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At the heart of general practice since 1960

A brave new world?

Steve Nowottny asks just how much the national IT programme will transform general practice.

Steve Nowottny asks just how much the national IT programme will transform general practice.

Watch the promotional videos and read the glossy literature, and the revolution in healthcare IT may as well be with us already. Shiny new systems making patient booking a doddle. Smooth referrals to a patient's hospital of choice. Seamless sharing of patient records, with nary a confidentiality concern or security breach in sight.

It's a tantalising vision – but at the moment that's all it is. So what might NHS IT really look like in five years' time?

The biggest change is likely to be with care records. Ever since its launch, the Summary Care Record has been a political hot potato. But in all the debate over consent models and confidentiality, what has been ignored is the impact it could have on the way GPs practise.

The most immediate effect will be in urgent care, with out-of-hours providers and A&E departments set to benefit from access to a summary of patients' medications and allergies. There will be benefits too for patients travelling outside their practice area, with records accessible anywhere in the country.

More generally, in a world of eight-till-eight polyclinics and increasingly fragmented care, continuity of record will become ever more important.

Dr Gillian Braunold, clinical director for the Summary Care Record, says: ‘GPs sometimes are strange. They'll say negative stuff about Connecting for Health and yet be quite keen on information sharing with Adastra and InPractice and EMIS. I think everyone understands patient information needs to be available where necessary.'

Beyond the Summary Care Record, detailed care records will allow local sharing of information across organisational boundaries.

Dr Mark Davies, medical director of the Information Centre, predicts major developments in the secondary use of patient records. ‘It will be about linking information across NHS organisations,' he says. ‘The most significant outcome will be measurement of health outcomes – Patient Reported Outcomes, patient experience and care quality indicators. This will be done routinely, as we do with the QOF.'

IT bosses expect referral through Choose and Book to be standard within five years. And other projects promise big wins.

Patients using Healthspace will be able to view their records and test results, book appointments and email their GP. The Electronic Prescription Service will enable GPs and nurses to send prescriptions electronically to a pharmacy of the patient's choice. And GP2GP will make six-week waits for records a thing of the past.

Pitfalls

Or maybe not.

GPs' unease over consent and confidentiality has been well documented, and even since the switch to ‘consent to view' there remain real concerns. Privacy campaigners warn audit trails may not be monitored and could be overridden.

Less discussed – and possibly more likely to affect GPs' working practices – are the clinical and medicolegal implications of a truly shared care record.

Dr John Lockley, a GP in Ampthill in Bedfordshire and chair of the iSoft User Group, explains: ‘Suppose one of my patients goes to Exeter and is diagnosed as having an asthma attack by a nurse practitioner. That is put on his national record. Then he goes off to, say, Rochdale, and is seen by a consultant who says it's not asthma, it's LVF. So you put LVF on the record, but you can't use a ß-blocker because the record says he's got asthma. Whose responsibility is it to change that original record? Maybe it's the nurse practitioner. But maybe she's gone back to Indonesia and nobody knows her address.

‘Every GP has had to go through notes removing errant entries. We can do that on our own systems because we've got absolute access – it's much more complicated when you can't affect something somebody else has written.'

GP confidence in the plans for care records may play a big part in their success or failure. Outright hostility may have been tempered by the U-turn on consent, but Pulse's survey suggests suspicions remain.

Only half of respondents say they plan to take part in the care record rollout, with a similar number planning to withdraw their own records. One in five GPs claim they plan to opt all their patients out of the scheme. Connecting for Health weathered

a threatened BMA boycott last year – but it's unclear how a wider rollout will go with such grass-roots opposition.

Patient confidence, too, could be crucial. Recent high-profile data losses could erode public willingness to allow records to be shared. One of the big unknowns is how the national programme would change if the Conservatives win the next election.

Official opposition

The Tories, recognising the benefits of improved IT but sceptical of the Government's approach, have commissioned their own independent review. It is led by Dr Glyn Hayes, former chair of the British Computer Society's health informatics forum, and with more than 50 written submissions already and hearings to follow, is expected to present policy options in March next year.

Conservative shadow health minister Stephen O'Brien won't prejudge the outcome, but insists there will be far-reaching changes if he makes it to Whitehall.

‘Patients are considerably more trustful of the doctor-patient relationship than any kind of Government super-computer system,' he says.

Instead, Mr O'Brien favours a bottom-up, locally led model with interoperability between systems a cornerstone. ‘I could see all these programmes will either be adapted or completely reconfigured,' he says. ‘There is a degree to which you could have a Summary Care Record consistent with my approach – if it had almost no information on it. But then is it useful?'

In the face of such uncertainty, there are signs the private sector may step in. Out-of-hours GPs in Liverpool were recently given access to thousands of shared patient records not by Connecting for Health, but through linking software from EMIS and Adastra. Similar pilots have been mooted for Gateshead and Tower Hamlets. Other software providers, such as TPP SystmOne, are exploring other aspects of data sharing.

Dr Trefor Roscoe, a GP in Sheffield and independent IT consultant, believes the next major IT developments are likely to be driven from the bottom up.

‘There are quite interesting commercial opportunities for companies such as EMIS because they've got such a wealth of experience in electronic records,' he says.

‘It's difficult to see where Connecting for Health is going to get over the next few years unless there are piecemeal approaches, local initiatives, and it slowly joins up.'

But the progress of primary care IT over the next five years may be heavily dependent on secondary care, which has lagged behind, warns Dr Lockley.

He asks: ‘How many consultants actually have a computer on their desk? Now many practices are paperless or paperlight, we're all sitting here waiting for the secondary sector to get its act together.'

What might IT in the NHS really look like in five years time? Five key challenges for NPfIT

• Consent and confidentiality – Connecting for Health's revamp of the consent system will help, but has it gone far enough in allaying GP and patient concerns?
• If different healthcare professionals in different parts of the country are adding to a single shared record, who will take overall responsibility and who will correct the errors?
• Patient support – high-profile data breaches have shaken public confidence in Government IT programmes: another big one could sink the project.
• Private companies – impatient with delays to the national programme, GPs could turn instead to local solutions developed by private companies.
• Political pressures – if the Conservatives win the next general election, the national programme's future looks uncertain at best.

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