R v.Lambert House of Lords and RIP reverse-burden-of-proof

[Adrian Midgley]

From: Ross Anderson <Ross.Anderson@cl.cam.ac.uk>

Mostly right, agreed.
One bugger factor is that for all the talk of paying for quality,
there is no way within NHS general practice for us to generate more
income by spending money on eg decent technology.
Indeed, since staff time is reimbursed at about 70% (being nibbled
away at) and computers at 50% of a small ceiling, using people to do
stupid repetitive stuff and working inefficiently is cheaper for us.
Plus as Ross says, the grip on design of systems from government, and
I would add the grip of owners of proprietary and non-verifiable
systems that cannot be relied upon to stay available (I call it Ars
Longa, IT Brevis)  really screws it all up.  Basically I see no
advances worth noting since 1994, coincidentally the time when the NHS
had a conversion to the idea we should all head for Windows-based
systems and that this was progress.
(EXCEPT the provision of a phone line and router to connect us free to
the 'Net, whcih is an advance and arrived about a year after I built
the same thing without reference to the NHS.)



>... a better way of protecting patients
>would be to use the practice number rather than putting the patient's
>plaintext name and date of birth on the sample.

Age is relevant and lab docs do give advice rather than just numbers,
and samples do get mixed up so some redundancy adds safety, but on the
whole I agree.  I do send an occasional sample with a serial number
and name filled out as A. Pseudonym just to keep in practice on it.

>Speaking as a patient, however, I think it's at least as important
for
>you to persuade more GPs to do as you do - have a web site, hosted on
>a private ISP rather than NHSnet, and a facility to send email to the
>practice. I note that you use plaintext email. I am fairly relaxed
>about that;
Agreed, it seems to go down well with people who actually use email
for work - they know they are sending postcards, and they find it
better than not being able to send messages.

>If I were a GP, I'd go even further down your road. I'd provide
>web-based forms for ordering repeat prescriptions, making
>appointments,

www.homefieldsurgery.nhs.uk
It isn't hosted on an NHS machine, Simon Child, a GP up North set it
up using Linux Apache MySQL PHP3
The setup for appointments is a bit cumbersome, but actually the
Practice doesn't do appts for doctors, in general, although they do
have some attractions.

>getting test results, and even supporting interactive
>care - e.g., where heart patients do INR tests at home weekly and
>report results. I'd try to build interactive systems for patients on
>weight reduction and exercise programmes to check in body mass,
weekly
>exercise attainments, resting ventricular rate, and so on - and
>provide them with suitable encouragement or chastisement.

Ahmad Risk and Trefor Roscoe and I and others have looked at ways of
doing that sort of thing.  I think it is a good idea.  I have some
early extraction stuff that I run in the Practice, and it is heading
toward some interactive web-ability, but it is hard to do on your own.
And worse if you let other people run it.

>In short, I'd run it like a practice in California.
Alas, my HMO won't play<g>  But yes.  My friend in LA pays more for a
month of contraception than the NHS pays for a year of contraceptive
services, dispensing and supplies in the UK.  I would much rather work
to that standard of comfort.

On the subject of GPs in California, I went over there in Feb this
year to Fresno 3 which was a meeting on open source.  One system that
is running near there is Alex Caldwell's tkFP which seems quite usable
albeit it grew in his practice and therefore is not productionised -
it would take quite an effort to bring it into mine, but I've got a
couple of copies to play with.

My view was that the UK could offer improved security, audit trailing
etc, whereas the US contingent were in a phase of actually making
things that made the work go easier and better.  We have passed beyond
that phase to one of a scramble for ceommercial advantage, political
power, and regulation by regulators who know little of what actually
helps.

>if I ran a surgery from 6-8 once a week for commuters, that
>would be web bookable only (to encourage the unwaged to use the
>daytime sessions).
I like that.  I have been thinking about explicit sessions or slots
for people with jobs, but we cannot even accept payment for a premium
service, and in the usual British way such are likely to stir up
resentment.

>Why don't most British GPs do this? Why is innovation is so moribund?
>Is it a side-effect of the generally low morale?

I am constantly impressed with the effort many of my colleagues will
put into preserving their ignorance and by the amount of assistance
they get in avoiding working IT from NHS IT droids.

>The lesson of GP computing, over the six or seven years I've observed
>it, is that systems paid for by doctors work, while those paid for by
>civil servants don't.

Absolutely.

and on funding
>Otherwise,
>as you hint, it's time to start a grown-up debate about how we should
>organise healthcare in Britain after the collapse of the NHS.

Yep.
Going with the flow and being brought into PMS projects and salaried
work will continue to lose the advantage that general practice
obtained in the introduction of IT - to quote a consultant colleague:
"It took me 3 years to get a computer on my desk, it still doesn't
link to the PAS (results etc).  B&Q has a more advanced system for
tracking pots of paint than this hospital has for keeping track of
paitnets."

I'd suggested that putting advice notes on a website might be helpful.