Feature / Cutting edge

There is a paradox – some would say irony – in the fact that recent calls for the NHS to go paperless were reported widely in daily newspapers. Indeed, you are likely to be reading this article in a paper copy of the magazine. But it goes to show that one of the initial promises of the internet – that it would make paper obsolete – has yet to materialise.

In the NHS, millions of patient contacts generate reports, notes for medical records and letters for referral, appointments and discharge. Add in invoices, guidance and letters from regulators, royal colleges et al and it is easy to see that the service is swamped with paper. It’s a question of best use of resources in the widest possible sense – people, finances and paper. It is inefficient and could affect the quality and the safety of the care on offer.

With the NHS in England trying to deliver more and better care while finding £22bn of savings, it’s no wonder attention has turned to paper. Last month, health secretary Jeremy Hunt reiterated his vision for a paperless NHS – full GP electronic patient records going online by 2016 and information on all health and care interactions available two years later. By 2020 the NHS should be paper-free at the point of care.

Outgoing NHS England national director for patients and information Tim Kelsey, who is also chair of the National Information Board, urges health and social care leaders to reduce unnecessary reliance on paper in the treatment of patients.

‘Health and social care services in England must end the unnecessary reliance on paper in the treatment of patients,’ he says. ‘It’s key to making services safer, more effective and more efficient. Every day, care is held up and patients are kept waiting while an army of people transport and store huge quantities of paper round our healthcare system.

‘This approach is past its sell by date. We need to consign to the dustbin of history the industry in referral letters, the outdated use of fax machines and the trolleys groaning with patients’ notes.’

Storage saving

There is another potential saving. The estimated annual cost of paper storage is between £500,000 and £1m for each trust – money that could be funnelled back to frontline care, he added.

There is a clear steer from the centre that it wants the NHS to tackle this problem. Technology is key. A rock solid electronic patient record (EPR), with the ability to interface with other systems such as finance and decision support software, will be at the heart of any efforts to go paperless. But what appetite will NHS organisations have for this, particularly with finances tight and with the service’s track record of implementing large IT projects likely to make boards nervous?

Certainly, there is a degree of buy-in, but EPR implementations can be problematic, as seen in the difficulties at Cambridge University Hospitals NHS Foundation Trust, where an EPR introduced last year has been linked to its financial problems.

Simon Marshall, director of finance and information at Ashford and St Peter’s Hospitals NHS Foundation Trust, says trusts are working hard on going paperless. He is a responsible owner for the Surrey Electronic Data Management Collaborative, part of the Southern Acute Programme, a paperless initiative sponsored by the Health and Social Care Information Centre.

As well as the Ashford trust, the programme initially included Frimley Park Hospital NHS Foundation Trust and Heatherwood and Wexham Park Hospitals NHS Hospital Trust, which have subsequently merged to form Frimley Health NHS Foundation Trust. Deployment is expected by the end of 2016, with near zero paper within four years.

Streamlining processes

Mr Marshall says the programme is about improving care through better access to information and streamlined processes. ‘We have been dependent on paper records in the past, but they can only be in one place at a time. This is unhelpful if you have complex cases or networks of clinicians supporting a patient.’

The HSCIC is funding supplier costs for a four-year period – in this case £10.6m – a move that is vital to the project’s success. Geoff Broome, director of Apira, a consultancy that worked with the NHS on the project, says funding can be an issue for trusts in the current financial environment. ‘It’s fair to say that some trusts are struggling with the affordability and some central funding would make a big difference.’

Naveed Ashraf, managing director of Pearl Scan Solutions, which is working with some GPs and hospitals to digitise their paper medical records, warns that the government deadlines may not be met.

‘Around one third of the trusts and primary care providers have already made a start towards the scanning and digital storage of patient records and the rest are following suit,’ he says. ‘But it may be that not all trusts fully achieve their goal of becoming paperless by 2018 or even meet the 2020 deadline. This will require a pragmatic approach towards meeting the required targets.

‘Health and social care leaders have been urged to end the unnecessary reliance on paper in the treatment of patients and make services safer, more effective and efficient. This potentially will bring multimillion-pound savings associated with digitising both clinical and back office information.’

