Shared ambition - but double standards....

In between the joys and pain of routine General Practice I have been spending rather more time on the work 'behind the scenes' with the sharing of clinical information to benefit clinical care.

Whatever the care setting, whoever the clinician and (almost) whoever the citizen or patient, all seem to agree that better sharing of information is essential to improve care and efficiency. We all claim to share this ambition.

In our real world however it is all too easy to sit back and wait in vain for leadership and directives to 'share' informations, drop our barriers and 'open up' the data. And here I must point to the lessons of the last few years. When there are central/national efforts to begin sharing, create opportunity and aspire to a new way of working WE ALL have a tendency to be defensive. We express concern over the lack of ambition - or the excessive scope, we argue over complex security processes - or the difficulty of access, we demand detailed information governance scrutiny - but trust Tesco with intimate details. So though an unpopular message, I believe all of us are at fault for the painfully slow progress of some National projects with amazing potential. The Summary Care Record best exemplifies this problem.

But amid the public and sometimes vitriolic criticism of perceived 'top-down' initiatives, we are witnessing significant progress with local schemes. Sometimes in small or discrete communities, sometimes based around organisations and sometimes around IT systems. One of the common features linking success is 'local ownership', with understanding and drive for local benefit. Within such local schemes it is possible to take control of the sharing agenda, and choose to blur the rules and guidance on security, governance and consent, for a clear and shared aim to improve care and safety. And this IS reaping local benefit - for patients and communities.

So what does this mean for National initiatives? Well, I hope that we can all learn from local success, without developing new and isolated islands of sharing with no ambition to engage with a wider community. 'I've solved my problem' is not a strategy for success in a National Health Service.

I hope that the 'Information Governance Review' under Dame Fiona Caldicott will help to re-establish a level playing field for information governance, that we can use what is left of the shrinking National Informatics resource to share innovative practice. I also still hope that clinicians and commissioners will re-look at National products NOT as a problem to be tolerated, but as an opportunity to use as part of a bespoke 'local solution' to information sharing - between organisations and with citizens.

And for citizens and patients viewing their own records? To learn quickly how to make best use of this opportunity, not telling citizens what to do, but responding to their suggestions, the requests for interaction and a new level of trust and shared control. The 'cutting-edge' enthusiasts, the reluctant followers and the 'sceptical laggards' all have a role to play. Access to GP records is a tiny element in the change we are all witnessing, that we cannot control, and that threatens the 'comfort zone' of care providers like myself. I think I am learning that although we share ambition this will not be a comfortable ride!

Peter S.

Records Access & 'The Big Picture'

Well the Christmas & New Year 'disturbance' is over - and life in the land of General Practice returns to normal (chaos) - amid the wind and rain, heated public debates over health, and ongoing economic gloom.

And will 'Records Access' solve the dilemma for the NHS of increasing demand, tighter financial limits and ever closer scrutiny? Probably not.... No DEFINITELY NOT.

So where does it 'fit in' to future healthcare evolution? Well there are interesting debates going on in many circles, and perhaps that is in itself a sign of change to come, a willingness to consider a more mature and interactive relationship, utilising new media and information sharing opportunities. And as ever there will be polarised views, those who resist 'risky and unsound change without an overwhelming evidence base', and on the opposite side the evangelists who find it hard to understand and sympathise with an often conservative profession that has real concerns about the risks and implications of radical change. So in the middle ground sit the majority of practices, interested to learn more at their own pace, nervous that they have no spare capacity for new 'innovations', and uncertain when and how to proceed and how access fits into the big picture of health and social care.

On top of the list of questions seems to be 'will Records Access' deliver benefits? And here the answer may at the moment be 'not on its own'.
So if not in isolation - what role may it play and why should we consider it?

Well the evidence so far in the UK and Internationally seems to suggest to me it may have an important role to play when combined with actions, transactions and communication. With the record, if we just 'look at it' little changes, the lesson of digital expansion and the internet is that the ability to 'do things' could radically move the agenda forward. GPs have learnt this lesson painfully over 25 years, moving from paper to electronic records - the exciting bits are when we 'do thing's with records - exchange information, audit, decision support and many other 'digitally enabled' functions. So perhaps I should worry less about 'Records Access' as a subject or target and start to think about the opportunities for efficiency and innovation, how this first step enables self-care, healthy choice awareness and to have the data to populate their own 'healthcare management' system and do other thing beyond my current experience and imagination.

