Political "Top-Trumps" and GP Record Access

No postings for more than 10 months - and no-one noticed…..

I have moved from GP partnership into the world of a 'Portfolio' GP, maintaining clinical practice at my former surgery, but working for HSCIC across a broader remit to link projects and programmes closer together, for patient and clinician benefit.

In England there has been consistent work going on 'behind the scenes' leading up to a flurry of activity in March to activate online interaction between citizens and General Practice. So with the publication of achievement figures today, there is a sense of surprise and amazement that the landscape of opportunity for citizens has changed so much.
Of course the sceptics will argue that 'only' around 5 million people are currently registered to use these types of service, and that very few yet go as far as to access the medical record elements.
While that is true, there are several markers of a 'step change' in attitude to the opportunity, approach and demand for digital interaction with Primary Healthcare services:

• General Practices themselves turned on the functionality - a positive attitude
• NHS England and GPSoC worked to educate and enable - facilitation NOT enforcement
• Improvements in Patient Facing Functionality - a market waking-up to opportunity
• BMA commitment to work with NHS England - constructive dialogue to expedite benefit
• Alignment with future strategy - Five year forward view

So I am very optimistic that General Practice IS leading the journey of discovery about how citizens and Health & Social Care services can effectively and safety interact in a virtual environment. We all need this to work, to mitigate the politically unpalatable reality of demand outstripping the resources we currently have, without radically new different ways of working.

Digital interaction, with supported self assessment and management, improved signposting and the effective delivery of a virtual service to support healthy choices and rehabilitation, is a major part of the ambition in the next 5 years. Without it the Health and Care services may well soon sink under the burden of 'wants' and 'promises'.

Health and Care services are there to deliver what citizens are assessed as needing, in a manner that is as acceptable and convenient to citizens as possible. Time to move on from Political 'Top-Trumps' to utilise digital interaction to improve the quality and safety of health and social care.

PS - Social Media Hermit…..

Memories of a great teacher

This week General Practice mourns the loss of Professor Sir Michael Drury, former RCGP president, professor and teacher at Birmingham University.

He was part of a 'double-act' with Dr Hull that provided most medical students at Birmingham a first glimpse of medicine, patients and future career options from a GP perspective. They were known affectionately as 'Dreary and Dull', although the teaching style was far much more progressive and challenging than ward based traditional methods.

From those early encounters I learned the important cornerstones to clinical practice of 'active listening' and the very special relationship between a patient and a trusted clinician. They have been important to me throughout the 30 years of my clinical practice.

But how do these principles fare in an era when we are moving towards more digital interaction, remote access, patient empowerment and control?

Well the evidence on uptake of digital Primary Care services is very biased towards clinical initiation and support being the key enabler. So where doctors, nurses and clerical teams take the lead, patients are far more likely to engage, use services and gain benefit. My own experience is that there is little expressed demand for 'control' where a relationship of mutual trust and involvement exists, but there is an increasing interest in using new technology to get information such as results and linked advice quickly and conveniently. Perhaps this is the 'control' I should be working on?

So we are working on registering as many patient as possible to have an opportunity to digitally interact, and we want to record patient communication preferences so that we can start to use the technology to keep patients informed, updated and able to safely self-care. As an increasing proportion choose a digital channel as the default first contact, we have new opportunities to educate, sign-post and support without further demands on Primary Care staff that are delivering beyond a safe and sustainable capacity.

There are risks and challenges, as outlined in MDDUS pointers this week in a GP medical publication, but without clinical leadership and development in partnership with patients, the temptation for political and strategy interests to dictate and micro (mis)manage will be irresistible.

Disruptive technology through electronic interaction between citizens and care providers is here to stay, and will increasingly change the way we expect to work and manage health. But I believe we need to maintain and enhance relationships between clinicians and patients, and not to give up ‘active listening’ in favour of computer algorithms!

PRDS

12/06/2014

Difficult times….

No Blog entries for months - has he lost interest, faith, his password or retired?

Well sometimes when things go quiet it is because lots is happening, and sometimes there is just so much confusion no-one has a clue what is going on.

In the front-line world of General Practice the 'demand' for service continues to increase at a frightening rate. EVERYONE is queueing up to land more work at the door, mailbox or 'e-inbox' of General practice. These are daunting, fraught and dangerous times, with no clear end in sight.

