northern Ireland's programme is more centralised, with all its hospital IT systems in two service centres.