e-Health in the United Kingdom

That said, the policies and best practices that drive the respective e-government initiatives in Scotland , Wales and Northern Ireland tend to mirror that of England, although with some distinct and innovative differences in emphasis. They also embody EU initiatives for trans-European integration in this area too.

The core systems are very similar, e.g. Electronic Health (or Care) Records (EHR), Picture Archiving and Communications System (PACS) etc. Therefore, the remainder of this section will use England and UK interchangeably unless referring to specific jurisdictional efforts.

Similar to the influence Lord Gershon has had on the e-government development in the UK (and Australia), the strategy of the National Health Service in the UK (England and Wales) has been heavily influenced by the reports of Lord Wanless which collectively point out the need to constrain ever rising costs of maintaining an essentially free health service (the NHS) and shifting the burden of healthcare from the service to society as a whole.

This broad review in 2001 in the NHS (England) highlighted the need to:

In 2005 the Department of Health entrusted the task of managing the ICT developments to a newly formed government directorate - Connecting for Health (CFH) which also assumed the IT responsibilities of the NHS Information Authority (NHSIA) which was subsequently closed.

The NHS Plan had also redefined the various relationships between the health services and the patient e.g. one-stop-shop with 24/7 access and services designed around the patient wherever they are; the service and social services e.g. extending heath services to nursing homes and into the field (social workers, etc.); intra-staff relationships, e.g. doctors, nurses, midwives, therapists, etc., e.g. new contracts of employment; and between the service and the private sector, e.g. using private facilities for overflow.

Systems interoperability and inter-organizational cooperation and consensus on a grand scale was needed to effect the changes being proposed in the NHS Plan, e.g. for booking, referrals, prescriptions, information exchange and extended reach, e.g. telemedicine.

The new NHS CFH implementation program inherited a number of key unilateral implementations, e.g. PACS, GP IT, and numerous other systems, of the day.

As a result a comprehensive national plan for IT (NPfIT) was born – resulting in the largest virtual private network, largest secure private single-domain email (1 million+ users) and civil IT program in the world and estimated to cost £12.4billion over ten years. The NPfIT’s Plan consists of a number of core components.

NPfIT Plan - Core Components

NHS Care Records Services – includes the ‘spine’ that supports

Additionally, the NHS CFH oversees numerous piloted e-Health systems, e.g. e-Health dashboards , and deployments nationally and each of the core components are themselves in fact multi-e-Health systems from various suppliers that will interoperate via the Spine . The CFH’s roadmap/s for delivery of the NPfIT e-Health program includes a timetable for achieving key functionality and systems delivery across England.

The Risks of Risk Mitigation?

The NHS CFH allocated a number of prime contractors (Service Providers) to undertake control of delivery of both national infrastructure and e-Health applications and local e-Health systems. National Infrastructure, e.g. N3, Spine (NISPs), National Applications, e.g. PACS, (NASPs), and Local Service Providers (LSPs) were subject to long-term contracts (up to 10 years) with major systems integrators, e.g. Accenture, BT, Fujitsu and CSC.

In line with large program management initiatives elsewhere in th UK the NHS CFH e-Health implementation strategy appears to have, to some extent, been almost too risk averse in its contractual arrangements with suppliers.

Local Service Delivery

To deliver e-Health systems and integrate them across the country, the original program divided England into 5 clusters – each to be serviced by one of four LSPs.

Following NAO’s recommendations and to appease local health authorities (who wanted more say) the NHS introduced the NpfIT Local Ownership Program (NLOP) in 2006. This effectively shifted responsibility for local systems delivery away from NHS CFH towards local healthcare organizations, i.e. the Strategic Health Authorities (SHAs), Primary Care Trusts and some Local Authorities from 2007.

Under the new NLOP arrangement three programs covering all the 10 SHA’s in England were to be serviced by the four LSPs. With the withdrawal of Accenture and Fujitsu the local program is being delivered by the two remaining LSPs – BT and Cerner following project resets.

This shift in accountability reflected the stiff resistance to centralized control by the NHS CFH and the one-size-fits-all approach being taken at the time. Unfortunately, this resistance has been regarded as ‘too – little – too late’ by many and the inevitable and consequential delays continue (in an environment of potentially massive penalties) to dog the program with the result that many of the original services suppliers have opted to leave the program or have had their contracts terminated .

Considerable debate (particularly from clinicians) also surrounds the functionality of the integrated e-Health care records service being made available through BT’s (Cerner Millennium) and CSC’s (IBA/iSoft Lorrenzo) solutions being deployed in different parts of the country.

National Infrastructure and Applications Delivery

The NHS CFH has contracted National Application Service Providers to deliver common infrastructure and e-Health applications e.g. N3 Broadband Network and Spine (BT), Choose and Book (Atos Origin), NHSMail (Cable & Wireless).

Although more firmly under the centralized control of the NHS CFH, these programs and projects have had their share of difficulties, e.g. NHSMail.

The integrated care record system

For example the detailed e-Health patient record was originally to contain lifelong episodic data – but continued disagreement as to what should be stored in the record continues to delay the project and dilute the original intentions.

