Digitising health systems is intended to promote healthcare’s triple aim of better health, better healthcare and lower cost, and is consistent with the objectives of the NHS Five Year Forward View. A recent report into health information technology concluded that trying to achieve the aims of the Forward View without giving highest priority to digitisation would be “a costly and painful mistake”.
‘Making IT work: Harnessing the power of health information technology to improve care in England’, which was written by Robert Wachter and published last August, pulls no punches in its estimation of the importance of the task. None of the enormous changes in culture, structure, governance, workforce and training required for the NHS to continue to provide a high level of affordable healthcare, it says, are likely to be as sweeping, as important or as challenging as creating a fully digitised NHS.
“The one thing that the NHS cannot afford to do is to remain a largely non-digital system. It is time to get on with IT.”
Wachter recommends that interoperability should be built into systems from the start and he focuses on the importance of data sharing. “It would be a mistake to lock down everyone’s healthcare data in the name of privacy,” he says. He also recommends that a national chief clinical information officer be appointed to oversee and co-ordinate NHS clinical digitisation efforts. All trusts should be largely digitised by 2023, he says.
The Department of Health has not yet formally responded to the report, so it is not clear how much of it will be adopted as policy, but the Secretary of State and NHS England have reacted positively, and some recommendations are already being implemented.
Recommendations made in the Murray review of clinical pharmacy services mirror many of those in Wachter’s document. Murray calls for electronic repeat dispensing to become the default for repeat prescribing, better interoperability and digital connectivity, and read-and-write access to clinical records.
The importance of digitisation to pharmacy is highlighted in the imposed contractual framework for 2017/18, which came into effect in December. The arrangements introduced the Quality Payments Scheme, under which contractors must meet a number of criteria to qualify for payments. To be eligible for any payment at all under the scheme, contractors must first meet four ‘gateway’ criteria, three of which relate to digital issues:
• A pharmacy’s NHS Choices entry must be up-to-date
• It must be able to use NHSmail
• There must be evidence that the pharmacy is utilising the electronic prescription service (EPS).
Digital quality indicators relating to SCR access and NHS 111 registration account for 15 of the 100 points available under the scheme – worth between £960 and £1,920 to each pharmacy, depending on how many pharmacies qualify for the payments.
To claim five points at the first review point (April 28), a pharmacy must be able to demonstrate increasing access to the SCR between December 1, 2016 and April 28, 2017, in comparison to the previous five months. To claim another five points at the second review point (November 28), a pharmacy must be able to demonstrate increased access between May 1 and November 27, 2017, in comparison to the previous seven months.
A pharmacy must have its NHS 111 Directory of Services entry up-to-date at both review points to claim 2.5 points on each occasion.
As well as being a gateway criterion for the Quality Payments Scheme, a NHSmail account is also necessary to provide the NHS Urgent Medicine Supply Advanced Service (NUMSAS).
NHS England and NHS Digital introduced a new central approach to the allocation of NHSmail accounts to pharmacies in December, and the provision of new accounts was due be phased in according to NHS England’s plans for the roll-out of NUMSAS (in four phases starting in December and completing this month). They want all pharmacies to have shared mailboxes that can only be accessed by authorised users who log in using their personal NHSmail account.
PSNC encouraged all contractors to sign up for a shared NHSmail account before the February 1 deadline. “Use of NHSmail can bring operational benefits for community pharmacy teams and their patients, so even if pharmacies have missed the February 1 deadline, we would encourage them to register to get a shared account as soon as possible,” says Alastair Buxton, head of NHS services at PSNC.
Two-thirds of prescriptions issued in primary care are repeats and account for nearly 80 per cent of primary care medicine costs. It is estimated that up to 330 million (80 per cent) of repeat prescriptions could eventually be replaced with electronic repeat dispensing (eRD) – yet, currently, eRD accounts for only 12.8 per cent of all prescriptions, according to NHS Digital.
A campaign running until March has attempted to increase uptake. Support materials include webinars, eRD e-learning, an online toolkit, and training/awareness sessions for both GP practices and pharmacy teams. Feedback has been “very positive”, says NHS Digital. Two more campaigns are planned for this year – one in spring to promote eRD for summer ailments and another in late summer on relieving winter pressures.
“eRD obviously brings benefits to patients and GP practices, but pharmacy contractors have also found it improves efficiency within the dispensary,” says Alastair Buxton. “As contractors look for additional operational efficiencies in advance of the funding cuts, they may want to consider using the campaign materials to encourage patients and GPs to adopt widespread use of eRD.”
The summary care record achieved a landmark 100,000 views in a single week by the end of January, according to NHS Digital. It also reports that:
• 96 per cent of patients have a SCR and in 18 per cent of encounters where the SCR is accessed, the risk of a prescribing error is avoided
• In 92 per cent of encounters where the SCR is accessed, pharmacists avoided signposting patients to an alternative NHS service.
