MR RICHARD GRANGER, MR HARRY CAYTON AND DR GILLIAN BRAUNOLD

26 APRIL 2007

  Q1 Chairman: Good morning. Could I first apologise for the few minutes' lateness of the Committee. It looks a bit thin around this side of the table but you are probably aware we have a Mental Health Bill in standing committee at the moment and members of this Committee have been heavily involved in it, in different forms, for the last eight years now. We have got some members up there who are currently doing standing committee work, but I suspect we will be joined at some stage this morning by one or two members. For the sake of the record, would you introduce yourselves and the positions you hold. Could I start with you, Dr Braunold?

  Dr Braunold: I am Gillian Braunold. I am a GP in Kilburn, and I hold the position of GP National Clinical Lead.

  Mr Granger: I am Richard Granger. I run national IT systems for the NHS in England.

  Mr Cayton: I am Harry Cayton, I was the Chair of the Care Record Development Board and I am Chair of the Ministerial Taskforce on the Summary Care Record.

  Q2  Chairman: Welcome back again. I think I said last time you were sat there you were better attended than some members of the Committee and it is absolutely the case this morning! I understand you want to make a short statement to us before we start this morning's evidence session.

  Mr Granger: I want to cover three things: firstly, the general progress we are making; secondly, to give you a snapshot of the typical transaction volumes that benefit patients every day in the NHS in England today; and, thirdly, I want to finish with a comment on the general environment around the introduction of new technology into health care. When the Government announced its investment programme in IT in the NHS in England in 2002 there was already a considerable quantity of computers in use in the NHS, and almost all of them were characterised by being nothing more than glorified electronic filing cabinets. If you wanted to move any information between buildings you typically had to move it using word of mouth or paper; there was very, very little movement of information between buildings. Of course patients generally do not just get cared for in one place. There are a number of people who would say that there have been enormous successes in the 1990s in investment in IT in the NHS. I would say, having come from a background of having worked in social security computerisation, the progress that had been made was lamentable—and yet at very significant cost of about a billion pounds a year at 2002. The revisionists are busy at work now trying to make out the progress that had been achieved before 2002 was extremely good and has somehow been retarded by the introduction of national systems; but the evidence does not substantiate that viewpoint. Where you have 33,000 or so GPs in nearly 9,000 locations, and you have none of them able to move patient records electronically between sites and yet over three million patients a year change the GP they are registered with, I do not see how that mess could be described as a success; and yet some eminent GP IT advisers have described it as a success. One of the other things I found extremely quaint when I started delivering this programme was most of the people working in the delivery of clinical systems in the NHS have what would generally be considered to be serious conflicts of interest. They are the owners of software companies, have a financial interest in them, or advise them whilst also undertaking clinical practice. It has the benefit of them being closely associated with the solutions they deliver, and the disbenefits of them having certain conflicts they have to manage. We introduced a process as part of the procurement which was Civil Service standard stuff that we required people to declare these conflicts of interest, and we would not allow them to work on procurement activities if they had involvement with any of the potential bidders. That caused some distress for some of the so-called experts in this domain. It is what has been described by many as "a bit of an alligators' playground". In the last four years we have doubled the availability of network connectivity to the NHS. We now have 19,000 places connected up, so we have one of the biggest virtual private networks on the planet and people take that for granted. In some locations it does not work as quickly as the end users would like—usually because their equipment is badly configured when we go to investigate. We are now computerising, to deliver prescriptions safely, 200 GP practices a week with the relevant software. We typically move 120,000 prescriptions electronically now on any given day. About every ten seconds a patient gets a booking completed electronically, not at the target we would like it to be at but, nevertheless, a significant volume. I think you heard in your audiology hearing how Choose and Book is being used regularly now to enable accelerated patient flows, and is also introducing a greater degree of transparency about where the bottlenecks are in the system. We have about 50,000 people go onto our national demographic database every day and access two million patient records. That is something that did not exist three years ago; something that most major organisations and most government departments in the UK have had since the early 1990s—an online customer index so that you can send letters to the right place. In fact we see a reduction, as a consequence of that, from about three-quarters of a million patients having a letter sent to the wrong place down to probably around a couple of hundred thousand. The hospitals that are hooked up to this system say the number of letters returned, having been sent to the wrong place, has come down massively, which is a significant concern around confidentiality with a paper-based set of letters going out to patients, and inefficiency where an appointment gets sent out to them, for example, and they do not even get notification of it. We have got an e-mail service that has: a quarter of a million users; sends over a million messages a day; is encrypted; and over a third of those contain patient identifiable information. We have a system which has very efficiently paid GPs money under a "pay for quality mechanism" under their new contact. There were a few problems for a couple of days at the beginning of the new financial year as they stampeded into submitting their returns to get their money quickly. However, that system (apart from a couple of days) has worked very well since it was introduced. We have a major secondary uses database working as well. In closing I just want to reflect on how difficult it is to introduce new technology into health, because it is personal for all of us; we care about it; and a lot of people have anxieties. In the North-West we are about to introduce the Summary Care Record which will provide information about patients outside of the GP setting in which the best information is currently held. Around 0.2% of the public, where we have sent information leaflets to their homes addressed to them in person, have concerns about this. You might not think that is the case if you spend a lot of time in this part of London, but that is the kind of data that comes from other areas of the UK, and the North-West where we are bringing this system in. However, there are a lot of people very concerned. In 1834 The Times said, regarding a significant piece of medical technology, that, "it will never come into general use notwithstanding its value. It is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble to both the patient and the practitioner; and because its hue and character are foreign and opposed to all our habits and associations. It is just not going to get used". That was The Times writing about an invention from 1816 which I do not think we generally consider to be adverse to medical practice now. They were writing about the stethoscope. I think the adoption of IT systems that move information between care settings and serve patients as they move around the NHS is in a similar position, of a great deal of anxiety because of the introduction of the new technology. People will look back on this in a couple of hundred years' time and wonder what all the fuss was about.

