Information transparency

The model of commissioning outlined in the government’s White Paper ‘Equity and Excellence: Liberating the NHS’ is dependent upon transparency of information. The Secretary of State went so far as to describe the need for an “information revolution”. In fact, you could argue that the entire transformation programme envisaged by the government is dependent upon the delivery of information and IT – a kind of worrying thought.

Changes ahead
The control infrastructure that has overseen the NHS for the past ten years is being torn up. Once there existed national targets set and monitored by the Department of Health (DH) and performance managed by SHAs and PCTs. Now performance will be set and monitored by GP commissioners and the NHS Commissioning Board. The whole system will be held to account by the public through choice of provider and commissioner, voice (public protest) and the legally enforceable NHS constitution.

The DH bureaucracy kept itself informed through an extensive data capture exercise covering everything from waiting times and waiting lists through to healthcare acquired infections and service changes. When the going got tough in the NHS, the DH would monitor directly the hot issues, such as the availability of paediatric intensive care beds in winter, and intervene if local performance was damaging the national position.

Targets are being abolished. Central reporting is being reduced. The DH and NHS management are being downsized. The government believes that constantly pulling up the plant to see if the roots are growing has damaged the NHS and set itself a self-denying ordinance that means that the Secretary of State won’t know about every bed pan dropped, for the first time since the NHS’s foundation. However, the removal of a supervising authority without empowering GPs and the public with the information they need, runs the risk of simply recreating individual self regulation – hidden waiting lists and the level of service that the provider feels is appropriate and deliverable.

Action required
Successful transition from the old state to the new will require the government to make a number of things happen.
1. The right data needs to be collected, of a high enough standard in order to be able to measure quality and value.
2. National and local data-sets need to be made available to commissioners, patients and the public in a variety of forms that will allow interrogation for decision making and accountability, directly and through third parties.
3. Data should be benchmarked against UK and international comparators to create an environment of competition and striving for excellence.
4. Core applications like hospital EPRs, GPs systems and Choose and Book need to be opened up so that they can communicated with by third party applications to create competition in user applications.

The think tank 2020 Public Service Trust argues: “A crucial element to providing the information expertise that commissioners need and inspiring the public to hold the NHS to account is breaking the virtual state-monopoly on the publication of NHS performance data. A market must be created in information analysis, so that world class support can be offered to commissioners and analysis that is relevant to individuals is offered to the public.”

Also, in the White Paper the Secretary of State said: “We intend to make aggregate data available in a standard format to intermediaries to analyse and present it to patients in an easily understandable way.”

Opening doors
So, industry should be pushing an open door in demanding a market in information. What do suppliers need to do to make this a reality?

The first thing is to recognise the economic climate. In this environment no one is going buy a product that adds to the administrative burden or has a payback period measured in years rather than months. If the industry is going to make the information revolution happen it will need to demonstrate that it understands the environment and the financial pressures, and has products that can really contribute to delivering an annual four per cent productivity improvement very quickly.

The second thing is to be specific about the data you need in order to deliver the transformation you are proposing. If the data is in the public domain already and all it needs is imagination to productise it, splendid. However, if the data exists but is locked away, such as incapacity benefit data, which would allow commissioners to target NHS interventions to patients off work and receiving benefits and thereby reduce NHS and welfare costs, you need to be specific. Part of the government’s problem is that it has so much data that it doesn’t know where to start and ministers are daunted by the size of the transparency challenge. Help them decide what to release, whilst they get into the habit.

The third thing is bringing good products together around identified markets and having enough confidence that you can make a difference that you are prepared to share the risk and benefits. Recycling old products will not be good enough when new customers need new products. There are a number of different constituencies with information needs:

GP Commissioning Consortia
If they are going to be effective the GPs need to be enabled to operate as a board rather than an executive – more like multi-funds than fund-holders, for those with long memories. This means that they will need a set of back office services that lifts them out of the bureaucracy of invoice matching and payment clearance and into thinking about how to improve the health of their population.

They will need management information systems that allow them to see variations in performance of their hospital and out-of-hospital providers and of their GP colleagues, so they can focus their board meetings on discussing what action to take, not worrying about the absence of data.

As commissioning consortia start to try to align their expenditure with health need and maximum impact, they will need population health analytical tools to understand health need against usage, segment their population, forecast the cost of interventions at an individual patient level and track whether expenditure and outcomes have shifted as planned.

As the NHS attempts to shift care out of hospitals into community and home based services, the real cost and productivity of hospital and community services will come under greater scrutiny. At present the understanding of community services’ costs is so poor that the hypothesis that increased use of community services will reduce NHS costs is simply a “bet” based upon a limited number of studies in other health systems. Systems that allow analysis of real costs in settings outside hospital, over periods of time rather than per intervention will be necessary.

GPs will have responsibility for the quality of the services they buy on behalf of their patients, so will require quality monitoring systems. They will need to be at least as well informed as their patients when they are asked for advice about choices.

The public
The public is being challenged to hold the NHS to account. If they are to do this they will need access to information that they have never had before – comparative clinical quality and satisfaction information at specialty team and consultant level. Surely the government commitment to allow patients choice of consultant is meaningless rhetoric if the patient is not allowed to know about the clinicians’ performance?

It will be hard, though not impossible, to create a business model for the supply of this information directly to the public, but two potential businesses may emerge. One is a business-to-business information supply operation, pulling together the mass of data that exists, creating interesting new connections and supplying it to public facing organisations such as patient charities or media businesses. The second is to be one of those public facing health information organisations. It is only necessary to read women’s magazines and the middlebrow newspapers to know that the public desire for health stories is insatiable. The websites that become established as interesting, relevant and reliable in this space potentially have huge markets.

Patients and carers
The government is committed to patient empowerment, not simply in the choice of services, but also in the management of their care. For this to be real the patient will need access to systems that tell him or her what they should expect from their healthcare provider so they can hold providers to account and systems that allow them to undertake common transactions remotely like appointment checking and changes from a range of applications.

They will need access to their clinical record so that patients are an equal partner in the decision making involved in their healthcare. How can there be an equal partnership if only one of you can see the record? Furthermore, choice is meaningless if only your current GP or your local hospital has timely access to your records and any other provider has to re-establish your medical history and undertake another series of expensive, invasive tests.

Catching up
Finally, the technology to support co-production of healthcare is likely to be one of the big growth areas in the coming years. The NHS lags behind the rest of the world, which has itself only scratched the surface of the possibilities, in providing patients with the technology and support to self medicate and monitor. Many conditions offer the opportunity for patients to take burden off the NHS, empower themselves and provider a cheaper and better NHS.

Just as those on the outside looking in say to the NHS that it must change the way it works if it is to harness the potential of information and IT and achieve a better, cheaper NHS, so must the industry. If we keep delivering the same products in the same way, we should not be surprised if we get the same outcomes – underachieving implementations, dissatisfied customers and a lack of an inclination to invest in IT when the going gets rough. The NHS needs innovative partners in transformation who can help them leverage the central informatics platforms that have already been put in place; it just doesn’t necessarily know this yet.The companies with great products who are prepared to make the market rather than wait for it have a tremendous opportunity in this time of change.

For more information:
Web: www.bcs.org