The press remains schizophrenic in attitude to NHS services, on one hand 'blasting' the publicised high profile failings, then on the other hand fiercely defending a National Treasure. Clearly part of the long run up to a General Election next year where Health will be a political battle ground.

So what is happening in a 'real' GP surgery, trying to find solutions on a daily basis and deliver a sustainable service? Well we have far too much on to spend any meaningful time to develop on-line services. Even basic transaction support becomes questionable when we have no spare capacity, so harsh but practical decision are made to support any service we feel helps capacity and safety, but to abandon those who do not seem to us to help or at least prove resource neutral.
Our decision:
Transactions actively supported for online medication requesting and appointment reminders
Transactions retained for appointment booking and cancellation
No active support (or withdrawal) for patient access to records

If we are in the vanguard of 'early adopters' for Record Access, what does this type of decision indicate for other practices? Well, we suspect that few will actively promote online activity that costs time, effort and money. We are well aware of the claims and reports by 'enthusiasts' over efficiency to the business, but we have NO capacity or resource to get that far - even if we believed these claims were realisable outside enthusiast practices. Transactions for appointment booking seem to have little value to patients giving 24/7 access when we have 10 days to wait for a free appointment! SO the point is that online interaction we currently have does not add to capacity, and some fear it may fuel unrealistic expectation.

For those who are sceptical of the claims from General Practice I can only report my real-world experience of the last Friday and Monday in GP land. Both were days 'on-call', triaging and seeing those with perceived urgent problems (medical, surgical, dental, social, financial, administrative etc etc), both lasted from 8am to beyond 7pm. No coffee breaks or lunch, and an intense run of 'decision taking' and 'risk assessing'. Having been 'dusted' around by cleaners on Monday evening at 7:20 pm I gave up, to complete paperwork the following day in the early morning before 'work'. Not sustainable or safe.

So the new GP contract from april 2014 promises to incentivise/require GP practices to interact in more modern online ways. But as a service we are close to breaking point in a way none of us long serving providers have seen before. If GP service collapses so does the rest of the NHS. Forcing Online interaction will not be the final straw, but perhaps there are other greater priorities?

Difficult times…..

What to do with the 'Information'......

I am going to attend a meeting this week to learn more about 'Information for Commissioning'.

What can Commissioners ask for or expect, what can they do with it and how will it change things?

It should be very interesting and relevant as we glide smoothly (?) into the era of CCGs.

But perhaps I have been living in a different universe from other Healthcare providers for the past 10 years or more. We have no end of data available already, we have 'grown-up' with local comparisons and 'bench-marking', we look in detail at prescribing, referrals, length of stay, urgent admissions, 'frequent-flyers' etc etc. What is so new in the ambitions now being expressed and the expectation?

Well - being the grey-haired sceptic I am, a few observations flow:

• The availability of data to the NHS is far from new - we have always had lots, but seem to be short of time and resource (and sometimes the will) to analyse & understand it, to identify areas of unwarranted variation and to act upon these.
• The data alone does not drive change - despite all the political ambition and rhetoric. 
• The commitment and resource to continually collate, analyse and reflect upon collected data and the information it reveals needs to be embedded within every care AND Commissioning organisation.
• When finances get tighter - we tend to cut resource to analytical staff & processes and 'assume' wrongly that the work can be absorbed into daily activity.

SO the message from a small healthcare organisation with a track record of reflection and action on comparative data is simple:

• Priorities what you look at and start small
• Be prepared to learn by comparison with peers
• Commit resource to data analysis as an administrative and clinical function
• Make changes as a team AFTER analysis
• Review future performance to check desired outcomes

In Commissioning  'learning' Healthcare Organisations at all levels, NHS England and CCGs are not just asking for delivery, they must resource practitioner and organisational level reflective analysis.

In my 'bubble' of digital Primary Care I am nervous that there will be a strong Top Down temptation to 'name-and-shame' those who are slower to embrace policy aims at the front-line, as revealed by National reporting. In a forward looking 'learning organisation' we would help each other to understand the data and the opportunities for change and improvement these reveal. To turn the sticks into carrots... the real power of data......

Peter S.

Life as a Hedgehog

It can be uncomfortable and dangerous, living ones life in the 'middle-of-the-road'.