  Q3  Chairman: Thank you for that. Many of the issues that you have highlighted, Mr Granger, we will obviously be pursuing in the course of this investigation, this being the first evidence session of the investigation. Could I welcome you and your colleagues as well. Going back 12 months or more now, most of the debate in the media (without the detailed things you have pointed out there) was people thought what was going to happen was that their patient record (and we assume by that, and I assume by that, it was one patient record) was going to go on the national spine and be accessible for people who wanted to know about my medical history. Actually we have got both a separate national and local electronic patient record now in front of us. Does this represent a failed compromise between the two different approaches? After all the talk about having one national record that was going to be all-singing and all-dancing for us, why have we ended up with two? Why is that?

  Mr Granger: That is not a change of direction; that is the details of plans which were documented in Spring 2002 in a document published by the NHS Information Authority, which I am sure one of your advisers is familiar with, which was called the NCRS, National Care Record Service. That document set out very clearly that there needed to be more widely accessible summary information and detailed local information; and the reasons for that relate to the ability of computer equipment to move large quantities of information around, and concerns about the need or absence of need for detailed information to be available outside of an individual care setting. We are trying to strike a balance between having nothing available everywhere, and everything available everywhere. Over the past three years my colleagues have undertaken a very extensive consultation exercise with clinicians and patients to strike what we think is the right balance there and to introduce that through a staged early adoption process. The delays we have had in doing that are a mixture of software complexity and an extended consultation period about how to do that.

  Q4  Chairman: Presumably the bulk of mine will be on the Detailed Care Record, and that will be what my GP and anybody in the South Yorkshire locality where I live most of the time will have. What added value will the national Summary Care Record add?

  Mr Granger: I think it would have specific value to you as you shuttle up and down the country between South Yorkshire and London. For example, your key allergies and current medication will be available if you need treating down south during the week or, conversely, when you are up in Yorkshire at the weekend.

  Q5  Chairman: What would be the difference then?

  Mr Granger: At the moment that information is not available.

  Q6  Chairman: It is not available down here, yes, I accept that. What will be the difference in the record? That record can follow me from South Yorkshire to London and back again; one record can follow from South Yorkshire to London; but I am trying to tease out of you, what is the added value of having a national Summary Care Record in addition to the Detailed Care Record which will be about me and my potential needs?

  Mr Granger: Quite a lot of the record about you will not be coded in a manner that would be safe for other people to use. It will be meaningful to the people who collected it, and it may be voluminous. It may not be particularly relevant to the care that you need on a spontaneous basis when you are away from home.

