The hoo-ha surrounding this week’s announcement of Tory plans for the NHS IT project begins to look rather misplaced once you actually read their report. The media’s over-emphasis on the role Google or Microsoft might play in future provision of the electronic patient record shows that we persist in understanding state service provision using the defunct paradigm of public versus private. It is only if we adopt a new paradigm – that of centralised versus decentralised information management and service organisation – that we will be equipped to critique the Tories’ plans in any detail.
The nearly 200-page report that spurred the headlines was commissioned by shadow health secretary Stephen O’Brien, and overseen by the former British Computer Society Health Informatics forum chair, Dr Glyn Hayes. Its references to the participation of Google, Microsoft and other commercial information service providers take place in a short, two page section. The mention is designed to illustrate the potential of a much larger reform – that of decentralising the provision of the electronic patient record and other information services – to lead to the twin goods of cost reduction and patient-centred care. It does not wed the British citizenry to relinquishing its medical secrets to Silicon Valley. Quite the opposite – it has the potential to give power over sensitive medical data back to the people who have traditionally been that data’s custodians – practitioners and patients.
The report calls for a balance between centralised standard setting and grassroots commissioning of IT services. If it works well, this approach would result in technology, commissioned by the people who are actually going to use it, that nonetheless allows systems across the NHS to communicate with one another. This at once avoids the disruption caused by the current one-size-fits-all policy of the NHS PfIT, where the needs of frontline practitioners collide with new systems they didn’t ask for and had no say in building, while also preventing the information silos of early digitisation projects within the NHS.
Rather than work with two or three suppliers to design the system top to bottom, healthcare practitioners and policymakers could, the report imagines, come together with information architecture experts to agree on a set of open standards that would make decentralised systems sufficiently interoperable, then let whatever appropriate mix of commercial, state-sponsored and civil society groups design the systems practitioners needed to manage information in their particular clinical setting. A high profile example of the successful application of this methodology already exists. It’s called the World Wide Web.
Crucially, this methodology, when attached to the electronic patient record, removes the argument for all our health details to be stored centrally. Instead, GPs and local health practitioners will be the natural guardians of this sensitive data once more. That means that individually, we can come to decisions about how we want to access our own health data, whether that be by storing it electronically with Google, Microsoft, the health service’s own fledgling “HealthSpace” patient access system, or simply under digital lock and key at our local surgery. And it means that collectively, the debates about if, when and how we let scientific researchers or civil servants access our data en masse in the name of medical advance or efficiency, can be had on their own terms, without the distraction of a juicy centralised database just waiting to be mined.
None of which is to say that if you vote Tory in the next election, you’ll be guaranteed a better NHS IT system. Such a radical change of direction for an IT project that is already partially implemented and at the same time four years overdue, will be a mean feat to pull off, both politically and pragmatically. But to understand if we are getting closer to the vision set out in this report, we must first understand what that vision is. That means embracing slightly more informed mental framework than “it mentions Google and Google [is/is not evil], so that [is/is not] okay”.