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Newsletter - British Medical Association's Working Party on NHS IT

December 2006

• Introduction
• The NAO Report
• The NHS Care Record
• Information Governance
• Suppliers
• Secondary Users Service
• Patient Safety
• Choose and Book
• NHSmail
• Electronic Staff Record
• Progress in Scotland
• Progress in Wales
• Progress in Northern Ireland
• Appendix - Membership of the BMA NHS IT Working Party

Introduction
The British Medical Association’s (BMA) Working Party on NHS IT was established in 2005 to ensure that the BMA has a strong collective position on NHS IT issues. Its membership includes representation from the BMA Branch of Practice Committees, the Medical Ethics committee, the Patient Liaison Group and the devolved nations. (See Appendix for full details of the membership).

On the staff side of the Working Party, Rachel Merrett (Senior Policy Research Manager) has been joined by Hugh Townsend who was appointed in August 2006 as Policy Research Executive.

This is the second Newsletter giving an update of the work of the BMA NHS IT Working Party. You can see the first newsletter here.

Local feedback from doctors is welcomed to inform our policy. Please email info.nhs-it@bma.org.uk if you have any views or comments on any of the issues raised in this newsletter.

National Audit Office Report
The National Audit Office Report on the National Programme for IT was published on 16 June 2006. Whilst the report was positive about most aspects of the programme there was some discomfort expressed by the Working Party that the positive aspects were felt to be overplayed. The report can be downloaded as a PDF here. One of the main recommendations of the report was that NHS Connecting for Health (CfH) should strive to communicate and engage better with healthcare professionals. Connecting for Health has been making efforts to engage stakeholders more and senior members of the BMA have continued to meet senior members of the CfH team. The BMA also has increased representation on User Groups including several Choose and Book groups, the Electronic Prescription Service, the National Advisory Group, Role Based Access Control Reference panel, and the Ministerial Taskforce on the Summary Record.

The NHS Care Record
Background
Since the last newsletter, you should have seen many more signs of progress, such as receiving information on care records and by now most of you should also have already been allocated your smart card. According to NHS CfH more than a quarter of a million NHS staff now have secure smartcards to access systems. James Johnson, Chairman of the Working Party and Chairman of BMA Council has written to all doctors in England about the changes. Included with the letter is the first of a series of guidance documents on Connecting for Health. The guidance and letter provides an overview of the NHS Care Records Service (NHS CRS) with the aim of making doctors fully aware of developments The letter and guidance are available here.

Summary Record Early Adopter Phase
The first implementation of the Summary Care Record within the NHS Care Records Service was due to be activated in some areas in August but has now been delayed. One reason for this delay was to allow more debate on what should be shared. The Working Party emphasised the need for the NCRS to be properly piloted. Work is in progress to select PCTs to trial the summary record. More than 50 PCTs have volunteered to pilot the scheme and a shortlist of six has been selected. Two PCTs will be selected to take part in the early adopter programme in the spring. Selection will be based on strict criteria and the pilots will be evaluated by an independent evaluation team.

Consent
The BMA has also debated the consent model of sharing healthcare information. The CRDB (Care Records Development Board) position is that implied consent is appropriate for sharing summary healthcare information. Confidential patient healthcare information will therefore be shared on a central system unless a patient informs a healthcare professional that they do not wish this to happen. The BMA’s policy is that explicit consent should be obtained before any healthcare information is uploaded onto the spine. Doctors feel that some patients may be unhappy about having their sensitive personal data uploaded onto a central system and a more gradual approach will allow patients to fully consider what information is contained in their records and whether they wish this information to be shared. Confidentiality is central to trust between doctors and patients. The BMA is currently seeking clarification from the GMC, MDU and MPS on how exactly this would affect clinicians in terms of liability.

Public Information Campaign
The BMA is in agreement with CfH that patients need to be adequately informed before any information is uploaded and therefore the success of the planned information campaign is vital. Patients must be properly informed of the changes so that they are equipped to make decisions about how records are shared. A national public information campaign must be fit for purpose and we have tried to work with Connecting for Health on the content of the campaign. The material must explain who will have access to records and how patients can limit sharing (the versions we have seen to date have not explained this to our satisfaction). The BMA Working Party on NHS IT will receive an update on the campaign at their January meeting.