  Dr Braunold: I think it may help to try and differentiate between the Summary Care Record and the Detailed Care Record, because they have different business functions and are intended to serve different purposes. The Summary Care Record is intended to be a first cut of information to help clinicians who have no access to any other records in the first instance who are unfamiliar with the patient, to help them to get started so they are not working in an absence of information. What we know is the first things that will go up will be the medications of the patients, the allergies and then it will be joined by significant medical history, but in a summarised way. We have left the content of the Summary Care Record of what will be uploaded in the first instance from the general practitioner to be customisable at a local level. The reason we have done that is because there is a different timescale in which the Detailed Care Record is being delivered around the country; and it is not coming in at the same time. There is the potential for the Summary Care Record to actually contain information that will serve local business requirements while they are waiting for the Detailed Care Record. If I take the example of a diabetic care pathway, one of our early adopter PCTs in the country is planning to use the Summary Care Record to help the people who are looking after patients with diabetes in the community, as well as in hospital and general practice; and they want to ensure that the content of the Summary Care Record will help to manage that care, and will have in it the recent results and the recent visits to the various members of the team. That will be enabled if that data is sent up from the general practitioner record. What is very important is that people in the locality where it is being used understand the use to which it is being put and the data set that is going in. My personal belief is that the amount of information in the Summary Care Record will start growing bigger and then go smaller again as the Detailed Care Records become the actual way that in the locality people start to share information; but, because this is a system in evolution, we have to start somewhere. We have started with the Summary Care Record in areas where there is not any other data-sharing quite often because those are the Primary Care Trusts that have said, "Yes, please, we want to be part of the early adopters process for the Summary Care Record". They are very keen and eager to do some data-sharing in their areas. It enables us to test very slowly some of the concerns people have had around confidentiality and access controls et cetera, which I am sure we will be discussing, and test them slowly and incrementally, as well as what information was most helpful.

  Q7  Chairman: It has been put to us that the exact content of Summary Care Records is not yet known. Is this an evolving situation?

  Dr Braunold: There are some things that are absolute. I can very firmly take people through what we are doing with the Summary Care Record in its first iteration. The first thing that happens is a leaflet goes out to the population in the area; and then eight weeks later there is initiation of the repeat prescriptions and the acute prescriptions which are put up as well as the allergies and adverse reactions. That is followed by significant medical history, and we are starting with the core data set the GP has put into their Summary, and they are discussing that with their patients and asking them if they are comfortable with that data set going up in addition to the drugs and allergies. That is in discussion with the patient about what else should join the drugs and allergies. We have not been definitive about what should go in that part, as I said before, to feed the pathways; but also because there has not been guidance previously as to what is in an ideal Summary. Harry will be able to talk about the recommendations from the Ministerial Taskforce about advice as to what should be in an ideal Summary.

  Mr Cayton: Perhaps I could say a bit about this, and perhaps I could go back, first, and just think about some of the benefits as I see them from a patient perspective. You are right in a way to question this concept of people travelling around the country. Of course, people do travel around the country a great deal more than they did, but that is not really, I think, the most important reason why this is important. I spent a day recently shadowing an emergency care practitioner with the London Ambulance Service and we spent most of our time visiting frail, older people whose carers or relatives had rung up with that most common of conditions of frail, elderly people which is "had a funny turn". "Had a funny turn" is not a very helpful diagnosis for a paramedic or an emergency care practitioner. Seeing what they have to do in practice, the complications of identifying which medicines a person is on, especially if that person is confused or not very well at all; trying to identify what conditions they have; the huge benefit to them of having access just to this very small data set initially of medications, allergies and adverse reactions; plus, of course, the administrative benefit of having a computerised system that they can use instead of very large amounts of filling-in of paper forms, with all the introduction of errors that often brings; I think there are some real benefits. One of the myths now is that we still have a profoundly long-term personal relationship with an individual GP. Many of us do up to a point, but GP practices no longer provide services in the evening and at weekends; so everyone who uses a GP service is inevitably using GPs who do not know them very well if they are inconveniently ill out of the hours in which GP offices are open. It is not just the situation around people who are travelling, or people who are unconscious in A&E; it is a situation for a vast swathe of frail, older people, and for every single one of us who might happen to be ill at an evening or weekend. In the Taskforce, to go back to the issue of what is initially in the Summary, we had a very extensive discussion. We had on the Taskforce representatives of the BMA, RCN, the College of Emergency Medicine, the Terrence Higgins Trust, nursing and so on; so we had a wide range of interests. We felt that the most appropriate way to go forward was cautiously and sensibly. We recognise that there are concerns; we recognise that there are doubts; and there seems to be quite a clear consensus, certainly around clinical people, that this small data set that Dr Braunold has described is a significantly useful data set in clinical terms and does not raise as many questions as might be raised by more sensitive information such as diagnoses or medical history. This is a step forward as we build a consensus around what works and what does not work.

