NHS England and the Department of Health have launched the NHS Long Term Plan. It includes a range of topics of interest. It doesn’t say anything about the National Data Opt-out and not much about data – the LTP repeatedly suggests jam tomorrow – as things that work will be replaced with things that might, which the recent NHS Digital Board discussed. There is still no guarantee of a competitive NHS market for decision support tools, despite the interest of the Secretary of State in some companies…

The Summary Care Record is a (mostly) consented system run by NHS Digital that works (after a decade), and will be replaced with NHS England’s LCHR programme, which is neither consented nor working (and will take at least a decade).

The fundamental point of the Summary Care Record (SCR) is that it is accessible nationwide. If you live in Cornwall and visit A&E in Carlisle, a doctor there can see the medications you are prescribed – unless you have chosen that they shouldn’t.

When the ‘NHS app’ launches, you will (should!) be able to see where your SCR has been accessed – although, as with other NHS.UK services in the queue, you need to be able to log in to NHS.UK before that can work. NHS Digital is still consulting on tweaks to the SCR for carers – a use case that the LCHR programme is far from being in a position to consider.

The LCHR programme, which we’ve covered before, often chooses mass data copying – so if you live in Newcastle and fall off a horse in Newmarket, it is unclear what happens, and whether or how those accesses or copies are consented. The LCHR programme breaks at every boundary you cross, because it is designed and run by NHS England for NHS institutions not patients. There is, as yet, no Information Governance model, there is no patient (or care provider?) accessible audit trail, and the change in name from ‘Local’ to Longitudinal Health and Care Records (page 99) also implies that the data held within them will be eternally expanded, rather than kept to the initial tightly defined dataset – care.data2?

The plan also refers to “The use of de-personalised data extracted from local records” (page 97), which suggests that LCHRs are intended to be used for both direct care and secondary uses – perpetuating the festering wound which is NHS Digital’s continuing disregard of the GDPR around the extraction and dissemination of data that GDPR considers identifiable. The use of “de-personalised” in this context (para 5.27) is a grasp at the figleaf of obfuscation that continues to be defended by the Wellcome Trust.

Lacking an appropriate IG model, there is no consent for the secondary uses of the records that LCHRs are sucking up – meaning the devolved LCHR teams are not only lying to patients but also, in contrast to the publicly owned SCR infrastructure, they have generally outsourced the data handling to the private sector. While replacing SCR is not necessarily a problem, replacing one data copy with a different, inferior data copy is not progress to anyone other than the IT companies that will get new contracts for what was previously a publicly-run service. NHS England delegating blame but not control is not a new phenomenon, nor is issuing plans that undermine and will remove what another part of the NHS is proposing to add to help patients.

The hint in paragraph 1.38 of online NHS services to help the mental health crisis is welcome, but the detail – barely two sentences of vague hand waving in chapter 5 – do not meet what is claimed, let alone what is needed.

Choices of the Secretary of State

The standards the Secretary of State sets for the NHS are not merely that its services are ‘safe’. He can have views on the user experience of an app, but user experience is not safety. There is a fundamental difference, and patients assume the NHS will never be unsafe – which is why there is such concern when it turns out not to be safe. The Secretary of State can say what he thinks ‘good’ looks like, but ‘safe’ must remain within the remit of qualified professionals.

Criteria for ‘safe’ are absolutely necessary, if not sufficient – it is entirely appropriate for there to be separate criteria for what is ‘good’. ‘Good’ apps may be what the public choose, but ‘safe’ is what they expect – apps can be both.

As an app example, Matt has chosen that the money for his GP registration should go to Babylon in London rather than the surgery in his constituency. He feels this works well for him, as someone who likely rarely needs a doctor, and disregards any wider harm that comes from taking funds away from the doctors in his constituency. The choice of what is ‘good’ is partially subjective, and different patients will make different decisions. The critique from the profession that the app is unsafe, however, is met with a response that someone thinks it is good. These are entirely different criteria, and both groups are talking past each other – the criteria of ‘safe’ and ‘good’ should be separated; as noted above, the former is necessary but not necessarily sufficient. The Secretary of State can add standards for what ‘good enough’ looks like, without reducing safety, if he so chooses.

At the insistence of DH, NHS Digital has pulled its consultation on the ‘Clinical Data Architecture’ Principles “so that we can ensure consistency with wider emerging strategies”. The Secretary of State continues to laud the first draft of his Vision, while the “Code of Conduct” update is delayed to let the AI companies lobby more, but how visionary is it?

NHS Digital’s recent Board papers have included their assessment of what they need to do to deliver on the Vision. While there are some things they wish to do faster, there are only two new things they need to start doing. One is new to NHS Digital only because it was certification work in which they weren’t previously involved (and it remains unclear why they are now), and the second is so substantive that we’ll quote it in its entirety from page 71:

“We will identify frontline staff whose skills and competence are evident to us and make them honorary colleagues (badges and certificates and all that jazz)”

The Vision the Secretary of State proclaims doesn’t seem any more visionary (or meaningful) than a late night monologue from an NHS manager in a hospital corridor about how GPs should work. The Plan suggests there will be new legislation, in which we will look for the National Data Opt-out to be placed on a statutory basis – rather than remaining a gift of a Secretary of State. We note that the National Data Guardian Act 2018 has now received Royal Assent, which is welcome progress.

Its recent Board papers state that NHS Digital is also going to “run all our public services in the public cloud with no more locally managed servers” (page 64) – presumably moving all services to Azure and AWS. Hopefully they will let tech-savvy journalists in to do long form pieces on what they’re doing, and provide reassurance, as this has the potential to go spectacularly wrong – with limited abilities for entities in the UK to clean up the mess, while doctors in A&E and GPs deal with the consequences of the national governance bodies screwing up yet again.

There is one final annual tradition DH has maintained – the new plan delays the full digitalisation of hospitals by yet another year; this target has been slipping by one year per annum ever since it was announced…