But am I in the foolhardy, spiky minority, am I taking risks?

The debate I follow, and the related ongoing subject of these postings, is the progress in GP practice on-line interaction with patients. And it seems to have been a noisey week in the press and social media!

On one side of the carriage-way are the articulate 'nay-sayers', expounding the risks of a free-for-all with sensitive information, mushrooming workload and a security nightmare. On the opposite side are  the proponents of progress at any cost, predicting doom, gloom and revolution if all the barriers to information access are not unceremoniously torn down immediately....

And so, I 'dither' in the middle of the road, looking both ways, but not really drawn to, or convinced by either camp of the rights and wrongs.
Like many of my GP colleagues, I have rapidly become a user of IT to access services and information that make my life easier and more convenient. I expect to check balances and transfer money on-line, to browse and shop in the evening for presents I have forgotten,  to communicate with friends and colleagues and to plan my family schedule.
But also recognise that I wish to be private and secure with my information, I shred documents and take care of passwords, I update anti-virus software and try to remain alert for security threats and 'scams'. I have been caught out before, and will be again, but on balance I still choose to 'take the risk'.

So am I on my own, in the middle-of-the-road'?

It would appear not! The majority of my colleagues, and quite probably of my patients, can see benefits and risks, but will increasingly try out on-line interaction in health as they do in other areas of their lives. Every practice and every patient will have different reasons and experience - all equally valid.

So it turns out that MOST of us are 'in the road', those shouting from the sides may well be the oddities with entrenched views and less grasp of reality. There really are NO cars or lorries bearing down on us, threatening instant oblivion - there are challenges to face, mistakes to make, evidence be gathered and lessons to be learnt, but not by sitting on the edge lecturing to others.

Being in the 'middle-of-the-road' may turn out to be the cool place to be!

Peter S.

A year of on-line GP practice services for patients

My surgery has been offering ‘on-line’ interaction with patients since 2006. We started with medication requesting and appointment booking, and more recently added access to medical records in November 2011. What follows is a summary of the activity during 2012.

Successful logins	8745
New patients registered for service	227
Appointments booked	2018
Appointments cancelled	591
Repeat medication requests	2468
Address detail change	226
Medical record viewed	115

So what are my conclusions at the end of a year that has seen a significant rise in political interest over ‘on-line’ GP services for patients?

• With a practice list size of 9000 and 6 years of on-line service behind us, we still have an average of less than one on-line interaction per registered patient.
• ‘Transactions’ at the convenience of patients dominate the activity.
• Medical record viewing remains at a very low level without active clinician promotion.
• There is significant potential to increase on-line activity and relieve telephone and front desk pressure with routine tasks such as repeat medication requests and GP appointment booking.

We do not know the age/sex breakdown of service users – this could be informative.

We are uncertain how we compare with other practices

We have not researched the barriers to use by patients

Medical record viewing has not been a major challenge or workload in the previous year.

So – ‘more of the same’, or ‘must do better’?

For serious consideration in 2013:

• Offering nursing and ‘task specific’ appointments
• Advertise the appointment and medication services more actively
• Target specific individuals for Record Access and test result notification
• Press for better activity reporting from system supplier

Happy New (Patient on-line) Year!

PS

Who will benefit most?

A big question with "Records Access", who stands to gain the most?

The patient, with or without a chronic illness?
The 'digital' surgery?
The affluent with modern technology and smartphones?
Advertisers and the IT industry?
Politicians claiming vindication?

No clear answer(s) at the moment.

Attending and contributing to an evening talk in Lewisham on Record Access sponsored by The Health Foundation has contributed to my knowledge and made me consider the potential to support citizens with diabetes more effectively. It is always good to have a mixed audience of patients, health care providers and local managers, polarisation of opinion is reversed, and some real progress can be made in awareness of mutual opportunity. The 'myRecord' project in this locality will be well worth watching as a locally owned and driven initiative to use technology to support care better.
Perhaps those present have shown/reminded me that the technology use is not just to improve care, rather to enable and encourage better SELF-care.

My second 'lightbulb' moment around 'on-line' services for patients comes from consideration of how patients may get access to test results, using new technology. A much repeated and topical government and policy aspiration.
For me, there are still significant barriers for many of the population to bother to search records and review results - it is likely to be a minority activity EVEN with enthusiasts. But to mis-quote many historical figures - perhaps there is 'a third way'!