  Q8  Chairman: That could be interpreted as being a compromise because the ideal is a national patient record, and what we have got now is that there are going to be two national patient records. It sounds to me as if this is as far as you can get. Was this a political compromise in terms of what you wanted in the first place and what we have at this stage?

  Mr Cayton: I do not know that you can use the word "political".

  Q9  Chairman: It is a compromise then?

  Mr Cayton: You might say it is a "professional agreement" around what is acceptable to conflicting interests within the system. Interestingly, as the patient or independent person on this, many of the conflicts are between clinicians; they are not between clinicians and patients on these issues; they are actually between different groups of clinicians who have different conceptions of their role within the Health Service; different conceptions of the balance of power within the Health Service; and who are trying to protect the interests of certain clinical groups, sometimes I have to say, under the disguise of protecting the interests of patients.

  Chairman: I have personal experience of the same group of medical people in my constituency who have different attitudes towards some of these matters.

  Q10  Dr Taylor: I want to move on to the Detailed Care Record. I can see how feasible the Summary Care Record is; I just cannot see how feasible the Detailed Care Record is. We gather it is going to be made up of different records from different hospital departments, from the GPs. The only information we have got in the Department of Health's submission about Detailed Care Records is under paragraph 29 where it says: "The Detailed Care Record component of the NHS CRS will support the care process and will typically contain: the name; address; date of birth; NHS number; past and current health conditions; allergies; assessment et cetera; care plans et cetera; treatments, including operations and medication; care reviews; and discharge information". I am very, very concerned about the amount of information that is in hospital notes, and please do not think I am denigrating GPs, because obviously they have got the shorthand type notes worked out to a high degree, and it is going to be relatively easy to computerise GP notes. It is going to be extremely difficult to computerise hospital notes, which are going to be needed in the Detailed Care Records. I would like some ideas, some guidance on how you are going to approach this and make this even possible. I have got lots of specific points to pick up.

  Mr Granger: If I could start on this and if Gillian could follow. I think there are two problems. The first is that the computer systems that have existed before this programme have typically only served doctors in one care setting. It has either been a hospital system or a GP system. The market was very firmly orientated in that manner. We have the challenge of getting suppliers of GP systems, and give you for example EMIS and TPP as two suppliers based in Leeds, both of whom are pushing upwards into community and ambulatory care settings with increasingly rich products. At the same time as you see the supplier for the South and London in the acute sector, Cerner, who run the systems that support a third of the hospitals in the US, you see them pushing downwards into what they would term "physician offices", into GP practices. That was a problem that existed before we started this programme, and it is still work in progress. The second problem is that, whilst GPs use Read codes and localised variations of them (and the variations are one of the greatest problems to information liquidity between practices), in secondary care a lot of the information is only coded up after the actual interaction between the clinician and patient. Our challenge is to introduce systems where people are coding information at the point of care; and some of the codification of those systems will be better supported by something we have been working on for some time, which is a proper international standards body called SNOMED CT, which is a much more detailed structured nomenclature to support secondary care, because obviously Read codes are inadequate in that setting. We have had to take the lead in launching an international body to do that and wresting that from the College of American Pathologists into an international body, and that will be announced later today. It is going to be a long and difficult process to get the complexities of secondary care to code information in a way that it can be used outside of the location in which it was originally created. We are going through some of those difficulties at the moment in the south of England with the implementation of the Cerner system, which is requiring much more data to be collected at the point of care, rather than it being coded up subsequently; which is introducing problems of efficiency in the way the NHS is currently organised in terms of rapid clerking of patients, followed by retrospective tidying up of records and production of billing information and so on. It is a challenge at the moment but we are working through that.

