* Patient Administration System
It was a great promise for the 2000s. The new hospital IT system was going to do everything the staff wanted and make it easier to provide a patient-focussed service. The hospital confirmed a successful implementation. So when the reported data from the new system showed hundreds of patients waiting over 26 weeks for an outpatient appointment, the hospital chief executive was reassured that the number did not reflect reality and was just a post-implementation workflow/reporting hiccup. He told the Department of Health that they did not have to worry. Their response was stark: the hospital’s reported number of long waiters would be forwarded to Ministers and included in the data provided to Parliament.
The chief executive had forgotten that staff working in the NHS have two roles – to work for the patient and the taxpayer, at the same time. The new system was in effect a replacement for the old Patient Administration System (PAS). It had been wrong to implicitly assume that the original PAS had been implemented just to help with the administration of patients.
The first NHS PAS implementations were driven by the need for hospitals to comply with the recommendations of the Steering Group on Health Services Information set up in 1980 by the Secretary of State at the Department of Health and Social Services (DHSS). The Group’s chair was Edith Körner, and its first report covered hospital data1. It proposed the minimum data sets required for the management of the health service. The report’s implementation required all hospitals to submit patient-level admission records to the DHSS via their Regional Health Authority. Each hospital was given a target date during the mid-1980s for their first submission.
This admission data could only be collected via a PAS, which most hospitals had to set about implementing. The first module to be implemented was the master patient index (or MPI, covering name, address, hospital number, etc) which helped staff keep track of the paper medical notes. Given the need to meet the data deadline, the next module implemented was the Inpatient Module. In my (not untypical) hospital the Outpatient and Waiting list modules were implemented a few years later, eventually followed by the A&E module. Only when all the modules had been implemented could it be said that the PAS helped staff with the administration of patients2. The strange order in which the modules were introduced is a reminder that the PAS implementation had to meet the needs of the taxpayer (via their government which wanted the admissions data first).
The data items to be input to PAS were those specified by the Körner Group as needed for management. This is why operational staff are tasked with the input of items like the patient’s Admission Method3 which is not relevant to the patient’s treatment. It is acknowledged that front-line nursing staff will never get these data items 100% right and so in some hospitals the data input by the nurses is later corrected by the data quality team.
NHS Method of Admission to hospital: codes and descriptions
Code Description
11 Elective Admission: Waiting list
12 Elective Admission: Booked
13 Elective Admission: Planned
21 Emergency Admission: Emergency Care Department or dental casualty department of the Health Care Provider
22 Emergency Admission: GENERAL PRACTITIONER: after a request for immediate admission has been made direct to a Hospital Provider, i.e. not through a Bed bureau, by a GENERAL PRACTITIONER or deputy
23 Emergency Admission: Bed bureau
24 Emergency Admission: Consultant Clinic, of this or another Health Care Provider
25 Emergency Admission: Admission via Mental Health Crisis Resolution Team
2A Emergency Admission: Emergency Care Department of another provider where the PATIENT had not been admitted
2B Emergency Admission: Transfer of an admitted PATIENT from another Hospital Provider in an emergency
2C Emergency Admission: Baby born at home as intended
2D Emergency Admission: Other emergency admission
28 Emergency Admission: Other means, examples are: – admitted from the Emergency Care Department of another provider where they had not been admitted
31 Maternity Admission: Admitted ante partum
32 Maternity Admission: Admitted post partum
81 Other Admission: Transfer of any admitted PATIENT from other Hospital Provider other than in an emergency
82 Other Admission: The birth of a baby in this Health Care Provider
83 Other Admission: Baby born outside the Health Care Provider except when born at home as intended
During the last 40 years the definitions of the required data items have been amended and extended so they could be used to determine £billions of income, performance measures and patient safety indicators. Data items were added following the introduction of new laws and regulations: the patient’s ethnic group had to be collected following the passage of the Equality Act. These items are covered by the NHS data model and dictionary3, which in turn reflects the current NHS management or operating model, i.e. the roles and inter-relationships of the various NHS organisations (foundation trusts, ICBs, GP practices, etc.). Each NHS reorganisation means changes to the data model and hence changes to some PAS data items.
What all this means in practice is that hospitals cannot use their PAS as they may want to. They must use it in a way that ensures the data it produces is comparable to that produced by other hospitals. Or risk being labelled an outlier. A problem arises when local innovation to improve patient care conflicts with how the PAS should be used.
Implementing ‘hospital at home’ means enabling hospital staff to manage patients in their own bed at home as part of a ‘virtual ward’. So why not set up a dummy ward on PAS for this purpose? But this would mean PAS generating data for submission that did not comply with the NHS data model. Suppose the data showed the trust to be an outlier on length of stay (because the time at home on the ‘dummy ward’ is included in the ‘provider spell’) or that deaths at home on the dummy ward (and unrelated to treatment) look like deaths in the trust, are therefore included in the hospital mortality measures and cause the hospital to be put in ‘special measures’ because its Summary Hospital-level Mortality Indicator (SHMI4) is above the expected range.
This illustrates the conflict between the needs of innovative hospital staff and the need to protect their reputation via the submission of ‘correct’ data.
Innovation or consistency? Hospital managers and clinicians must work with their data specialists to do both. A start in addressing this issue positively is to ensure there is a common understanding among all involved staff (including those outside the organisation at national level) of the facts described above. It’s no good telling hospital staff their innovation must ‘comply’ with the needs of a system designed as if there is NHS-wide consistency, or that they must wait until the NHS data model (and then PAS) catches up with their innovative approach to patient administration. It is good news that the new 10-year health plan5 has a vision ‘where frontline staff are empowered to reshape services’.
There will always be a need to ensure that what’s reported is correct. Just as the service innovation is local, so must be the data capture system required to support it – something that cleverly meets the need of the innovators and sits alongside PAS without negatively affecting the data submission and the hospital’s reputation. In a publicly-funded service, there will always be a need to look after the patient and the tax-payer.
Note: the view and opinions expressed in this article are not necessarily those of Northumbria Healthcare NHSFT.
References
- Edith Korner, Improved information for the NHS, British Medical Journal vol 289, 8 December 1984
- The implementation of the 18 weeks’ referral to treatment target in the early 2000’s led to PAS being required to link records between modules and this helped further with some patient administration aspects (https://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/rtt-guidance/)
- https://v3.datadictionary.nhs.uk/data_dictionary/attributes/a/add/admission_method_de.asp@shownav=1.html
- https://digital.nhs.uk/data-and-information/publications/statistical/shmi
- https://www.gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future/fit-for-the-future-10-year-health-plan-for-england-executive-summary
The NHS: observations of an Information Specialist 