Yet despite longstanding campaigns for pharmacy access to patient records, SCR uptake among community pharmacies in England was only 50 per cent in December, a year after the roll-out began. But more than 20,000 pharmacy professionals have completed online SCR training and almost 90 per cent of community pharmacies have participated in briefing sessions to support SCR implementation. The top 10 community pharmacies for SCR usage are accessing SCRs on average 50 times a week.
“It is really encouraging that half of community pharmacies now have access to SCR, allowing them to support patients with better informed and tailored care,” says Mohammed Hussain, programme head for integrated pharmacy at NHS Digital.
SCR access provides “a real step forward” for pharmacists in providing better patient care, says chair of the RPS English Pharmacy Board, Sandra Gidley. “There is strong support in principle from the profession and across healthcare, but it takes time to implement this kind of change and for pharmacists to become confident using it.”
Not all pharmacists had received training by the end of January, with the last sessions being rolled out by NHS Digital at that time. “Using the SCR will undoubtedly become part of everyday practice but, in the meantime, pharmacists are using a range of information sources to ensure the safety of their patients, including the SCR when appropriate,” says Ms Gidley.
Read-and-write access to patients’ health records would allow pharmacists to make more informed clinical decisions in partnership with patients about their care, she says. This would help optimise the use of medicines, support improved treatment of individual patients and deliver better integrated primary care. Hospital pharmacists and some pharmacists working in GP surgeries already have access to the full record. “It is a step on from the SCR but vital in the development of new roles for pharmacists.”
Phase 4 of the electronic prescription service is the point at which electronic rather than paper prescriptions become the default. The pilot scheme has been delayed but is expected to begin in a few GP practices later this year.
For full EPS to be possible, the regulatory requirement that a prescription can only be issued once a nomination is in place must be removed. A patient who has not set a nomination or does not wish to do so would be issued with a token allowing them to visit a pharmacy of their choice. These tokens will initially be paper, but electronic formats such as an email from the GP practice might become possible in the future.
PSNC is working closely with the Health and Social Care Information Centre and NHS England to address ongoing EPS issues.
HSCIC has identified a number of prerequisites that must be in place prior to the move to phase 4 including:
• A review of the EPS service model
• System supplier EPS agreements to be in place
• Schedule 2 and 3 controlled drugs can be prescribed and dispensed using the EPS
• PSNC and NHS England to agree on a joint working group to review the costs of the EPS for community pharmacy.
PSNC has identified a number of other issues that must be dealt with before phase 4 can begin. These include:
• Improved system resilience and business continuity for contractors
• Improved smartcard access via local registration authorities
• Further action to tackle prescription direction.
NHS Digital will soon be testing a way of sending CDs through EPS in the same way as regular medication. If the tests prove successful then, once prescribing systems have been updated accordingly, it will be possible to send CDs by the EPS.
Nobody would claim that EPS is currently perfect, says Alastair Buxton, “but NHS Digital is continuing to work with the sector to put in place enhancements, like CD prescriptions being sent via EPS. The individual experience of pharmacy teams will vary as a result of many variables, including the way local GP practices use EPS and the functionality of the pharmacy’s PMR system.”
Pharmacy teams that have taken a step back to examine their dispensing process and how EPS can best be integrated into their systems report that taking this time pays dividends in the long run, he says. Pharmacy teams have also described the benefits of discussions with GP teams about the business change processes for all involved. Suggestions on what to discuss with GP practices can be found on the PSNC website.
“Ultimately, the most efficient EPS system will be one where almost all prescriptions are sent via the system and this is what NHS Digital’s pilot of phase 4 of EPS is designed to test. It is therefore very unfortunate that this pilot has been delayed. We are in regular discussions with NHS Digital and are urging them to make progress with starting the pilot as soon as possible.”
By January, 18 health organisations representing more than 60,000 primary care clinicians had collectively responded to the Scottish Government’s consultation on “A Digital Strategy for Scotland 2017 and beyond”, outlining the urgent need to radically transform the digital infrastructure to support multidisciplinary healthcare services.
The response outlines the current challenges in health and social care and demonstrates how improved digital infrastructure and access to information could improve healthcare services and increase efficiency within the NHS. The organisations are calling on the Scottish Government to implement a digital strategy that enables improved record-sharing across primary care.
“With today’s increasingly complex care, it is now more important than ever that essential information is shared to enable efficient assessment, care and treatment wherever people are in our healthcare system,” says Alex MacKinnon, director, Royal Pharmaceutical Society in Scotland.
“The examples provided from across all the professions demonstrate why the strategy needs to speed up the pace of change. With so many health and social professionals now involved in patient care, we simply need to have a digital infrastructure that enables us to work as one team.”