  Dr Braunold: I totally understand the question, and I suppose it is important to have a goal. I will try and describe the picture very quickly and then look at the steps we need to go through to get there. As a GP I get something like 125 letters a week from my colleagues in secondary care about my patients and those are structured usually most about the history of that patient—that has always been there; and occasionally there may be some recent results and the medication that has been used; and then there may occasionally be a sentence asking me to do something. I have to read that letter very carefully in case there is an action and I need to file it in my records. In order for me to do that, that has come from a hospital usually dictated by a consultant such as yourself, and it is then typed up by the secretary onto a computer; it is then printed out; and it is then sent by snail mail to me; and I then have somebody who receives it, scans it, then puts it into my computer and somebody codes it back into the computer and checks there are no results or anything I need to do; and then, finally, I check for any actions. For me it is not only a saving of all the scanning and the obvious things that an electronic message could do, but I want to save some of the coding issues so that instead of me receiving stuff for information, which we should share in a Detailed Care Record, that we would change the way we work; that we would only need to send each other actions, instead of sending each other information that we share on a Detailed Care Record. That for me is the Holy Grail of what we are about. It is about really changing the effectiveness and the efficiency of how we work. To get there is not going to be quick. It has taken general practitioners a decade or more to learn how to code carefully and accurately. We have worked through a data quality exercise that we are doing at the moment, on actually saying only GPs who pass the data quality accreditation can submit to the spine, because we want data that is fit for sharing. There is an enormous amount of work to do with secondary care. I understand your concerns. One of the things which my colleagues as the National Clinical Leads for hospital doctors are very keen to do is to really look at incremental ways of delivery of product. This is not a shiny spaceship going to land on secondary care where suddenly everybody has got to do this. I went to visit the Homerton Hospital where Simon Eccles one of my colleagues is based and I said, "I've heard the Homerton is great and it's running this great system". I came from general practice and I am used to flying with my machine and, I have to say, from a general practitioner's perspective I was very disappointed. The reason I was disappointed is because I am used to a very functionally rich system. What gets secondary care colleagues excited is a particular product delivery of particular issues. They have got Order Comms (Order Communications). Order Comms means if they send off 15 blood results they can see at a glance if 12 of them have come back, click on it and see them. They have got bar coding so they know where the results are on the system and they can track them, and that is great. It is the equivalent for me of where we were when we got repeat prescribing. We knew what to do with prescriptions and waves of GPs started to use computers because there was a business benefit to them. I see the secondary care delivery of products as Cerner and Lorenzo and all the others going through their various iterations delivering more and more functionality, year by year. People start saying, "What's coming next? That was quite good". The challenge for us really is to make sure that we do not make that challenge too painful; because you cannot ever get gain without pain. You cannot take on a new laptop without having to learn something. It is always painful gaining new functionality. We have to make sure that we do not challenge the NHS too greatly in the delivery of these extra functionalities. I hope that explains what the Detailed Care Record is for, because I really think it is worth having and it is a challenge worth taking up; but it is not going to be speedy.

  Q11  Dr Taylor: I am not saying it is not worth having, I am just wondering if it is a possible dream in the long term. I can quite see how it is easy to put on X-rays; it is easy to put on path results; it is easy to put codes and prescriptions. There is an awful lot of importance in narrative text in hospital notes. How are you going to cope with that? I am thinking particularly that the complaints we get as MPs largely are associated with lack of communication between staff and patients. The basic defence you have got as a doctor is that you have recorded what you have said to the patient or the family. How is that sort of narrative text going to be in the Detailed Care Record; or are we still going to have a paper record in the background? The idea is to get rid of paper altogether.

  Mr Granger: One of the feedbacks we had from the new system we put in in Winchester was that the nurses were delighted with the noting functionality. We are looking at trying to increase the quantity of information which is codified so it can be used safely in multiple locations, even within an individual institution; and we are providing a facility which allows people to put the notes in free text format onto a computer system, so that they carry forward as well. I recognise a lot of people like to use free text because it can be easier for them than codifying things but it has a systemic inefficiency for the NHS unless they are the only person caring for that patient.

  Q12  Dr Taylor: But you cannot codify a unique conversation between a doctor and a relative?

  Mr Granger: No, but one of the things we generally do not codify, for example, is causation. We will codify that somebody has broken various bones but we will not codify the fact that is because they fell over; so we discharge them from hospital and they trip on the carpet and come back. What we need to get to is the root cause of lots of people falling over as they get older and their housing conditions. You start to collect coded information about a fall which does exist in SNOMED; you start to get some very useful information about the root cause of the admission; whereas just typing that in free text, "Had conversation with patient; she told me she fell over again", is not very helpful.

  Q13  Dr Taylor: You are not taking my point. What I am really bothered about is the conversation between staff and a family, explaining what is going on with the patient.

  Dr Braunold: I think that is absolutely right. For me that still has to be recorded. There is no reason why it cannot be recorded on the computer in free text format.

  Q14  Dr Taylor: How is that actually done? The doctor writes down in the notes in longhand?

