Cross Talk goes over the border (twice)

In his regular column, Mike Cross looks at how the different healthcare IT programmes in England, Scotland and Wales have approached the development of electronic health records, and argues that the three systems should be more willing to learn from each other.


For all its supposed homogeneity, the modern world is full of opportunities to experience a different culture just by crossing a border. Most Britons live within two hour train ride of a foreign national health service; and they don't even need to show a passport on the way.

I'm talking, of course, about the distinctive flavours of NHS that have developed in England, Scotland and Wales after a decade of devolution.

Some of the differences are well-known and controversial; Scotland’s free parking and Wales' free prescriptions, for example. Others have a lower profile, but are nonetheless significant; Scotland’s focus on public health and Wales’ consultation on abolishing the internal market, for instance.

Although journalists and pressure groups love moaning about "postcode lotteries", I think diversity is welcome. Apart from the intrinsic worth of any particular policy, variation on a national scale is a valuable test-bed and evidence-base for change. Provided, of course, we are willing to learn lessons from our neighbours.
“Most Britons live within two hour train ride of a foreign national health service; and they don’t even need to show a passport on the way.”

Mainland, not one land

An especially exciting evidence base is emerging in health informatics. Thanks to differing political and funding priorities and local management traditions, England, Scotland and Wales have taken very different approaches to the same end - providing useful electronic health records wherever they are needed.

Predictably, England has grabbed the lion's share of attention thanks to (not always well informed) media and political interest in NHS Connecting for Health's National Programme for IT in the NHS (NPfIT).

So far, it has managed to get the NHS Summary Care Record, a centrally held mix of patient details, allergies, medications and other events, into five pilot areas. But it has also been dogged by a seemingly endless row about whether patients should be able to “opt in” or “opt out” – and if so, to and from what – that has prompted a national Big Opt Out campaign.

But devolution in healthcare IT isn't just a story of England versus the rest – Cardiff’s and Edinburgh's programmes differ from each other at least as much as they differ from London's.

In Scotland, speed and simplicity seem to rule. Based on a long independent tradition in healthcare IT (which, among other innovations, pioneered the 10-digit NHS number) Scotland was able to launch a national summary care record in 2006.

The Emergency Care Summary is a read-only record of demographic information, allergies, adverse reactions and current prescriptions pushed from GP records to a central server. Earlier this year, it celebrated its use in 1 million patient consultations; so far only 1,400 patients have exercised their right to a "no questions asked" opt-out.

Wales, by contrast, sees little value in the summary. The philosophy of Informing Healthcare is to provide the whole GP record electronically, but within trusted communities, with patients giving their consent each time the record is viewed.

By necessity, rolling this out has been a slower process. However, this summer Informing Healthcare was able to announce that the Welsh Individual Health Record, originally introduced for Out of Hours services, has now started to roll out in secondary care.

Inside the devolution laboratory

Faced with radical differences in philosophy and execution, commentators and policy makers tend to succumb to one of two temptations. One is to imagine that all is perfect over a chosen border. The other is to condemn the cross-border experience as irrelevant, or, worse, a threat. “Computerising healthcare is not a race, much less a civil war.”

Both temptations are mistaken. While international experience has always been important in health informatics, it is often difficult to translate the lessons learned in one health service to the working practices of another. And the mere fact that an innovation originates in a radically different health policy and management model will arm sceptics with ammunition to reject it.

Experience drawn from another part of the UK should be a different matter entirely. Despite the widening political differences apparent in health policy, England, Wales and Scotland (and Northern Ireland) share the same NHS. This is why devolution is of such value in creating an evidence base. We should be celebrating that, and making use of it.

To do so, of course, may require some swallowing of local pride; but the outcomes should be worth it. Computerising healthcare is not a race, much less a civil war. It is a fascinating, multidimensional set of challenges which must be approached with all the tools and evidence at our disposal, whichever part of these islands we inhabit.

About the author: Michael Cross is a freelance journalist specialising in healthcare informatics and e-government. He is a member of the British Computer Society.