LECTURE NOTES

Peter Talbot

8th December 1997

Information in Health Authorities

Health Authorities are the local publicly accountable bodies in the NHS. Our function is to receive money from the government and distribute it to various parts of the Health Service. Much of our information function, therefore, is straightforward accounting. We record where the money went, present annual accounts, try to prevent fraud and mismanagement, and so on.

We also try to plan the best ways of spending the money, and monitor the outcome of plans. Since the 1990 Act (1989 White Paper) we have attempted to do this through the "internal market". The function of Health Authorities can best be understood against the background of the various acts of parliament which determined our function.

Socialised medicine was introduced by David Lloyd George's Liberal Government in 1913. This Act left the hospitals under the control of charity committees and consultant clinicians (who enjoyed both the salary and the opportunity to perform research, and the freedom to earn fees from private patients) but brought General Practitioners into contract with the state. The principal of patient registration and capitation payments was established. The local Insurance Committee kept records of what patients were registered with which GP practice and paid the GP's accordingly; they also were responsible for the safe keeping and transit of the primary care medical record - the "Lloyd George envelope". These functions subsequently fell to Family Practitioner Committees and thence to Health Authorities.

In 1947 the hospitals were nationalised by Nye Bevan. District Health Authorities replaced the charity hospitals' management boards and embodied an element of local democratic accountability. Local government was charged with new public health responsibilities and the task, jointly with the NHS, of building Health Centres. Regional Health Authorities were established with the particular aim of balancing the stark inequalities in healthcare provision - particularly between North and South - through funding allocation policies which were subsequently codified in Richard Crossman's RAWP formula.

In the 1960's there was a crisis in General Practice. The Wilson government introduced incentive payments to encourage GP's to work in the unattractive remote rural areas and the inner city. The Jarman score was established as a measure of deprivation (and rural mileage) to modify the capitation income of GP's.

The 1945 Labour Government had envisaged that universal healthcare provision, together with investment in housing, sanitation, education and other public health measures, would banish disease and that therefore the taxpayer's expenditure on the NHS would decrease as time went on. The opposite happened, and so work began to find out what the doctors were spending the money on.

The 1976 Royal Commission identified numerous difficulties and problems in the NHS including abiding inequities. It also concluded that government had no management information upon which to determine what went on in the NHS, and established the Korner Committee which defined a host of information returns required of the service by the Department of Health. Key amongst these were the Hospital Episode Statistics (HES), and computer systems began to be established to record hospital treatments at this time.

Wide variations in the costs of ostensibly similar hospital treatments were demonstrated by the McGhee studies. The Resource Management Initiative sought to investigate this aspect and was accompanied by the appearance of Diagnostic Resource Groups in the USA. This led to the development of HRG's - an anglicisation of DRG's.

The 1989 White Paper combined Alain Enthoven's ideas about applying US-style HMO practices with a compromise over clinicians' status and Kenneth Clarke's "idea in the bath" of GP fundholding. The "purchaser/provider split" was introduced. This gave greater clarity than ever before to the idea of financial equity in NHS spending - a population-based funding formula determines the budget of each Health Authority and of each GP fundholding practice, from which to purchase healthcare for the target population. HES was the only real information available at the time, and thus the Finished Consultant Episode (FCE) became the main Contracting Currency.

When Edwina Currie was junior health minister, the threat to women from cervical cancer became a major political issue. Since Family Practitioner Committees held lists of registered patients, they were charged with the task of call-and-recall for screening programmes, and given computer systems. These systems were soon also put to use to calculate the capitation payments to GP's, as well as the increasing number of incentive payments made to General Practitioners for Items of Service such as contraceptive advice, child health surveillance etc.

Family Practitioner Committees became FHSA's and were then amalgamated with the purchasing authorities to become the new District Health Authorities formally constituted at the beginning of 1996. The GP patient list - at its most basic an age/sex register - became readily available to support the healthcare purchasing function.

Health visitors, midwives, CPN's and other parts of the Community Health Services remained the "poor relations" in terms of management information systems - as perhaps they remain overall!

Health Authorities thus today run two main non-financial databases. The "Exeter" system contains the list of registered patients, the GP Items of Service details, and the screening registers, and is usually augmented by MIS systems for primary care. HA's also have a Contract Management System which accumulates FCE records of hospital treatments given to the Authority's residents.