Ministerial Taskforce on the Summary Care Record
In July 2006, Lord Warner announced that a Ministerial Taskforce on the Summary Care Record would be established which would attempt to resolve ethical and practical issues in implementing the Summary Care Record and help introduce the first phase of the NHS Care Records Service. The taskforce is due to report back to Lord Warner in early December (after 4 meetings). Both Jim Johnson (Chairman of Council and Chairman of the BMA NHS IT Working Party) and Hamish Meldrum (Chairman, GPC) are members.

In October, members of the Taskforce including Jim Johnson and Richard Vautrey (BMA NHS IT Working Party member) visited Washington to study the IT system used by the Veterans Administration (VA). The VA has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 healthcare facilities. This was dramatically demonstrated when VA patients were evacuated from New Orleans to Washington after Hurricane Catrina. Unlike New Orleans residents cared for by other health care providers, VA patients did not lose any of their health care records and were able to receive treatment in Washington with a full record available. The taskforce visited the VA main hospital in Washington to have a look at it in practice. They reported that it is a most impressive system from the point of view of a hospital doctor and would revolutionise access to data both for clinicians as well as patients who will have access to the full clinical record through a system called MyHealtheVet (MHV). Members of the group raised the problems that are troubling current discussion on the NHS IT systems, for example the question of opt-in or opt-out and the need for sealed envelopes and the ability of patients to limit what individual doctors see. The VA had not encountered these problems due to their different healthcare model. Opt-in or opt-out was never discussed in the system implementation and one of the things that a patient signs up to who wishes to be treated by the VA is that his records will be computerised and that, although it is possible to prevent administrative staff from seeing the entire record, there was no question whatsoever of hiding any part of the clinical record from medical staff nor could they restrict sharing information with a variety of third parties agreed under Federal law.

Role Based Access Controls (RBAC)
Role-Based Access Controls (RBAC) are a technical means for controlling access to computer resources and an integral part of the security process. Following comments by the National Advisory Group and the BMA, CfH is considering how to simplify the system to reduce the number of job roles (currently 350), areas of work (currently 290) and activities (currently 350). The role of sponsors will be crucial in ensuring roles are correctly allocated and updated. This could require extensive training. The BMA supports the development of access controls and moves towards a simpler model with fewer roles and has been meeting the RBAC team to consider the issues arising from simplification of the controls. Such controls must not impinge on working practices and the BMA has stressed that they must be properly piloted as there are concerns about the practicalities of implementation

Sealed envelopes
The Working Party has continued to comment on sealed envelope proposals, which will enable patients to restrict the sharing of sensitive items. The Working Party recently considered a paper on the detail of how this could work. The Working Party was generally supportive; however, some concerns were discussed about the practicalities of their implementation which have been raised with CfH.

Care Records Development Board
The Care Records Development Board has produced a revised edition of the NHS Care Record Guarantee which sets out the rules that will govern information held in the NHS Care Records Service when it goes live in the next year. The full text of the Care Record Guarantee is available as a PDF by visiting the CfH site here.

A children’s version of the Care Record Guarantee is currently being developed in three formats - one for children over 7, one for children over 12 and one for parents. The Working Party will consider the issue of children and the NCRS at their next meeting.

Information governance
Harry Cayton, National Director for Patients and the Public and Chair of the Care Record Development Board was tasked with conducting a review of Information Governance in the NHS. The review was published in September 2006. The BMA regularly receives correspondence on information governance issues and supports the recommendations, which promote a stronger information governance structure. One of the recommendations is to establish an Information Governance Board which, in brief, will be an advisory group, operational post April 2007 tasked with advising Ministers on information governance in relation to patient/client records and monitoring performance. The Working Party has considered the draft terms of reference for the Information Governance Board and has been informally advised that a BMA representative will be invited onto the Board.

