The technological advancement of the healthcare service has been anything but straightforward. The NHS's £12.bn-plus National Programme for IT (NPfIT) suffered an annus horribilis last year, with the withdrawal of service supplier Fujitsu amid disputes over system changes and criticisms over delays and glitches.(1) This came shortly after the British Medical Association (BMA) said doctors were "disillusioned" with NPfIT after "slipping deadlines … and the premature release of systems that are not fit for purpose".(2)
Already 2009 has not been much better. In January, further delays to the NPfIT were announced,(3) and a BMA report found that doctors were still "struggling" with Choose and Book, with some finding it "not worth using".(4) In February, the chief executive of London's Royal Free Hospital said its new computerised records system, designed to link GP practices to hospitals, had caused "heartache and hard work" for the trust's staff.(5)
In this cranky computer climate, how do practice managers feel about their healthcare IT systems? Rather positive, according to the Management in Practice survey of 435 managers and associated GP staff, who were not only happy to utilise technology to benefit patients, but also were largely supportive of NPfIT measures, including Choose and Book and the Summary Care Record (SCR).
A quick breakdown of the respondents: the vast majority (79%) were practice managers; 8% were assistant practice managers, 5% practice directors or partners, and 4% business managers. The remainder comprised practice administrators and technical support staff.
Most (93%) were from England, and the clear majority (72%) worked in urban practices. This was an experienced lot: more than half (53%) of respondents had worked in general practice for more than 10 years. In terms of size and staff, there was a wide spread of results, though the average respondent's practice had a list size of 4,000 to 8,000, employing three fulltime GPs.
Uptake of IT services
As Figure 1 shows, practices seem to be embracing technology as a means to improve patient services and access, with more than three-quarters facilitating email requests for repeat prescriptions and one in five allowing new patients to register online. And while the 5% allowing email consultations is a small number, it nonetheless reflects a readiness to introduce new ways of communicating with patients that may have raised Luddite eyebrows just a few years ago.
Furthermore, 64% of practices had their own website, with another 16% planning to set one up. The clear majority said patients had benefited from this. A practice manager from Leeds said their website allows patients to "make appointments, request repeat scripts, [and access] self-help information, current topics, health information and online registration". Just a few cited concerns over costs/time involved in setting it up and with ongoing maintenance.
Just under half (46%) also had a practice intranet, with 10% planning to set one up. Again, the vast majority enjoyed the benefits of easy access to practice procedures/policies and enhanced communication, with a few lamenting the time needed to maintain it. But for some an intranet is essential: "We have had an intranet for six years now, and could not do without it," said a practice manager from Staffordshire. "It is a readily available store of information for both doctors and staff – we update regularly with useful clinical information, and holiday details, etc for other staff."
Responding to the survey results, practice management consultant Fiona Dalziel said: "What leaps out is how much practices have moved to embracing the opportunities that IT offers, especially in the last 2–3 years. I had been concerned that, with the move from practice IT budgets to central funding, innovation would be stifled and new developments would be introduced at a glacial pace; I appear to have been wrong!"
Tom Brownlie, Chief Executive of AMSPAR, was cautious: "It is reassuring to see that many practices want to embrace IT due to the benefits it can provide for their patients and themselves. This should be tempered by the fact that most of the respondents were from larger urban practices – and, of course, it was an online survey, so most would be IT exploiters."
To add to the general positivity, most said they were happy with the standard of IT support provided by their primary care trust (PCT) or health board (see Figure 2) – just 12% were unhappy, describing support as "poor" or "very poor".
Perhaps this is just as well, as just 6% of respondents had a budget for additional IT support, and only 24% said they employed IT staff within the practice.
Most practices clearly trained staff inhouse for using computer systems – just 11% said they had a minimum entry standard for staff using IT (eg, the European Computer Driving Licence or a demonstration of the necessary computer skills).
Choose and Book
Judging by this survey, many practice managers are supportive of Choose and Book (CaB), although opinion is starkly divided. Just over half (54%) thought that a practice's failure to engage in CaB disadvantaged patients, and 23% were unsure.
