Introduction: 1998-2008

Chronology:

How to use this site

This site deals primarily with the the sixth decade of the NHS, 1998-2007.  Previous decades that were printed in the book are accessible through links.  This introductory page covers some general issues, but as in the hardcopy of the book major themes, for example hospital service, money, policies, have separate pages with appropriate hyperlinks.  There is a search box on the home page.  Comments and suggestions are welcome.

The decade 1998-2008

Changes in British Society

Changes in society, as ever, affected the health services. In general the economy was sound but the UK, like many other countries experienced terrorism, often fuelled by radical Islamic influences.  The devastation in New York 9/11, atrocities in Spain and the London Underground, and the Iraq war cast long shadows. Following the Kyoto Protocol in 1997, climate change and carbon emissions became a national and international issue affecting policies on energy and transportation and a further hesitant step forward was taken in Bali in 2007. Globalization, the pressures of the European Community, and the digital revolution were also driving change. The introduction of the Euro in 1999 fuelled the national debate on our place in Europe and a European constitution that ebbed and flowed throughout the decade. To bring Britain in line with the Community ambulances changed colour from white to an eye catching yellow.

Population movement was increasing. First London and then the country as a whole experienced an influx from the European Union.  Early in the decade tens of thousands of young French people arrived.  Even before the EC expanded eastwards many workers from Eastern Europe and especially Poland arrived, filling jobs that the indigenous population did not want and creating new businesses. Local authorities complained of the pressure on their services from a substantial increase in the local population.  Retired English travelled to France and Spain for the quality of life or week-ended near Calais. Emigration from the UK increased steadily to nearly 200,000 in 2006. Public reaction to economic migration and asylum seekers changed the political landscape throughout Europe. In 2004 the Department of Health issued an emergency multilingual phrase book, produced by the British Red Cross Society  translated into 36 languages.  It covered 60 of the most common medical questions and terms to help staff communicate with patients who did not speak English.

Some migrants came from areas with a high prevalence of AIDS, tuberculosis and hepatitis B.   While Bevan had explicitly accepted that the NHS should be available to everyone, resident or visitor, government now took the view that it was not intended to be available free of charge to those who did not live in the UK. Government repetitively proposed to tighten regulations.  Front line staff had little time or inclination to ask their patients too many questions.

["How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified. What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody. Happily, this is one of those occasions when generosity and convenience march " (In Place of Fear, Bevan, 1952)]

The World Health Organization's twenty-year plan to bring ‘health care to all’ failed of achievement.  Famine, flood, civil war and genocide offset the efforts of aid agencies.   More than 2 billion people still had no basic sanitation. The European Region’s Health for All, equally ambitious, was also far from fulfilment. (Moore W. The impossible dream. Health Service Journal 2000: 6 January: 8-9.)  The campaign for the reduction of third world debt made only limited progress, and poverty, famine, wars and the AIDS crisis was worse day by day. 

Within England the north/south divide seemed to be increasing, and the housing market took off.  The need jobs to commit 24 hours a day 7 days a week to one's employer stressed some.  In the countryside, crises hit agriculture (BSE, foot and mouth disease) and the provision of rural services became a major political issue.  Within the urban areas our multi-ethnic society was increasingly apparent.   Racially motivated riots (Oldham), protests against a global economy and violence in the streets, sometimes black on black, and even against NHS staff, soured the atmosphere. The fashion for body-piercing and cropped tops changed the townscape while pressure led to the establishment of  smoke free public places and offices. To the profit of pharmacies, a gullible public spent increasingly on ineffective "alternative" medicines, while a split in the anti-vivisection movement led to the use of violence and terror tactics. For the young, adventure holidays and gap years proliferated, with a rising use of recreational drugs and clubbing. Institutional and financial malpractice, threats to the pension schemes and banks (Northern Rock) created anxiety.

Major constitutional reform, changes to the House of Lords and devolution to a Scottish Parliament and a Welsh Assembly were soon under way; health was the biggest single issue to be handled by the devolved assemblies.  There had been longstanding differences between NHS services in the four countries which now increased.   In 1998 Labour devolved power to an elected Parliament in Scotland, an elected assembly in Wales and, until it was suspended in 2002 for a period, an elected assembly in Northern Ireland. Four different health services emerged.  In England there was an accent on improving performance and setting targets, in Scotland a professionally led integrated system based on clinical networks, in Wales, partnership between the NHS and local authorities.  Both in Scotland and Wales, the health service provided benefits not available in England, for example in the care for the elderly, drug availability and in prescription costs.  The differences in funding, under the Barnett formula were apparent. 

While within each country formulas guided allocations to improve equity, no such policy has ever been applied between the counties.  Scottish spending approached the European average; English did not.

The NHS and Labour

Throughout the sixth decade of the NHS Labour was in power yet the private sector was involved in NHS provision as never before.  Dynamism is an intrinsic characteristic of health care for challenges, part of the interest of working in the NHS, change as one problem is handled and others emerge.  In 1998 long waiting times for outpatient and inpatient treatment, even "trolley waits" for emergency admission, were major issues.  Ten years later this had been replaced by the perception that there was poor access to the family doctor service and hospital infection was out of control. The service cannot stand still when advances are international, driven by the spirit of enquiry, commercial gain, competitiveness and globalisation. In basic research the early steps in nanotechnology, stem cell research and developments in genetic medicine were taking place, supplemented rapid advance in pharmaceuticals and the technology of imaging.  Patient expectations continued to rise and media coverage of health affairs to increase.  Each expensive new technology not only raised costs but increased demand as treatment became more effective and less traumatic.  Government faced the dilemma of reconciling national standards, for reasons of parliamentary accountability, with a perceived need to decentralise decision making.  Slowly at first, and then increasingly rapidly, