PART IV : NATIONAL SERVICES
E- Government Interoperability Framework
• Infrastructure in NHS organisations.
National Services
Part IV describes the range of national services which will be implemented and supported by the NHS Information Authority. Local solutions will need to integrate with these services, and
conformance to published interfaces will be a mandatory requirement.
These services cover three main areas: infrastructure services, application services and information services. Relevant examples of each are given below:
• infrastructure services: includes the core networking facilities, security and confidentiality services and core services such as e-mail and directory;
• application services: includes operational areas such as the Health Records Infrastructure, NHS Strategic Tracing Service and NHS Direct Clinical Assessment System, together with the more analytical services such as the NHS Wide Clearing Service. A range of business support services is also being implemented, including the Electronic Staff Record Service;
• information services: includes the National electronic Library for Health, nhs.uk and the development of support for e-learning and the NHSU.
Consultation
We are anxious that as full a consultation as possible takes place with NHS IT directors and staff, clinical and GP leads on IT and NHS IT industry and suppliers around both ICRS and national standards and specification. Comments on the Integrated Care Record Services should be directed to the National IT Programme Office by 31st August 2002 [email protected]. We welcome comments on the following issues:
• is the vision for ICRS consistent with the overall objectives for the NHS ?
• what phasing of ICRS functions is required in order to create a long-term basis for growth, whilst meeting specific targets and objectives in the shorter-term ?
• are there any major gaps in the specification which need to be filled ?
• is the level of detail sufficient for the procurement of such services ?
• are the standards and national services appropriate to support implementation of the local services ?
Part I : Overview
1. INTRODUCTION
1.1 Context
1.1.1 April 2002 brought three key developments for the NHS:
• increased investment in the NHS from the 2002 Budget – more investment to fund a ‘catch-up’ period leading to health spending of 9.4% of GDP by 2008
• the publication of Delivering the NHS Plan – that sets out how the new model for the NHS and extra investment will bring improved services to patients
• the final Wanless report on securing the future health service.
1.1.2 Together they mark a watershed in both the funding and future of the NHS and the role of IT in securing the most from increased investment, driving forward reform and delivering prompt, convenient and high quality health and social services.
1.1.3 Delivering the NHS Plan develops the vision already set out in The NHS Plan of a
“service designed around the patient”. Patients will be offered more choice of where and when they get treatment.
1.1.4 IT in the NHS will support that vision and empower both patients and professionals by offering explicit choice, for example with information about access to and performance of services. By the end of December 2005 every hospital appointment will be booked for the convenience of the patient, making it easier for patients and their GPs to choose the hospital and consultant that best meets their needs. This will be supported by electronic booking systems. By the end of December 2005 the first generation of electronic records will also be available. IT will support the frontline delivery of care and treatment, though it will be 2008 before the full array of clinical applications and functionality from electronic records are available in all PCTs and Trusts.
1.1.5 Delivering the NHS Plan also clearly states that a greater share of the new funding will be provided for training, capital infrastructure and modernised IT to ensure that the large extra investment the NHS is now getting is translated into reform and capacity growth.
This will take the form of a step change in capital spending, higher investment in information and communication technologies and the training and enabling of health professionals.
1.1.6 The Wanless report has several key recommendations for IT in the NHS including a doubling of IT spending that is protected to ensure it is not diverted for other purposes, stringent national standards for data and IT that are set by the centre and better management of IT implementation. It states, “without a major advance in the effective use of ICT, the health service will find it increasingly difficult to deliver the efficient, high quality service which the public will demand. This is a major priority which will have a crucial impact on the health service over future years.”
1.2 National IT Programme for the NHS
1.2.1 The national strategic implementation programme – Delivering 21st Century IT : Support for the NHS - is concerned with major developments in the deployment and use of Information Technology (IT) in the NHS. It aims to support the delivery of the NHS Plan through the use of modern information technologies to:
• support the patient and the delivery of services designed around the patient, quickly, conveniently and seamlessly;
• support staff in the delivery of integrated care, through effective electronic communications, better learning and knowledge management, cut the time to find essential information (notes, test results) and make specialised expertise more accessible;
• improve management and delivery of services by providing good quality data to support NSFs, clinical audit, governance and management information.
1.2.2 The national strategic implementation programme focuses initially on the NHS but developments in Social Care will be taken forward in parallel so that services can be integrated as and when local communities are ready.
1.2.3 The major change proposed is to move away from the concept of a number of separate information systems based primarily around organisational structures and with which health and social care professionals interact, to a situation in which professionals are provided with access to an Integrated Care Records Service (ICRS). This service will include access to records, the functionality needed to support clinical practice and supporting services training and helpdesk. ICRS incorporates the Information for Health concepts of both the organisation-specific Electronic Patient Records and also the cradle-to-grave Electronic Health Record.
1.2.4 The strategic programme and new approach is summarised by the following diagram.
Figure 1 – National Strategic Programme
Build
Partner with eGov & IT industry to deliver compliant, open systems & clinical applications
- National, regional , local , phased approach - EPR standard system specification first priority
Accelerate connecting the NHS with secure broadband
Build national data and data-interchange standards based on open XML technology
Create foundation services for NHS IT architecture - authentication, consent & confidentiality
National direction and performance management of IT - manage funding, procurement process, application portfolio
- assist introduction of new working practices - capture & re-use experience / knowledge
1.2.5 At the very heart of the strategic programme for IT are four major national deliverables:
the infrastructure, prescriptions service, bookings service and care records. This document provides the specification to take forward the pillar relating to the integrated
care record service; this document will be used to support the procurement and implementation activities.
1.2.6 This document is being published with a summary of the procurement strategy and will be followed in September 2002 by the full procurement strategy document and next version on ICRS following this initial consultation. At this stage, it describes the overall vision for integrated care records, and should be read in this context.
1.3 Structure of this Document
1.3.1 The specification comprises the following:
PART I – OVERVIEW
1. Overview of Requirement
2. Vision of Integrated Care Records Service PART II – OUTPUT REQUIREMENTS
3. Generic Functions 4. Specific Requirements 5. User Environment 6. Delivery Requirements 7. Service Requirements PART III – STANDARDS
8. Standards
PART IV - NATIONAL SERVICES 9. National Services
1.3.2 A number of source documents have been used in the development of this specification, including the Output Specifications from the South West EPR, London Mental Health, London Primary, Community and Social Care Records and the Academy of Colleges Clinical specification. Additional material has also been used from the Primary Care Information Board, the Pathology Modernisation Project and those involved in the development of the Diabetes Information Strategy.
1.3.3 This document is a draft and will continue to be developed. There are a number of known gaps (eg support for other NSF areas) and work will be commissioned to address these. Following this round of consultation, formal version control will be exercised by the NHS Information Authority on the specification from September 2002.
1.3.4 The specification has been deliberately pitched at a high level at this stage. Within the requirements section, a range of functions has been described. At the end of each sub-section, there are boxes with numbered questions for suppliers to complete. These questions are intentionally broad, in order to give suppliers more scope to describe their proposed solutions.
2. OVERVIEW OF INTEGRATED CARE RECORD SERVICE
2.1 Context
2.1.1 The NHS Plan has set out the vision of a service designed around the patient. This section describes what this means both for the health service and, more specifically for the IT needed to support it.
2.1.2 The announcement of the Spending Review 2002 (July 2002) set out the Public Service Agreement targets for the NHS. The prime objectives for the National Health Service are to:
• Improve service standards;
• Improve health and social care outcomes for everyone;
• Improve value for money.
2.1.3 The full set of agreed targets are shown overleaf in Table 1.
2.1.4 “Delivering the NHS Plan” set an agenda for achieving the necessary reform, to include:
• expanding capacity;
• incentives for performance;
• choices for patients;
• plurality and diversity;
• strengthened devolution;
• health and social care; and
• strengthened accountability.
2.1.5 Delivery plans are being developed for each of the priority areas of work for the Department of Health and the NHS. These are underpinned by four requirements that are common to all:
• Values;
• Networks;
• Standards;
• Information.
2.1.6 The exploitation of information and communications technology to support care processes is a critical component of delivering the NHS Plan and the development of new patient focused services. Increasingly, care professionals should be able to rely on information systems and technology to support them in undertaking specific care activities with individual patients or service users; and in the operational management of those care services.
2.1.7 However, it is vital that such plans for information address the needs of the whole health family. Any attempt to create a solution for just one issue (eg one NSF area) or organisation would compromise the working of the NHS system. We need to cover the full care continuum and for the NHS that will include acute, community and primary care trusts, Foundation trusts and GP practices. The specification described in this document therefore intends to capture the overall requirements for all health and social care users.
Table 1 – Public Service Agreement (PSA) Targets for the Department of Health (Spending Review 2002)
Aim: Transform the health and social care system so that it produces faster, fairer services that deliver better health and tackle health inequalities.
Objective 1: Improve service standards
1. Reduce the maximum wait for an outpatient appointment to 3 months and the maximum wait for inpatient treatment to 6 months by the end of 2005, and achieve progressive further cuts with the aim of reducing the maximum inpatient and day case waiting time to 3 months by 2008
2. Reduce to four hours the maximum wait in A&E from arrival to admission, transfer or discharge, by the end of 2004; and reduce the proportion waiting over one hour.
3. Guarantee access to a primary care professional within 24 hours and to a primary care doctor within 48 hours from 2004.
4. Ensure that by the end of 2005 every hospital appointment will be booked for the convenience of the patient, making it easier for patients and their GPs to choose the hospital and consultant that best meets their needs
5. Enhance accountability to patients and the public and secure sustained national improvements in patient experience as measured by independently validated surveys.
Objective 2: Improve health and social care outcomes for everyone
6. Reduce substantially the mortality rates from the major killer diseases by 2010:
from heart disease by at least 40 % in people under 75; from cancer by at least 20 % in people under 75.
7. Improve life outcomes of adults and children with mental health problems through year on year improvements in access to crisis and CAMHS services, and reduce the mortality rate from suicide and undetermined injury by at least 20 % by 2010.
8. Improve the quality of life and independence of older people so that they can live at home wherever possible, by increasing by March 2006 the number of those
supported intensively to live at home to 30% of the total being supported by social services at home or in residential care.
9. Improve life chances for children, including by:
• Improving the level of education, training and employment outcomes for care leavers aged 19, so that levels for this group are at least 75% of those achieved by all young people in the same area, and at least 15% of children in care attain five good GCSEs by 2004; (The Government will review this target in the light of a Social Exclusion Unit study on improving the educational attainment of children in care)
• narrowing the gap between the proportions of children in care and their peers who are cautioned or convicted; and
• reducing the under-18 conception rate by 50% by 2010.
10. Increase the participation of problem drug users in drug treatment programmes by 55 % by 2004 and by 100 % by 2008, and increase year on year the proportion of users successfully sustaining or completing treatment programmes.
11. By 2010 reduce inequalities in health outcomes by 10% as measured by infant mortality and life expectancy at birth.
Objective 3: Improve value for money
12. Value for money in the NHS and personal social services will improve by at least 2% per annum, with annual improvements of 1% in both cost efficiency and service effectiveness
2.2 IT in the NHS
2.2.1 Historically, the NHS has not used or developed IT as a strategic asset in delivering and managing healthcare. While there have been good, usually local, IT initiatives sponsored by enthusiastic visionaries, these have been outweighed by the overall lack of funding and development priority given to IT at all levels.
