Preparing for an information revolution

Health is one of the last major information- intensive sectors awaiting fundamental transformation, and like other sectors before it, this can not be accomplished without using information and technology to reinvent both its internal operational functions and its outward facing business model. An information revolution can support and help drive the changes that are required in the processes and methods of care provision at the start of the 21st century.

The Department of Health has now closed its ‘Liberating the NHS: An Information Revolution’ consultation to inform the forthcoming NHS information strategy. In response BCS, The Chartered Institute for IT, has conducted one of the largest engagement exercises that it has ever undertaken, bringing our deep expertise to bear on a holistic approach to the informatics challenges.

Our response contained almost 100 recommendations, but a number of themes occurred regularly throughout, including those presented below.

Using information effectively
The scale and pace of the productivity challenge faced by the NHS over the next five years cannot be met without much greater and more effective use of information and IT.

The NHS is seeking to deliver 20 per cent productivity improvement over the next five years through better commissioning and more effective provision. This is hugely ambitious and failure will result in reduction of services offered to patients. The NHS must seize the opportunity offered by information and IT.

Creating the culture of ‘change at pace’ is vital for a world-class health service. We have recommended that a risk-based approach should be adopted to allow prototyping of new patient-centred technologies and consumer information. It doesn’t have to be right the first time so long as risks are understood and mitigated.

We believe that to deliver the impact that information technology has to offer, at pace, IT and QIPP programmes must be integrated and technology used as a method to rapidly spread and enforce good practice. We have recommended that the NHS develops with the main software vendors standard implementation of best practice processes and places these in the public domain. For example, the three best ways to run emergency admissions are built into the system, so that a hospital can chose which to adopt and make the appropriate operational changes, rather than either implementing the technology and worrying about the process change later or behaving as though their A&E requires a total unique solution.

Implementation
The implementation of information services and IT needs to be viewed as a necessary supporting infrastructure to the redesign of service, not as an end in itself.

Successful implementation of the information revolution will involve very substantial behaviour change on the part of clinicians, patients, managers and others. Simply providing the information and IT will not itself guarantee that the information will actually be used – or even collected, analysed and understood in the first place.

To meet the massive productivity challenge, the information revolution must start with the design of working practices and cover the whole operating model of care to determine how processes are adapted and how resources are used, prioritised, planned and mobilised as a consequence of better information. The opportunity is to completely rethink the way a service is delivered, whereas implementing modern technology into old processes just makes them more expensive. A library of successful examples with a focus on ROI delivered would support boards in making investment decisions.

The electronic patient record (EPR) held by health and care organisations remains a foundation stone, yet these still haven’t been widely adopted in some care settings. Consequently we have recommended that all organisations providing care to the NHS should be given notice that they will be expected to be using an EPR in a meaningful way within five years. Following review of the US criteria for meaningful use, the NHS should create a set that is appropriate to the UK.

Enforcement
The rigorous enforcement of standards is not an example of heavy-handed government interference, but a necessary condition to allow a flourishing market of interoperable solutions.
    
Critical to its success, the information revolution requires the creation and nurturing of a viable market for information services, software and transactions to deliver high quality information services to patients, clinicians and organisations. However, for this to happen and for IT suppliers to invest most effectively, the centre should give very clear signals to what it will be doing and what it will be leaving to others to do.

To rapidly innovate solutions, the market requires a quickly established set of minimum standards and guidelines, built on existing good standards, for information collection, production, storage and use by the different actors across health and social care, set against a clear vision for the future. We believe this requires a single overarching approvals and/or assurance body for informatics standards, directed by the Secretary of State for Health, covering health, social care and population health.

In some cases standards must be rigorously enforced, for example we recommended that commissioning, regulation and financial penalties for non-use of NHS Number by all care providers should now be applied. At the same time we must make sure that ICT supplier accreditation schemes keep standards high, but also keep barriers to entry low. The NHS Interoperability ToolKit accreditation is a good recent example that has allowed rapid innovation from ICT suppliers – this should be extended as a kite mark for interoperability, with an opportunity to learn from Integrating the Healthcare Enterprise’s approach and experience.

Competition
The NHS needs to build on the infrastructure of the National Programme for IT, but take rapid steps to reintroduce competition into the NHS supplier market.