Nonetheless, nearly a quarter (23%) thought otherwise. Box 1 gives a sample of respondents' views both for and against CaB.
GP Dr Grant Ingrams, a member of the BMA's Joint IT Committee, said the divided results reflect how well CaB is actually operating across the country: "Put simply, if you're in an area where it's working well, you would conclude that patients would be badly affected if a GP wasn't using it. But if it didn't work well, you wouldn't think that."
Dr Ingrams is now using CaB to patients' benefit, but this wasn't always the case: "Two years ago, a referral for CaB would take me 20-plus minutes. And in a 10-minute appointment that's just not possible. It would stop working halfway through or it just wouldn't work at all – it was frustrating for me and frustrating for the patients."
Cathryn Bateman, Consultant Editor of Management in Practice, is a latecomer to CaB but did so to benefit her patients: "We are probably one of the last practices to take on CaB, and we only agreed to it because we were clearly disadvantaging our patients by not doing so," she said.
"Our local hospital was offering more CaB slots then 'other' slots, and patients seen through the CaB system were seen much quicker. Also, patients can be seen by a private provider on the NHS through CaB. Our local private provider would not take referrals through any other route."
But, says Dr Ingrams: "Choice is actually worse through CaB than it was when I started as a GP. There's still not an unlimited list of hospitals, whereas I used to be able to refer to anywhere in the country. And now CaB won't allow me to refer to a named consultant".
CaB link-up with hospitals is clearly a difficulty for many – 67% of respondents said the system should be more integrated with secondary care. "Information relating to patient demographics, referring GP, etc, should be directly added to the secondary database," said a practice manager from Yorkshire. "This would stop letters being returned to the wrong doctor." A manager from Lancashire said: "Secondary care asks us to tell the patient that their hospital appointment has been cancelled".
Shared care records
Indeed, a joined-up IT service seems to be desired by most practice managers. When asked what single innovation in general practice IT they would like to see, respondents overwhelmingly wanted an integrated and "compatible" information system between surgeries and hospitals.
Perhaps this is why practice managers seem largely in favour of the SCR: 66% of respondents believed this would benefit patients, with just 2.6% firmly believing it would not (the remainder were unsure or thought electronic records would not make a difference). Responses included:
Responding to the results, Dr Gillian Braunold, Clinical Director for SCR and HealthSpace, NHS Connecting for Health, said: "I am delighted by the positive reaction by practice managers. It mirrors the experience I have had at Management in Practice Events. Our managers understand the benefits the SCR will bring patients".
However, despite the support, security was a significant issue – just 35% thought the NHS Spine was secure; 27% said they believed it is not secure and 38% said they did not know. "History has shown that electronic records are never totally secure," said a practice manager from Donegal, Northern Ireland. "Everyone knows someone who works in the NHS, and therefore the potential for unauthorised access by 'authorised' personnel is there," said a practice manager from Cambridge.
Dr Ingrams echoed this comment: "You will always find someone who, for whatever reason, will abuse the system," he said. "That's one reason why the SCR should be a select summary, not people's whole life history. If I'm referring someone to have their toenails treated, why should that health professional have access to the patient's two miscarriages and a termination? We must protect patients' privacy."
In response to the MiP results, Dr Braunold said: "It is sadly commonplace for computer terminals to be left logged on and unattended in general practice and people to share log-on details. The Spine is a great deal more secure than our GP systems – however, we know that humans are the weakest point in any security system. Practices now need to ensure they comply with the higher information governance standards as they act as guardians of patients' information."
1. See http://www.managementinpractice.com/default.asp?title=NHScomesinforcriti...
2. See http://www.managementinpractice.com/default.asp?title=Doctors%93disillus...
3. See http://www.managementinpractice.com/default.asp?title=Furtherdelaysexpec...
4. See http://www.managementinpractice.com/default.asp?title=Doctorsstillhaving...
5. See http://www.managementinpractice.com/default.asp?title=Doctorsstillhaving...