Likewise the policies associated with uploading the summary e-Health patient records to the spine (opt out) and the ability of the patient to limit access at the time of treatment and have access to the record online have all been heavily debated. All of which has contributed to the delays.

Progress

Despite the many problems associated with a program of this magnitude NHS CFS stoically publish their progress and defend their actions . Their progress, though much delayed remains, none-the-less impressive:

Findings and Analysis

The greatest challenges to the UK’s e-Health program are political and reflect the constant conflict between centralized solutions and decentralized decision making. There are advantages and times when each has its benefits.

Transitioning between centralized control and devolved decision making always presents an issue of coordination for a program of this magnitude. The CFH have been heavily and widely criticized (not unexpectedly) for their management of the e-Health program and the lack of transparency, e.g. program management gateway reviews not published.

Most recently in a Parliamentary Accounts Committee (2009) which stated that the program was some 4 years behind schedule, key management had resigned and not been replaced, clinical and other promised benefits have not been delivered and suppliers have grossly overstated the capabilities of the products and financial standing of their businesses.

In hindsight the degree of change was poorly handled and it will be difficult for the NHS CFH to re-engender enthusiasm and confidence once it has been lost on a program that will in key areas like the Care Records Service and full integration (image sharing capability) of the PACs system likely take another four years to complete.

The NHS CFH have also been criticized for paying too little attention to standards and this invariably introduces difficulties in the integration of product suites and between different product suites from different suppliers, particularly where development of the products often pre-date certain standards and openness.

The spine was meant to alleviate the problem of information exchange – but without agreed standards, both technical and semantic coupled with a lack of consensus the current difficulties were to a large extent inevitable.

Staying the course will be the greatest challenge for NHS CFH, particularly in the event of political change.

From an ICT perspective (rather than patient care perspective) the greatest danger to the UK program is gradual fragmentation before it reaches a critical mass – with the NHS CFH already bowing to political pressure and allowing SHA’s to adopt interim solutions (doubling the implementation effort) or worse still allowing them total freedom to go their own way (increasing the integration difficulties).

Maintaining good vendor relations will also be a challenge given the contractual history of the project, large losses by companies, harsh contracts and continued functional changes being insisted on by clinicians who are easily bale to hold the moral high ground – patient confidentiality, patient rights, patient safety, etc.

Analysis

The strength of the UK program is its comprehensive coverage and despite its delays – its maturity.

Once again the UK is in a position of being on the verge of completing the ‘hard yards’. If it manages to reach a critical mass (and the progress to date above would indicate it is) the changes will become irreversible – acceptance will become easier, compliance and consensus will improve and the problems it faces now will be but a distant memory – such is the psychology of change. This development will mirror the UK’s e-government program.

In addition, as each year progresses more IT friendly clinicians reach senior positions making it easier to effect policy change. At the same time, the public’s expectations are increasing and confidence in the Internet and IT will rise with greater familiarity helping to push the changes through.

As the Internet begins to deliver Web 2.0 functionality on an ever increasing scale, e-Gov. moves inexorably towards Gov 2.0 – Medicine 2.0 will begin to force change from the patient and health group (third sector) side – either isolating clinicians or forcing them to move with the times. The NHS has long been a political football in the UK and the recent parliamentary accounts committee re-emphasizes this – with opposition parties being the most critical of the NPfIT and the DHS CFH.

Given that the chorus of dissent is coming from politicians ahead of elections is accompanied by the BMA , senior clinicians, the British Computer Society, and the IT industry – it seems almost impossible that the program will not be severely affected in some way.

The much weakened position of the supplier coalition (since Fujitsu’s departure) coupled with the NHS and NHS CFS directorate on the defense does not auger well for survival unscathed. Once the critical mass has been accomplished and the many challenges like patient privacy, program management and transparency have at least been partially resolved – the IT landscape across the NHS will have been changed for ever.

Benefits realization will no doubt come in time from this first iteration. It took twenty years for benefits to be realized from many of the existing legacy systems of the NHS.

With a more uniform and interoperable ICT landscape new developments and the move towards Med 2.0 will begin to transform the NHS and provide a platform for innovation that will more likely come from the clinicians themselves rather than the IT industry or central government.

Infrastructure like N3 and the spine along with delayed applications provides a sparse and unexciting benefits picture – and is largely seen as theoretical or too far in the future.

However, given a more uniform technology and data landscape, infrastructure and policy setting environment has been achieved - the opportunity to realize the benefits will become much more evident and exciting yet simple (given the infrastructure) developments like the current wave of decision support dashboards will finalize the paradigm shift in thinking and new ways of working. The interim period between 2009 and 2014 presents the greatest threat to the program. The program is reaching its critical mass but remains vulnerable on many fronts.

If the NHS CFH and the remaining software suppliers cannot maintain the momentum (or increase it) and provide the functionality to clinicians quickly – forces could fragment the program. This will require a concerted and innovative effort to deliver and sell the capability of the products and manage the expectations regarding functionality of the clinicians. The emphasis must be to communicate better the success stories without burying the problems – once the balance is shifted towards the positive – the threat will diminish dramatically.

A further threat exists from outside of the country – in that the negative aspect of the British NHS and its various programs are being used to delay the proposed changes to the health system in the USA and negative sentiment there will be picked up in the UK.

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