We need to have belief in a paperless NHS

Aware of the short time that ministers are in a post, Jeremy Hunt decided when he became secretary of state for health that to make a difference he should have only four priorities.

‘A paperless NHS, the mantra goes, will mean safer, high quality and move convenient care’

They are, he told the Cambridge Health Network last Wednesday, improving the quality of care, putting dementia higher on the agenda, reducing mortality from conditions like cancer and embracing the revolution in information technology. The last, a process improvement, is, he has realised, very important for achieving the first three.

Many were surprised when Hunt was appointed as secretary of state, thinking that he was more likely to be sacked rather than promoted after his embarrassment with the Leveson inquiry. Some said that on television his boyish looks make it hard for him to achieve the gravitas that is expected of a minister.

But I have to say he did well on Wednesday, walking to the front of the stage, cracking a joke and then speaking without notes or hesitation of his determination to improve the NHS and make it paperless by 2018. Those in the audience, mostly hard-boiled men in crumpled suits, had between them about 10,000 years of experience of the NHS, whereas Mr Hunt has just a few months.

A paperless NHS, the mantra goes, will mean safer, higher quality and more convenient care and will avoid patients endlessly have to repeat their story. It should also, in the long run, reduce costs, put the patient truly at the centre of care and promote prevention and self-management. Importantly, it will be fundamental to integrating hospital, community and social care.

Flying blind

The government has set milestones to reach the 2018 target, which Mr Hunt pointed out is conveniently beyond the next general election. By April 2013 primary care must produce specified data. Hospitals must do the same by April 2014, and hospitals and primary care must be linked by April 2015.

Contracts have asked for basic data in the past but they have not been enforced, said Tim Kelsey from the NHS Commissioning Board at the same event, but in future they will be: no data, no funding.

Mr Hunt and Mr Kelsey also announced that they aim to have at least one region with hospitals, the community and social care fully connected and functional before the next election in 2015.

‘Connecting for Health has cast a long shadow over the NHS and probably held back progress’

The immediate reaction of the men in suits was “We’ve heard all this before.” I remember interviewing William Waldegrave when he was secretary of state in 1991, and him saying how it was essential to have good data on outcomes and costs in order to manage the NHS and how the internal market would produce such data.

In fact, said Mr Kelsey, we have no idea how many people in the NHS are having chemotherapy and what the outcomes are. That’s just one example of information failure, and a man from Monitor said how it was struggling to set tariffs because of the lack of cost data. Penny Dash from McKinsey described how she had been working with a major hospital on its strategy but had struggled because of the absence of good data. The NHS is flying blind.

Lessons learned

The current secretary of state recognised the scepticism but praised Labour for the aims of Connecting for Health. The aim, he said, was wholly right, but the means of top-down contracts without clinical buy in was wholly wrong. Connecting for Health has cast a long shadow over the NHS and probably held back progress.

Why, asked Pam Garside, one of the leaders of the CHN, will it work this time? First, Mr Hunt said, because the government has learnt from previous experiences and this project will be bottom-up not top-down. “I won’t be signing any big cheques,” he said.

Second, a population that uses the internet all the time is ready for it and expects it. Third, it fits with the big challenges of coping with an ageing population and keeping the NHS financially sustainable − an NHS that has seen an annual 4 per cent increase in funding in real terms for 30 years now has to cope without increases. Retail banking has cuts its costs by a third by moving customers online and the NHS should also be able to make savings.

As the audience made clear, out in the hurly burly of the NHS financial pressure may be the main driver to becoming paperless.

‘Confidentiality is another barrier. People worry a great deal about their information being hacked’

If paperlessness is achieved by 2018 not every patient will be obliged to interact with the NHS online, said Mr Hunt, which is just as well as curently 7 million people in Britain don’t have online access and 16 million don’t have sufficient computer skills to make an online transaction. These data came from Graham Walker, the CEO of Go On UK, an organisation that aims to make the UK the most digitally capable nation by 2020.

Design systems, he said, not for the early adopters but for the late adopters. But he is enthusiastic about the NHS embracing technology because health is the issue people care most about online − so a paperless NHS will encourage more people to “go digital.”

Technology sideshow

Most of those in the audience were excited by the vision of a paperless NHS and didn’t need to be convinced, but they worried about the practicalities of getting there. The technology is a sideshow, said one medical director; this is a huge change management project.

It will take time to convince everybody and who will pay? Producing a business plan is a challenge. “Where are the incentives?” asked a manager. The incentives are both positive and negative, said Mr Hunt and Mr Kelsey: no data, no money; but progress can mean better services for patients and reduced costs.

Many of those at the meeting were from the private sector, and the private sector will be one of the main players in achieving a paperless NHS. But, said several speakers, NHS procurement is a nightmare and doing business with the NHS is always difficult. Mr Hunt and Mr Kelsey both promised improvements, and the latter is holding a day-long meeting for technology entrepreneurs.

Everybody agrees that convincing clinicians is essential. Mr Hunt said he’d learnt that consultants are more important than senior managers in hospitals. (What he may not have learnt, I thought, is that consultants may have the greatest influence but it’s often not over all their colleagues. They are more effective at stopping things than making them happen.) Clinicians, said a businesswoman, tend to want evidence from randomised controlled trials, but such evidence is hard to produce for these schemes.

Persuasion needed

Confidentiality is another barrier. Some people worry a great deal about their information being hacked, and, said Mr Kelsey, the social contract demands that if we are going to make anonymised data widely available then we have to have the highest standards of information governance. Some programmes that currently exist will no longer be acceptable.

‘Creating a paperless NHS is more a dream than a reality, but that was also the case with banks’

Please stop talking all the time about hospitals, said Baroness Cumberledge, a former Tory healthy minister. District nurses, not GPs, are the people, she said, who keep patients out of hospital; and their numbers have declined by a quarter in the past 10 years, and they are using the most primitive information tools − exercise books. They should be some of the first to be helped with technology, not least to increase their productivity from seeing only four patients a day.

Another member of the audience criticised those in the NHS for always talking about health and social care and then forgetting social care, while somebody else wanted much more emphasis put on prevention.

Research was mentioned only in the last gasp of the meeting, and even then the emphasis was on how better data plus genomics could mean growth for “UK plc”.

Luis Alvarez, the CEO of BT Global Services, started the event by saying he thought this was an evening that would long be remembered. Creating a paperless NHS is more a dream than a reality, he said, but, as a former banker he remembered when that was also the case with banks. But banks have done it.

Asked at the end what was needed to achieve a paperless NHS he answered “belief”. Most of those in the room believed, but some outside don’t and they will need to be convinced.

Richard Smith works for UnitedHealth, and UnitedHealth UK, one part of the company, was one of the sponsors of the meeting. He is the chairman of Patients Know Best, a start-up that is working to improve connectivity in the NHS. He has shares in the company and so could benefit financially from a paperless NHS. He is also a former editor of the British Medical Journal.