My inspiration is to use technology to assist the current process, not to invent new pathways or generate more work for General Practice. We already have swift return of results through electronic laboratory links, and in most surgeries these are rapidly reviewed, commented upon, actioned where necessary, then filed into GP records. There are already very efficient mechanisms to confirm results belong to the correct patients, despite the 'distrust' of some senior officials, and trusted processes to deal with important results! What is missing is a way to convey the result and clinical interpretation/advice directly to the patient. Currently most GPs write, telephone or instruct patients to contact the surgery to check results - an inefficient process for all of us, patients particularly.
The solution? Immediate 'one button' option to copy the result AND the clinical advice/comment via the channel chosen by the patient - an SMS message to mobile phone or e-mail are equally possible. (US Blue Button' concept). And before there are too many complaints - we already pay for NHS mail and SMS text messages through N3. There are some issues around such a proposal - but all are simply soluble IF we have a will to do so. Perhaps such a solution makes getting test results and supportive advice a lot easier and quicker than the cry for 'full record access' can deliver? It could then easily extend to other 'bite-sized' bits of information - Immunisation status, hospital letters, consultation notes....

So lots to ponder - but a solution to message my patients securely would save me an hour or two a week.... and probably more than that for my patients.

Are you paying attention GP system suppliers?

Peter S.

Hearts & Minds

I have just returned from a GP system user groups conference, filled with enthusiasm, new ideas and ambition - that is what these events are about. But through the buzz of new announcements and promises there were three distinct 'threads' that relate to 'Records Access', and my small scale experiment in opening records.

The first, and probably the most important is that the general professional resistance to this proposal has significantly reduced, with a shift to apathy or even interest in how it may be done! I suspect the clear policy message in the Information Strategy has had an impact - but there were still practical concerns voiced, and scepticism as to the true demand from patients.

The second was a clear recognition by the company that 'Information' is the clear thrust of their future strategy. Making the record available when, and where needed, information to support clinicians, practices and organisations, and very clearly integrated with high quality information for patient use.

The third more practical promise was of forthcoming improvements to the system functionality, enabling easier administration and delivery by practices, and easier patient use.

All three of these are needed to win the 'hearts & minds' of clinicians, patients and organisations in order to deliver so much more than the simple transaction and viewing services we have now. It cannot be long before all the providers of IT systems to Health & Social care services start to take similar steps - or are required to follow. This is not a race, but an exciting time of opportunity, leaning and innovation! I believe the NHS has the spirit and ideas to innovate using technology, and in partnership with industry - I just hope it is given the freedom rather than constrained by targets and red-tape.

Peter S.

Control....

In the British Medical Journal this week, the lead theme is 'patient control of records', with an editorial comment, main article and personal view.

I have spent a significant amount of time pondering the meaning of 'control'. There does seem to be a wide variety of views and, surprise surprise, no easy answer.

For the most determined advocates, control has been explained in terms of patients 'holding or posessing' the records, determining who and and when the records are accessed and being the central 'hub' for all who request access. The most negative sceptics articulate a very different vision, where the existing organisational medical records are maintained and shared for patient view only with strict technical controls and information governance procedures, in order to ensure confidentiality.

Perhaps most are missing the point - what is it we as patients and 'citizens' expect as control?

For very many of us this elusive ‘control’ is not ‘posession or ownership’ of the record or about asserting our ‘rights’ to  see all the notes about us, but rather a ‘confidence’ and trust in those who care for us – confirmed through the routine ability to see and understand plans and records, should we wish to do so. Most of this is focused on the relationship between clinician and patient and ‘shared decision making’ over all aspects of health and care.

As a clinican in a professional relationship with my patients, I want them to feel comfortable, informed and valued in all our contacts – in other words, ‘in-control’. I cannot always make this happen, but I feel that control is NOT about asserting rights, but rather having the confidence that they are being respected.

Peter S

Practical Matters.....

Just setting up 'Records Access' is not a complicated task - but continuing to manage and administer it is proving to be!

Despite a lack of 'overwhelming demand' there is the on-going challenge of basic administration. As soon as anyone is active with a surgery 'transaction' facility there is the burden of managing forgotten passwords, and even worse - 'technical questions' that relate more to internet problems and the layers of security.