Whilst the benefits of the National Programme for IT are frequently down-played by people who forget the chaos and lack of progress that preceded it, we are now at a point where the NHS moves to multiple independent care providers, the focus on care pathways rather than institutions and the pressing need for every NHS organisation to be making progress simultaneously means that a more dynamic and entrepreneurial supplier market is required.

In an environment of monopoly suppliers, every new innovation that the NHS wants needs to be specified, priced and paid for. We require a competitive environment, where suppliers will build in the functionality that the market wants to enable them to win the next contract. Additionally the centre will want to maximise the use of legacy investments in information collection, transfer, storage and reporting – vital if the execution of the information strategy is to be affordable.

We recommended that existing NHS procurement frameworks such as ASCC should be enhanced so that new vendors can be added to the framework if they demonstrate that a product meets the national minimum requirements for information governance, functionality, data standards and interoperability, or removed if they are subsequently seen to fall below those standards. Equally the government should ensure that frameworks are sufficiently flexible to allow small companies to bid for contracts.

The informatics community
The NHS and the informatics community need to win back public and care professional trust through better explanation of the benefits of the information revolution and more care in ensuring that the individual patient is engaged and activated in their health and wellbeing.

The transformation of care services needs an improved relationship between care system and individual patient. This will require a combination of information, education and support, delivered through trusted relationships. We require patients to become equal partners taking control of managing their own health, choice to liberate patients and incentivise providers, and transparency so the public can hold the NHS to account. The consultation has not distinguished between these different purposes of the information revolution and must now do so in order that they are individually approached with patients (and their care professionals) in the right way to achieve the desired outcomes.

We have recommended that, where sharing is appropriate, there should be a statutory obligation on healthcare providers to release information as a minimum standard if contracting with the NHS. The NHS Commissioning Board should require the publication of meaningful comparative performance data at the level at which patients are being offered choice and that the public will understand and value. To mitigate the risk that, in the early stages of data release, organisations, clinical teams and individuals will be unfairly judged by inappropriate interpretation of data that is not fully explained, we recommended that ministers, the Department of Health and commissioners will need to take a mature attitude in responding to data release and be at the forefront of explaining to the public and the media why over-reaction is inappropriate, though this will not be easy.

Many believe that patient groups and others with trusted relationships could step into new key roles as health intermediaries and navigators. But we must recognise that this will not happen of its own accord; they will require help overcoming concerns around liability, skill sets and ability to scale to meet market needs. Technology also has strong potential to engage people in the care system and the NHS should utilise existing technologies that people use on a daily basis, and harness fresh and exciting technology, including web 2.0 approaches to leverage social capital, to meet patients’ desire for better interactions with health and care systems.
 
Research & development
Finally, the NHS is failing to provide the support that it could to the research community, to the detriment of R&D, the UK economy and patients.

England has three of the world’s leading university research establishments in Imperial, Oxford and Cambridge, as well as world-class pharmaceutical companies such as GSK. This places us at the forefront of Europe.

Our integrated health system offers us the opportunity to provide a world-leading environment for clinical research and trials, creating jobs and getting patients early access to ground-breaking treatments. However, the NHS has failed to support this occasion to its fullest extent, as unproductive debates and ignorance around information governance have held back the sharing of data.

We have recommended that work is commissioned to develop effective linking systems with medical data and the informatics tools already in use in research institutions, to enable medical data to be used in conjunction with scientific data from pharmaceutical companies and other researchers. Opportunities should be sought following any permissive regulation changes and appropriate patient consent processes to improve communications of clinical trial eligibility to patients through the use of EPR systems.

These core themes, the information revolution and the awaited information strategy will all falter if we fail to invest in our health informatics workforce capacity and capability. A sustainable health informatics workforce infrastructure is required to be put in place, spanning health, public health and adult social care, and the public, private and third sectors. Such an approach should be encouraged by commissioners and regulators as a means of improving the quality and professionalism of the health informatics workforce and thereby the quality of data and the management of patient- and organisation-critical IT and information systems.

Acknowledgements
We would like to thank our members for rising to the challenge of our consultation response, our Specialist Groups for their contributions, our Strategy & Policy Committee and Health Executive for their oversight and leadership, Clever Together for the provision of innovative crowd sourcing services and KPMG for their sponsorship and helping to facilitate our open debates.

For more information:
Web: www.bcs.org