Health Authorities also use the "Pactline" system, whereby the Prescription Pricing Authority feeds back the details of drug prescriptions written by local GP's. This has been stunningly effective in containing the escalating cost of pharmaceuticals in primary care. The data also serves as a proxy for the prevalence of many disease conditions.

In addition, the census and General Household Survey provide demographic information, and the Office of National Statistics analyses Death Certificates and the HES to produce the Public Health Common Data Set - the major source of mortality and morbidity information used by public health clinicians.

FHSA's managed the computerisation of General Practice, and today many GP surgeries accumulate morbidity information in much the same way as hospitals use Patient Administration Systems. Primary Care is thus increasingly a source of valuable epidemiology data.

Health Authorities' wide-ranging responsibilities cause them to keep information about numerous other items such as waiting lists, communicable diseases, nursing homes and long-stay patients. They are charged with the task of promoting clinical effectiveness and have access to medical research data resources such as Medline and Cochrane.

As the Internet continues to link computers together, these many sources of information become increasingly accessible to people working in the NHS. This is just as well, since if the future (like the past) consists of a series of government-led re-structurings of NHS bureaucracy, the network should allow us to obtain the information we need regardless of where we sit. For example GP locality commissioning groups will require similar information to that currently used by HA's to determine purchasing plans, and HA's may in future have a key role in ensuring that GP purchasers are supported by adequate information. Or they may be drastically slimmed down by a government seeking to reduce bureacracy, leaving the GP's and local government to reconstruct the public health function - we wait to see.

In any case, whoever inherits the task of attempting to plan healthcare provision will require information with which to do so. Demographics - especially measures of wealth and poverty, historical patterns of morbidity and of service provision, population projections etc will all be needed if rational decisions are to be made about the allocation of resources in the NHS.

Suggested Reading:

Carr-Hill & Sheldon, 1992 "Rationality and the use of formulae in the allocation of resources to health care", Journal of Public Health Medicine, vol 14 no 2

Perrin's chapter in: Henley, Holtham, Likierman and Perrin, 1990 "Public Sector Accounting and Financial Control" Van Nostrand & Reinhold / CIPFA - Note that this book pre-dates the "internal market" but a chapter was added to reflect the government's plans at the time. It is interesting to consider the further implications of the 1997 Labour Government's locality commissioning proposals.

Perrin, 1988 "Resource Management in the NHS", Chapman-Hall

Frankel & West, 1993 "Rationing and Rationality in the National Health Service" Macmillan

Jaques, 1978 "Health Services", Heinemann - Good stuff about the 1976 Royal Commission!

Keen "Information Management in Heath Services" Open University Press 1994, and "Should the NHS have an Information Strategy?" in Public Administration, Spring 1994, Blackwell. Justin Keen is something of a bete noir as far as NHSE IMG are concerned!

Frankel and Coast, 1996 "Priority Setting: the Healthcare Debate" Wiley. Presents the current theory of combining rational/formulaic approach with pluralistic bargaining.

Required reading:

"Inequalities in Health" - Penguin 1992. Comprises an updated version of the 1980 Black Report together with Whitehead's 1987 review "The Health Divide"

Update: May 1999

In December 1997 the government issued the White Paper "Modern and Dependable" which confirmed the concept of GP-led locality commissioning groups. Primary Care Trusts are set to replace many of the existing functions of Health Authorities as well as being responsible for the management of the Community Health Services. Health Authorities will be smaller organisations than at present and will have a strategic planning focus; they should perhaps be seen more in the context of regional government. What is not yet clear is who will be steward of the information currently collected and processed by HA's; this may be the role of a "Local Health Informatics Service" - a concept from the 1998 NHS IM&T Strategy "Information for Health".

Information for Health sets out an ambitious seven-year plan for the development of Information Management and Technology in the NHS. It requires every individual to have an "Electronic Health Record" which records every encounter with the NHS - primary care is expected to be the custodian of the EHR. Hospitals will have Electronic Patient Records (EPR's) recording the details of patient treatment. The two-tier model of EHR and EPR is similar to the way computerised health records are organised in New Zealand.

Another key theme in Modern and Dependable and Information for Health is the benchmarking of performance against standards exemplified by Clinical Governance. The National Institute for Clinical Excellence and Service Frameworks will give clear guidance as to what the patient's expectation of treatment should be. Government has made it clear that consumer access to this information will be encouraged by making the National Electronic Library for Health available for public access. Information Technology is expected to deliver better clinical practice, public accountability and consumer responsiveness, as well as efficiency.