2.2.2 In 1998, the NHS recognised that IT had a major role to play in healthcare, and
“Information for Health” (IfH) defined the strategic approach for the use of IT. Since the advent of IfH, there have been improvements in the level of IT funding and in the uses that are made at local, regional and national levels. However, there remain a number of critical barriers to the effective use of IT as a strategic tool in the delivery of healthcare by the NHS, including:
• small amounts of protected IT funding that has had low priority for many Trusts – leading to very low levels of investment;
• lack of a national mandate and direction and lack of a cohesive, nationally-led IT architecture for data and system standards that allow information and processes to follow the patient’s journey through the NHS seamlessly;
• the need to improve co-ordination of IT resources and procurements to increase the pace of implementations and provide fast, better value for money IT projects;
• low levels of secure, high-bandwidth connectivity for NHS staff, backed by means of authenticating users to access sensitive patient information.
2.2.3 The publication of the NHS Plan in 2000, and the work that has since been underway to implement the Plan, has brought about a key change in the attitudes and structures and overall philosophy in the planning and delivery of care services.
2.2.4 The fundamental premise is that the NHS is moving towards care services which “offer people fast and convenient care delivered to a consistently high standard with services available when people require them, tailored to their individual needs.”1
2.2.5 The key principle is that there are care services designed around the needs of patients and service users and not based on NHS institutions.
2.2.6 This means that the information systems which directly support patients and service users, support professionals in providing care, and support those involved in planning and running the NHS, also need to be designed and delivered based on the needs of the patients and service users, not the institutions.
2.2.7 This represents a shift from the current situation, where systems are generally run along institutional lines and therefore only deal with a portion of an individual patients’
interactions with the NHS – they deal with sections of the total patient journey
2.2.8 The vision for information and IT is therefore to connect delivery of the NHS Plan and the modernisation of care services with the capabilities of modern information technologies to enable that modernisation process to be more effectively delivered.
2.3 IT Support for the 21st Century NHS
2.3.1 It is possible to identify a number of key themes which the Government intends should be reflected in the future including:
1 The NHS Plan
• The use of integrated care pathways will integrate care for patients, health care professionals, and between health care organisations and care settings;
• Co-ordination and collaboration in the planning of integrated services across NHS organisations, local authorities and other agencies and the allocation of resources for groups of patients and service users;
• Informed patients, service users, carers and local populations, who are able to participate in decisions on the care that they should receive;
• Accessible services, which are responsive to the changing expectations of patients and service users;
• Evidence based care that is effective in achieving outcomes;
• Patient safety through quality-assured services that are regularly monitored and reviewed and guarantee “equity” in care across the care communities;
• Efficient services that are benchmarked both locally and on a national basis.
2.3.2 Figure 1 illustrates at a high level the range of services which need to be supported and the normal settings within which those services are delivered.
Figure 1 – Range of services to be supported
Promotion
Investigation / Assessment / Diagnosis Treatment/Care Inputs
“Rehabilitation
Primary and
Community Care Secondary
Care Tertiary and
specialist care
Maintenance / Respite / Palliative Care
Social Care
Integrated Programme of Care for a Population, Patient or Client Group
Screening and surveillance Prevention
Care Continuum
2.3.3 Based on this context it is clear that the service must support the provision of all of the components of care that an individual patient or service user requires. These are not confined to a single care setting, or provided by an individual organisation or group of care professionals.
2.3.4 In an NHS designed around the patient we need to recognise that patients have an increasingly sophisticated relationship with care services, and that their relationships are with multiple institutions and across a continuum of care. It is useful to consider care required by individuals in terms of the care continuum, which extend over time and across care settings, care professionals and organisations.
2.3.5 For example, the care of a particular condition such as a stroke may involve:
• an initial urgent call to an Out of Hours Service;
• emergency patient transport services and an emergency admission to an acute
• emergency patient transport services and an emergency admission to an acute