Suppliers
There has been much press about the suppliers for the National Programme for IT. Accenture, the biggest and most successful regional contractor working on the NHS's IT overhaul, has recently pulled out of the project. The areas previously covered by Accenture will now be covered by CSC, meaning that CSC will now become the prime contractor – local service provider - responsible for delivering the Connecting for Health NHS IT upgrade to 60% of England.

There has been much controversy over iSoft, one of the NHS IT upgrade programme's key software suppliers, which reported pre-tax losses of £343.8m in August this year and is being investigated by the Financial Services Authority after admitting that potential accounting irregularities had been found in its books. iSoft has recently been linked with a sale as its debts and troubles mount. The BMA Working Party are keeping a watching brief on what effect this will have on the National Programme but have also expressed concerns that changes in suppliers will add to a lack of confidence in the programme amongst clinicians.

Secondary Uses Service
The Secondary Uses Service (SUS) will be provided through the NCRS and will provide pseudonymised patient-based data and information for purposes other than direct clinical care, for example, commissioning, public health, clinical audit, research, clinical governance and benchmarking. The BMA welcomes SUS as one of the key ways in which a national electronic health records system could bring major benefits to health and healthcare. The BMA is represented on the SUS Working Group, which is considering issue such as who will have access to the pseudonymised data etc.

Patient safety
At the July BMA Annual Representative Meeting (ARM), doctors voted in support of a motion calling on CfH to ensure that patient safety is given much greater consideration and elevated to a core requirement of the programme. Maureen Baker (Clinical Safety Officer, CfH) and Michael Thick (Chief Clinical Officer, CfH) attended the October Working Party meeting to provide an update on patient safety. They presented the findings of the National Patient Safety Agency’s second review of the programme, which found that there was a much greater awareness of patient safety than found in the 2004 review. A Clinical Safety Committee, has also been set up by Connecting for Health. The BMA will continue to monitor developments in this area.

Choose and Book
On 25 August it was announced that more than a million referrals have now been made through Choose and Book (C&B). However, despite the measurement period for the C&B incentive DES starting on 1^st September 2006, at the beginning of September, four out of five referrals were yet to be put through the scheme according to the National Clinical Director of Primary Care.

Release 3.2 of Choose and Book was released at the end of September and has been hailed as a successful upgrade in terms of timing and budget. This upgrade to Choose and Book is the first release where the new functionality was deployed into a demonstration environment before making the service live which may have contributed to its successful implementation. If you have any comments on this latest release we would be very interested to hear them. Email us at info.nhs-it@bma.org.uk.

Concerns have been raised over the true nature of a patient’s choice after press reports that some NHS trusts are opting out of offering patients a choice of hospital under Choose and Book. In August, GPs told Pulse magazine that they were unable to book appointments using Choose and Book for hospitals with long waiting lists. The BMA has raised this concern at the National Clinical Reference Panel and several other internal meetings and are currently ascertaining how regular this practice is. Connecting for Health has responded that the problem is not a problem with the system but with hospital management. However, they claim that in these instances, a choice of provider is offered through a manual or paper-based system. The Department of Health has said doctors could still make the appointment if patients wanted to wait longer than 13 weeks.

Recent concerns have been expressed over the incompatibility of Internet Explorer 7 with Choose and Book. CfH advises that IE7 should not be downloaded and used until it is confirmed that all National Programme for IT applications are compatible with it. Choose and Book and Atos Origin have been working proactively to test the Choose and Book application with IE7 and CfH is confident that these tests have shown that the Choose and Book application will function correctly with IE7. CfH recognise that some Choose and Book users will, either inadvertently or by choice, have installed IE7 and for this reason guidance on using Choose and Book with IE7 will be available from mid November. However, CfH advice remains that IE7 should not be downloaded or used until CfH has confirmed that all National Programme for IT applications are compatible with it.

The BMA has conducted a small survey of doctors’ experiences of Choose and Book. Initial responses suggest great discontentment with the system. A more extensive survey is being drafted to explore the views of GPs and hospital doctors further. If you receive one of these surveys, please help us by filling it in so that we can feed back views and problems to Connecting for Health.