There are pockets of success around the country. Cumbria has implemented a countywide e-referrals system (see box overleaf) and Barts Health NHS Trust is moving to a paperless hospital, based on its Cerner Millennium EPR. Clinicians in its haematology unit, for example, have highlighted the benefits of reducing paper, including the ‘end of the traditional paper chase’ and enhanced patient safety.

An HSCIC deep dive into the benefits of the EPR implementation at Barts published last year, pointed out a number of seemingly small savings, including a time saving of up to 90 seconds per pathology order in outpatient clinics – but this soon adds up as about 2,500 orders are made each day.

Many of the savings highlighted would prove significant if replicated in other areas of the trust, it said. These include a reduction in the time taken for patient handovers and time savings when multiple tests are ordered from different pathology disciplines for the same patient in the emergency department.

The Southern Acute Programme has a degree of scale, with the accompanying scope for efficiencies, while remaining sufficiently focused on local needs, Mr Marshall says. Three trusts were involved initially, but this is likely to be expanded with the proposed merger between the Royal Surrey County NHS Foundation Trust and Ashford and St Peter’s. The Competition and Markets Authority gave the merger the green light in September.

The Southern Acute Programme has a number of aspects. The first involves the transfer of existing records to digital format. This will be carried out by scanning firm Hugh Symons. The second is a system to make the digital records available to clinicians through the Kainos Evolve EPR. ‘That’s where the real benefits come, as you can streamline clinical practices around a digital system and standardise care around what drives better outcomes and better processes for patients,’ Mr Marshall adds.

NICE support

Decision support will include guidance from the National Institute for Health and Care Excellence built in, as well as best practice guidance. The system will be integrated, so that over time clinicians in the community can access medical records.

‘There will be the full EPR, with a lot of decision support software built in as part of the layers of functionality are added to the core system,’ says Mr Marshall. ‘This is a big change and about 60% of the functionality is provided by other systems linked to the core system.

‘There are lots of ways of getting to a fully digital hospital and this initiative will take us around three-quarters of the way there. The NHS is so complex it would be difficult to get everything onto one system, so we have a core system interfacing with other systems.’

Mr Marshall says the move away from paper will bring ‘massive benefits’, including giving up to two million people living in Surrey access to their acute medical records. The trusts will be able to offer a seamless service to patients, where they are not asked for their history each time they see a new clinician. Equally, the records will not have to be moved around as they will be accessible digitally – members of clinical teams can be in different locations when meeting for a case conference or for a clinical audit, for example.

‘It impacts on the way the hospital does business – how clinicians approach medical records and how junior doctors write up medical records,’ Mr Marshall says.

Taking account of all quantified benefits and costs, the collaborative trusts expect a net saving of about £30m over 10 years by moving to digital records and giving their staff mobile access. The cash savings, notably from releasing office or clinic space, reductions in medical records staff and consumables savings, amount to £137,000 a month in cash-releasing benefits for each trust when fully realised. In addition, across the collaborative the release of clinician time (from searching for and filing paper) is expected to produce a combined non-cash saving of £5m a year in time-to-care benefits. This is based on HSCIC research on junior doctor footfall. ‘We have a choice on how we deploy that time,’ Mr Marshall says. ‘We could take it as savings, we could choose to give clinicians more time to spend with patients or we could use it to see more patients. It means each hospital has a bit more flexibility and more choice in how it runs itself.’

Seven-day support

He adds that the paperless agenda could help the trusts address the seven-day services initiative. ‘How we staff our hospitals seven days a week is one of the biggest challenges we face. But if we can take away some of the cost during the week by reducing admin time and redeploy that time, we may be able to cover the weekends. It’s one way of starting to find that headroom we will need.’

Mr Broome adds: ‘Cash savings include the reuse of space and from the number of jobs no longer needed. But there’s also a huge benefit in releasing time to care – it’s better that junior doctors and nurses are caring for patients rather than searching for paper.’

The government is determined to make the service paperless or as near to it as possible. There is no doubt it could be transformational in terms of the quality of care and, potentially, greater efficiency. But to achieve these transformational gains, clinicians and trusts must use the technology to redesign their practice and processes.