‘Oh great! Yet more change! And the world's biggest IT programme for them to screw up. Just what we need!’ Working as local clinical lead for the National Programme for IT (NPfIT), such comments are routine. For all the talk of clinical engagement it seems that the old NHS duchess ain't moving into gear yet, no matter how many fancy new IT cogs she gets. And, of course, it is easy to get engaged to the software when it's all dressed up in flimsy vapourware but, like any long-term relationship, making it work is about getting through the trouble and strife.
But I am an NPfIT enthusiast. Choose and Book may not be to your taste (although I think in a world of online holidays, and e-Bay we will wonder what all the fuss was about once it is up and running). But the Care Record Service (CRS) promises to integrate services across settings in a way that has huge benefits for patients and clinicians.
Initially hospitals and GP systems will communicate via the NHS Information Spine but, over time, all patient records, including primary care data, will be stored in a few large data warehouses. As GPs we will still look at this data set via a proprietary front end, supplied by EMIS, Torex, or whoever — but, in principle, primary and secondary care data within any region will form a single dataset.
At this point it becomes possible to unbundle the NHS. Providing a diabetic service to half a million people will no longer depend on the ability to access 10 000 paper records held in five different hospital basements. Consequently, it will be much easier for new providers to enter the market. If I can read what the pharmacist providing anticoagulation did this morning, and the results of the outpatient appointment this afternoon, then services no longer need to be provided by monolithic hospitals. Or by 10 000 small, under-capitalised general practices.
Instead of unpopular hospital closures, services will be unbundled: the A&E and trauma departments stay open to avoid a local political firestorm, Nuffield wins the contract to turn Out Patients into an integrated geriatric service, 70% of which is delivered in the community, and all other services are transferred up the road to St Elsewhere's.
The ability of CRS to unbundle the NHS will bring many changes. Joint ventures between practices, vertical integration of practices with secondary care, and alternative providers of GP services are all possible — many driven by the limited liability partnerships outlined in the adjoining article. The trick will be to seize these opportunities to bring a radically different version of primary care into being, one that combines high bioscience and community, but also retains the best of NHS values.
- © British Journal of General Practice, 2004.