For a practice like mine, this generates more work for the 'team', and in my case - for myself as the key system administrator and manager. But I am increasingly nervous that this will rapidly become unmanageable as the pool of patients with RA slowly grows.  I cannot be available daily to address individual questions, or to provide an evening and weekend service when away from the surgery building. I certainly am NOT the one to ask computer and software questions of - or to provide an informal 'support-line'.

Anecdotal comments from other surgeries and enthusiasts echo this concern. A whole new 'system' of working and support is required - and for such aspirations to become widespread in General Practice, patients, clinicians and surgeries are going to need a whole new level of support and back-up - or we let patients down. It is pretty obvious that there are resource implications in the pipeline.

Doing it right is a significant and enduring challenge......

Peter S.

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.

Technically challenged.......

Well the leaflets continue to disappear from my waiting room - so some of my customers clearly find the subject of records access interesting!

But my next challenge is far more technical. Before we can reliably enable our patients to view their own records we have to have an efficient, and reliable, process to register them. And here we have challenges. Having established a reliable process to register patients for appointments and repeat medication, there are additional 'back-office' tasks to generate an additional password, set permission and text viewing dates. And after these are circulated to patients they have an additional password to remember, and to navigate through a brand new Practice Website.

Complicated? No-wonder at least one person has locked themselves out of On-Line access altogether! So we will be creating some understandable frustration for the enthusiastic patients before we are confident and reliable in managing this transition.

The software suppliers also have some work to do, to make management and administration of Records Access easy at the GP surgery end. They will also have to consider more useful reports on activity - so we can better understand when it is useful and what patients look at.

SO firmly on my wish list:

• Make it easier to administer
• Improve the reports
• Consider a 'tab' to show the current uploaded 'Summary Care Record'

You never know - it might get more popular with the practices...

Peter S.

Oh so slow.....

Confession time - too busy to actively promote the service at present.

Result - nine requests for Records Access to date, and only one fully processed.

Main blocker - me, the staffing and administration of the process!

Action - pursue current interested parties to fully implement RA for them.

Constraints - staff sickness limits my current ambition and expectation.

Concern - what would we do if this became a 'target'?

Requirement - GP system software that makes RA administration easy.


Conclusion - Snow Patrol are excellent in concert.......


Peter S.

Another perception-reality gap?

Some weeks I read medical magazines & journals and wonder at the effort we put in to the accumulation of 'irrelevant' knowledge. But this week I have been stimulated  and challenged by a number of articles in the BMJ, if you are fortunate enough to have access, links are provided below.

Shared decision making - BMJ 2012;344:e256

Where will Records Access fit in to enhance shared decision making, and help to close the 'perception-reality gap?

Matters of Life & death and quality of life - BMJ 2012;344:e775

Will it just be the 'major' items in Health records that interest patients, or are there things that to clinicians appear trivial, that patients will consider important to understand and address?

Stop the medicalisation of old age - BMJ 2012;344:e803

Will patient and advocate scrutiny of records suggests that we (clinicians) often pursue targets/protocols and guidelines rather than the informed best interests of the older people we treat?

More questions to ponder......

Then again - I could spend all my time debating the issues and questions and be to busy to change anything or try for myself.....

Peter Short

Days when 'Access' in bottom of my agenda....

There is no doubt in my mind that there is NOTHING like a full day of front-line clinical practice to put in perspective the challenge that we face in allowing new and innovative ways for patients and citizens to interact with their Health advisors.
After eleven and a half hours at the sharp end of 'undifferentiated illness, uncertainty and discontent' with hardly a break, I am shattered and drained of sympathy and enthusiasm. The benefit of 28 years of experience, grey hairs and a generally mild manner has not protected me from the pressure of 'trying to do the right thing', non-stop on the conveyor belt of General Practice.
And all-round the country tomorrow, my colleague GPs and Nurses will start again with the same routine.

Am I really very inefficient?
Should I 'free up time' to analyse what I should be doing differently?
Why do I find it so difficult to adopt a 'low appeasement strategy' advocated recently by  a respected mentor?
Is this sort of experience and combination of feelings the reason why so many of us are reluctant to consider the combination of Records Access, virtual consultations and expanding communication channels?
We just have difficulty imagining how we can fit it all in........

Answers on a post-card.

Peter Short

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)