The BMA has representation from both primary and secondary care on the Choose and Book Design Steering Group
and National Clinical Reference Panel and we are happy to receive local feedback from users so that this can be fed into the discussion.

NHSmail
The national email service for NHS staff, including medical students, once known as ‘Contact’ has been endorsed by the BMA Working Party for the transfer of patient identifiable information. However, the Working Party felt that information governance issues need to be addressed, for example, ensuring that emails are not left in inboxes and making sure that the correct person receives the mail when there are multiple users with the same name. It was felt that users needed better training on these issues. The Acceptable Use Policy is being redrafted by the CfH NHSmail Team so that it is more user friendly.

After suggestions at the last Working Party meeting, NHSmail users can update their passwords from outside their place of work. In addition, the password expiry time will be extended from 42 to 90 days in the next upgrade as members felt that 42 days was too short.

NHSmail also provides a national directory of people in the NHS, which has over one million entries. NHSmail is centrally funded and therefore free to trusts. The BMA is represented on a National User Group and can feed back any local views. Further information on NHSmail is available on their website.

A recent user survey by NHSmail received over 11,000 responses. As a result, 13 improvements to the functions available to users have already been made including enhanced facilities to allow users to rename their folders and ability to sort their inbox by date and keep the setting. A further nine improvements are due for implementation.

Electronic Staff Record (ESR)
The Electronic Staff Record a single, standard payroll and HR system that is being deployed throughout the NHS in England and Wales. A number of doctors have expressed concerns about having their data stored on a centralised system. At the 2006 consultants conference, doctors voted that staff data should be protected by pursuing a staff charter, which sets out rights to privacy. The BMA has worked with the ESR team and we are hopeful that this will be signed off by the Department of Health shortly.

Devolved nations
The issue of IT links between the home countries was raised at the October BMA Working Party on NHS IT meeting. The particular issue concerns patients who live close to borders and ensuring that they are not disadvantaged by the non compatibility of IT systems. The Chairman of the BMA NHS IT Working Party has written to Richard Granger (Director General of IT for the NHS) as well as IT leads in Scotland and Wales to seek clarification on the issue.

Progress in Scotland
Scotland is also committed to developing an integrated record. Developments are based on existing structures such as the SCI Store (Scottish Care Information) and the Emergency Care Summary. These existing structures will be expanded and integrated to form the single record. The Scottish Emergency Care summary is reportedly going well, with access of records well into the thousands and very few patients requesting not to have their records included.

The BMA are awaiting results of an independent review of the General Practice Administration System for Scotland (GPASS) which has been completed by Deloitte. A draft report, seen by the BMA, says that the Scottish Executive Health Department intend completely disinvesting from GPASS over the next 36 months while procuring, through national contracts, general practice clinical systems capable of also supporting community based staff. A meeting has been set up to discuss this report.

The post of NHS Scotland Director of e-Health went to interview on 9^th October and failed to appoint to the position. There are fears that this will lead to further delays for IT implementation in Scotland.

Progress in Wales
Informing Healthcare is a national IT programme in Wales, which will be delivered through a series of projects and increased investment in IT. Further details on the programme are available at the Wales informing healthcare pages - visit the Informing Healthcare site. A BMA Welsh IT Subcommittee has been established, which meets regularly with the Welsh Assembly to discuss issues such as funding, priorities, data quality and the interface with the rest of the UK.

In recent meetings the IM&T Subcommittee in Wales discussed border connection issues and specifically the difficulty that will occur when England downgrade the National Health Applications and Infrastructure Services (NHAIS) computer system (previously know as the ‘Exeter’ system) which will mean that the Exeter links are no longer updated and therefore this system will rapidly become inaccurate and of no use to Wales. This will have an impact on patients and their access to healthcare. There is a Department of Health board overseeing the changes to the NHAIS system and the GPC have a representative on it. The DH will be asked to report on what actions they are taking on this issue. James Johnson (Chairman, BMA Working Party on NHS IT) has written to IT leads from the Department of Health and the Welsh Assembly Government to seek clarification.

