Richard Smith: A paperless NHS by 2018?

Richard SmithCognisant of the short time that ministers are in post, Jeremy Hunt, decided when he became Secretary of State of Health, that to make a difference he should have only four priorities. They are, he told the Cambridge Health Network on Wednesday night, 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. And 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 Hunt has just a couple of months.

A paperless NHS, the mantra says, will mean safer, higher quality, and more convenient care, and will avoid patients endlessly having 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.

The government has set milestones to reach the 2018 target, which Hunt pointed out is conveniently beyond the next 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 have not been enforced, said Tim Kelsey from the NHS Commissioning Board, but in the future they will be: no data, no funding. Hunt and Kelsey also announced at the meeting 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.

The immediate reaction of the hard boiled men in crumpled suits was “We’ve heard all this before.” Indeed, 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 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 lack of cost data; and 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.

Hunt 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 Cambridge Heath Network, will it work this time? Firstly, answered Hunt because 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. Secondly, a population that uses the internet all the time is ready for it and expects it. Thirdly, 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% increase in funding in real terms for 30 years now has to cope without increases. Retail banking has cut its costs by a third by moving customers online, and the NHS should also be able to make savings.

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

If paperlessness is achieved by 2018 not every patient will be obliged to interact with the NHS online, said Hunt, which is just as well as curently 7 million people in Britain don’t have online access and 16 million people 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-and so a paperless NHS will encourage more people to “go digital.”

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 Hunt and 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. Hunt and Kelsey both promised improvements, and Kelsey is holding a day’s meeting for technology entrepreneurs.

Everybody agrees that convincing clinicians is essential. I’ve learnt, said Hunt, 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 of their colleagues. They are more effective at stopping things than making them happen.) Clinicians, said a businesswoman, tend to want evidence from RCTs, but such evidence is hard to produce for these schemes.

Confidentiality is another barrier. Some people worry a great deal about their information being hacked, and, said 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.

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 evening by saying that he thought that this was an evening that would long be remembered. Creating a paperless NHS is currently, he said,  more a dream than a reality, but, 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 will need to be convinced.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Competing interests: RS works for UnitedHealth, and UnitedHealth UK, one part of the company, was one of the sponsors of the meeting. RS has no responsibility for UnitedHealth UK. RS is also the unpaid chair 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.