  Dr Braunold: That will be subject to the local business processes in that Trust. It takes a while for people to move forward. When we went, for instance, to the States (because I went to have a look at how it was working there) quite often the consultants were dictating, and other people were entering the data; and they may have written in long form and somebody would then take it and put in the computer; whereas in other places people are putting it directly into the computer. What some of the software is able to do, however, is as you type in it is able to suggest codes for part of the text you are typing in so that you are not losing the opportunity to have the coding happen simultaneously. It will offer you a code for part of that. Some of the pain we have gone through in general practice is that, frankly, if I look at some of my colleagues' records the most frequently used code in general practices is "had a chat to patient", and then everything is underneath. The move to a richer coding set came with the input of the quality and outcome framework, as people started to realise if they did not code peak flow measurement properly as a code, rather than somewhere in that text as they had done previously, they were not going to get acknowledged for the work they were doing in looking after people with asthma properly. It is around getting people to understand payment by results and your actual peer audit are things that will encourage people to code properly; but that should not take away the text that we have to still write.

  Q15  Dr Taylor: Has there been any attempt to get agreement from hospital doctors on what goes in the Detailed Care Record?

  Mr Granger: There has been a process that has been going on since the early 1990s around that. I am sure you are more familiar with that than I am in fact. The specifications we have produced software against have their most recent origin in work that was done between 1998 and 2002—electronic record pilots; and in communities around England that were in the process of buying local systems which were generally unaffordable when they got through their procurement process in the South-West, the West Midlands, for example, the Shires procurement and Blackbird procurement. Those were specifications that had been produced by local clinicians, lots of hospital doctor input; and that is then iterated and refined continuously around the country as we take early versions of systems and refine them. It is an uncomfortable process because the requirement changes with time, as people become familiar with systems; so to start with people may want lots of free text input and they may want to do that via a Dictaphone or manuscript, then they want to move to typing some of it. One of the challenges that exists in the hospital sector is that it is only now, in fact a couple of months ago, that the first computer that might actually be really useful for a doctor on a ward round was launched. It is a device which has been developed between the NHS and Intel. Before that you had, at best, a laptop, which is a very nice repository for clinically-acquired infections; or you had a computer on wheels, known as a "cow" generally, dragged around a ward with batteries or wires hanging out the back of it—completely useless for somebody moving through a hospital on a ward round. The hardware is only now catching up with the way that hospital doctors work. We have had the same challenge with rolling out PACS (Picture Archiving and Communications Systems). It is very easy to put a light box in lots of places; they are not very expensive; you move to putting in computers and you need very high resolution screens that are £10,000-£15,000; they need a power supply; they are heavy; they need hanging on walls in theatres; people who might have had screens on three sides with their light boxes and now you have got a problem putting the IT in with the same information availability.

  Q16  Dr Taylor: So when is this marvellous equipment going to be available? Is it something you speak into and it automatically gets it on?

  Mr Granger: We have that running already. Voice recognition is being used.

  Q17  Dr Taylor: Is it now reliable?

  Mr Granger: It is getting reliable. It is being used in several hospitals for reporting in picture archiving. These are emerging technologies. They have been around for a long time but they have generally been designed to work in office settings. Most computers that work in hospitals at the moment are office equipment; they are not hospital equipment. Their portability; their cleanability; the ability to make them hygienic; has been very poor. We have been developing the specifications for washable keyboards, wipeable computers that do not have lots of ports that are uncleanable and so on. The first batch of that equipment was trialled in Salford over the past few months and will come onto the market over the next few months.

  Q18  Dr Taylor: Will that allow, for example, the detail of the houseman's history, the detail of the houseman's examination to be recorded on the system?

  Mr Granger: Yes. Those tablets that are the size of a notebook, they will do handwriting recognition, voice recording or allow typing either by touching or tapping; and they will allow images to be displayed with a reasonable degree of resolution as well.

  Q19  Dr Taylor: Is this going to delay the system further?

  Mr Granger: No, but this is something we have to do. From 2002 in the strategy to introduce these systems we found a number of barriers. One barrier was there was not nationally available broadband. We have had Telco (Telecommunications) companies digging roads up and putting cable down in the South-West, for example. Another barrier is the computer equipment that has traditionally been used in clinical settings, certainly in acute settings, is not optimal, and we have had to work with industry to develop that. This is the NHS doing things in a world-leading setting and it has been difficult and it is time-consuming.