So as I work to stimulate interest from selected patients in my surgery I do so with a realistic expectation that 'Records Access' is not my goal, but more likely to be a step in the right direction to patients taking back some of the burden, responsibility and interest in their own health, and in doing so to help me look after them better.

It's good to have ambition!

Peter Short (glass-half-full)

BRAVE NEW WORLD!


Hello brave readers, and welcome to my first ever ‘blog’! This is an attempt to inform, engage, delight and frustrate (bore) anyone else who has an interest in seeking, or granting, patients a real time electronic view of their own GP medical record. I will be doing this by recording each step of the way, sharing the joy, pain and experience + a number of irrelevant pictures.

But to avoid being rude some introductions are needed.

My name is Peter Short and I am a General Practitioner in Buxton, Derbyshire. This has been my base for nearly 23 years as a family practitioner performing the usual mix of doctoring functions to the best of my ability. My practice is one of three in our town, and serves 9,000 patients in addition to supporting local Community Hospitals. (I have no need to advertise – they are all ‘good’ practices!)

In addition for more than three years I have been giving clinical advice to NHS Connecting for Health, as a working GP with experience of the joys and challenges of transferring to a world of electronic records. To be very clear, this ‘blog’ is not an attempt to spread policy from any particular organisation, but rather a personal open exploration of what ‘access’ entails and might achieve.

So why am I embarking on the challenge of giving ‘Records Access’ to my patients now, and reporting on the process as I go along? Well there are a number of reasons I can clearly identify, but also some doubts I need to resolve for myself by going through the process. The current political aspiration is to ‘put the patient in control of the Health Service’, and to anticipate that they will ‘hold the NHS to account’. As a clinician with plenty of face-to-face contact each week with live and very interactive patients, I feel they already hold me closely to account! They can get a copy of the full electronic GP record already under the Data Protection Act, but it takes time and there is a cost. I cannot remember the last time one was requested, but I have provided paper and electronic records to people moving abroad or working away for long periods.

For me, and my practice, the key reason for giving access is not patient demand, policy pressure, financial inducements or commissioning necessity. It is instead an exploration of how sharing the patients own record with them can further enhance mutual trust, improve the knowledge and care experience for all parties, and perhaps more fully involve the willing, enthusiastic patients in their own care planning and delivery. Nothing if not ambitious! To work this new development must benefit the patient and the practice – and hopefully the NHS.

I am well aware that some highly enthusiastic practices have had active patients sharing records for years, but have doubts about what we can do without the same level of commitment. Some of our doubts have been reduced by publications such as the Royal College of GPs  ‘Electronic Records Access’ guidance – but there is nothing like doing it yourself to check that theory CAN be translated into real life.

We are starting from a position of confidence that ‘on-line’ access to GP records in a secure way is possible, and building on cautious implementation of appointment booking and repeat medication ordering.

Looking back on these changes we can reflect how nervous we felt in 2007 that appointments would be ‘consumed’ on-line leaving no day-to-day flexibility, and that medication requesting would be haphazard and hard to control. In fact nothing of the sort happened, and usage of these functions grows year on year – seemingly very popular with our patients without the anticipated feeling of ‘loosing control’. Reviewing our activity is seems to nearly double each year – so we must be doing something right! We are also able to see that the bulk of use is during the day, when the surgery is open – so we are confident we are saving receptionist time. There is also significant activity in the evening when we are closed, and during the first 4 years over 1,400 appointments were cancelled on-line, equating to a minimum of 234 hours of doctor/nurse time saved.

So where am I starting?

Re-reading the ‘Electronic Records Access’ guidance, involving my practice and patient participation group, then activating the software on ‘dummy’ patients. I also want to target my patients to see what they think about the idea before they start, and later the reality of access to records. Is it easy or worthwhile, do they have confidence in the security and in the aims of the practice, and does it make a positive difference to their lives and healthcare? I will have to think of the most useful questions. Do you have any suggestions?

Next time I will have to put down my plans and expectations, and perhaps later point you to other sites where GP surgeries have done this well for years!

See you soon, and feel free to post comments,questions and suggestions.

Peter Short