Tuesday, May 30, 2006

"An Elephant--

a mouse built to Government specifications."

I may be paraphrasing slightly, but so says Lazarus Long in his collected sayings partway through "Time Enough For Love". Today my old friends on Radio 4 have been talking a lot about NHS IT which is a case in point.

Most UK readers who have visited their own surgery in the past 15 years will have been aware that their surgery is computerized. In the past decade we have become increasingly reliant on IT for prescribing and note recording. Indeed over the past 3-4 years many (over 80%) of practices have finally done away with those little brown envelopes (still referred to in GP circles as Lloyd George folders- dating back as they do almost 100 years to the National Assistance Act brought in by that eminent philland'-- ummm philanthropist who "knew my father"). We have gone "paperless" in the jargon of the day, though to look at my intray this morning you'd never believe it.

The process has been one of evolution. We started with green and black CRT DOS based systems which would hold records and run prescribing for us but were very slow and clunky when it came to data handling. We recoiled in horror when presented with the new fangled "Windows" systems of the mid '90's, but within three years had one installed. We have upgraded twice more from there and now the system will do just about anything we want it to, (and lots we don't, like nagging us to check the blood pressure of every third patient and ask toddlers -- oh, ok, fourteen year olds-- if they smoke).

This experience has been repeated in most practices up and down the country, at a variable rate, but always "demand led". There were perhaps 8-10 suppliers of GP systems in the beginning and these have dwindled over time to 2 or 3 "big" ones and a couple of bespoke niche suppliers. With each new release of their operating systems they have included features suggested by users or (more recently) mandated by changing contractual arrangements. The key has been slow piecemeal development.

The process has not been entirely painless. At each change of operating system some oddities have been thrown up by data transfers, (most spectacularly all our patients with allergies to any form of medication suddenly switched to having an allergy to deodorant on our last data transfer), but none have been unrecoverable and some, as above, have been a little amusing.

But now Big Brother (you remember-- the original one not the endemol rip off one) has decided to get in on the act and computerize the NHS for the good of all. No longer will we need to back our records up to our own secure servers. We are to get a "Spine" supplied by BB himself to do the job for everyone. Referrals will be based on "choice" and be as easy as "booking an airline ticket" (god forbid). We will all have an electronic health record so that anyone authorized anywhere in the NHS will have access to our full record at the click of a mouse.

So far the whole project is at least two years adrift and stands to come in at least three times over budget. The initial choose and book launch involved a tiny minority of practices and crashed within a few hours of launch, though like the "dead" man in MontyPython and the Holy Grail it "thinks it's getting better". Many clinicians have fears that BB will want others to have access to certain levels of the "Spine" for less than pure motives (e.g. the DSS or DoE).

We have legitimate fears that we are going to be presented with an Elephant at the end of this process. One can only hope that it won't turn out to be as pale as it is threatening to be at present.


Damian said...

Speak for yourself - our local GP in Notting Hill still uses little library card sized pieces of paper in envelopes. We tried to make an appointment once and I was told that my wife was not registered. I said she should be, because her registration appointment was straight after mine - I even held the door open for her. They came back on the phone and said that actually, she had emigrated. I said, "Why would she have done that, we've just emigrated here." Receptionist said that she'd told that doctor that and that it was written in the records. I said that sounds unlikely, given that we had never actually met the doctor - having only just registered. (They made her have a pap-smear before they would re-register her - some sort of punishment we assumed.)

Most recently she needed more Clexane (she gets DVTs) before a long haul flight. She sat down and asked for the prescription, in single dose syringes, and reminded the doctor of the dose. The doctor said, "You've only had glandular fever - you don't take Clexane for that." She agreed, and said she was recovered from the glandular and that the Clexane is for DVTs. He said that there is no record on her record. She said that there should be, because she had given it to them - about fifteen pages of letter, test results and medical history. He said she didn't, and he wasn't giving her the drug. She reminded him that Clexane is not exactly a party drug, and asked him how many people had casually requested it over the course of his career. He said none, and he couldn't just give it to her. She said he'd better, because she wasn't leaving until she did.

At that point, a stare down ensued. Now my wife is not your average Notting Hill yummy mummy. For starters, she's not a mummy. She is a hardcore investment banker, and you don't get there without being able to stare someone down. Slowly the rustling from the waiting room became louder and louder. She stared. His phone rang with and enquiry from the desk to see if everything was OK. She stared. He started to figit in his chair. She stared. He may even have perspired a little. She kept staring.

Finally he went to his cabinet, took out a handfull of samples and said, "How much do you need."

She thanked him, placed the syringes into her handbag, zipped it shut and left. Honestly, it's easier to get the stuff through customs.

So I say bring on a system that doesn't rely on the ability of three dessicated, resentful, old biddies who prefer to gossip about the patients than manage the records. Bring on the professionals!

(Phew, I think I'll go and post this on my own blog. And I'll send your URL to my brother - he's a doctor and he'll love it.)

Doctor Jest said...

Bloody Hell Damian.

That's something you don't see in Richard Curtis movies. Make a cracking scene in one though. And the getting through customs with the booty afterwards come to that...

Sorry to hear of Mrs D's troubles. I'd have to say that demarcates the difference between leafy Borsetshire and the grimy Inner Cities then. Round here you can't find a GP not hardwired to his / her IT.

The Smear thing is about "targets". All very Nu-labour (sic) and in no way intended to be punitive. It's just that in GPland "points make prizes", or more properly "if you don't do it we take cash off you".

Re the DVTs, has she considered the alternatives? I thought you hi powered city types did it all by video link nowadays, and for leisure why not cruise. no risk of DVT then, so no need for nasty jabs....

Ever helpful,

Damian said...

Alternatives? They put her on Warfrin after her first (well, actually second, but the first was undiagnosed) DVT, which turned into a pulmonary embolism the day after we attended Sydney Olympic Opening Ceremony, of all things. But Warfrin is dreadful stuff - makes her feel sick, wrecks her skin; and puts her completely out of sorts for the first week of taking it, and the first week of not taking it.

Doctor Jest said...

Sorry to hear that. I was meaning travel alternatives rather than alternative treatment options. I agree warfarin is a nuisance to use and must be a complete bastard to take.

I have this facetious streak which can get me in to trouble in consultation sometimes, but mostly is taken in good part by my long suffering vict-- I mean punters.

BTW where do you have to emigrate from to end up in Notting Hill?