Approximately 30 practices in Wales are already enabling their patients to order repeat prescriptions over the internet. Welsh Assembly Government hopes to be able to roll out the successful sample bar coding pilot to all practices this year.

Welsh Assembly Government has started work on electronic referrals to support any to any referrals. This specifically focuses on the design of the body of the referrals message at this point, i.e. the clinical information that is required to be communicated.

The Welsh Clinical Portal will provide one common user interface for clinical staff throughout Wales.

Progress in Northern Ireland
A ten year Information and Communication Programme (ICT) was launched in March 2005 by the Minister for Health, Social Services and Public Safety. A BMA cross craft sub-committee dedicated to Northern Ireland IT issues was set up to focus on these developments. There are a variety of individual projects some of which are at a more advanced stage than others. A NI ICT Strategy Board was set up by the Department of Health and is in place to oversee development of various ICT projects. A number of workshops will shortly be held with stakeholders to develop this strategy with an initial emphasis on GMS. There are a number of other projects already underway. The Board has overseen the GP ICT Modernisation Project which involved connecting all GP surgeries to the HPSS network and making available secure internet access and secure email on the HPSS system. This project was undertaken together with the Health and Care Number Project which has introduced a new unique patient identifier to be used across the HPSS.

The Department has entered into a contract with Hewlett-Packard (HP) Ltd UK for the development, installation and support of an Electronic Prescribing and Eligibility System (EPES) for Northern Ireland. Full roll-out to all Community Pharmacists is expected within two years. The BMA has hailed the automation of the prescription process and it is hoped that this project will reduce transcription errors and prevent fraud.

The Payments Calculation and Analysis System (PCAS) was successfully implemented in March 2005. Since then it has undergone major development work. Updates seem to have been successful but further work is required to modify the payments systems for GPs to accommodate changes to the GMS contract. This requires major changes within the PCAS system and a Business Case is being prepared for this work.

A Review of Public Administration aims to examine the ICT implications of the recommendations of the RPA in Health. There are 15 workstreams/projects which were set up as part of a Programme managed by a Reconfiguration Programme Board chaired by the DHSSPS Permanent Secretary. One of the projects is dealing specifically with assessing, planning and delivering the ICT implications of the proposed reforms. The BMA has a representative on this project group. The first task of the project was to identify the changes required to the existing ICT systems, infrastructure and services and any new provision which might be required.

For more detailed information on Northern Ireland IT issues please see the latest BMA NI IT Update which is available here.

BMA Working Party on NHS IT
November 2006

Appendix
Membership of the BMA Working Party on NHS IT 2006/07
Chair:
Mr James Johnson - BMA Chairman of Council

Members:
Dr Paul Miller - Central Consultants and Specialist Committee
Dr John Powell - BMA Health and Information Management Committee, former Chair
Dr Peter Tiplady - Committee for Public Health Medicine and Community Health
Dr Richard Vautrey - General Practitioners Committee, Negotiator
Dr Paul Cundy - Joint GP IT Committee, Chair
Dr Jo Hilborne - Junior Doctors Committee, Chair
Prof. Michael Rees - Medical Academic Staff Committee, Chair
Mr Michael Livingston - Medical Students Committee
Dr Michael Wilks - Ex-Chair Medical Ethics Committee and CRDB member
Dr John May - Patient Liaison Group
Mr Derek Machin - Private Practice Committee, Chair
Dr Greg Dilliway - Staff and Associate Specialists Committee
Dr Tony Calland - Medical Ethics Committee, Chair and Representative from Wales
Dr Stuart Scott - Representative from Scotland
Dr Jimmy Courtney - Representative from Northern Ireland
Dr Gillian Braunold - Connecting for Health National Clinical Lead – GP
Mr Simon Eccles - Connecting for Health National Clinical Lead – Hospital Doctor
Prof. Vivienne Nathanson - Director of Professional Activities
Mr Tony Bourne - BMA Chief Executive/ Secretary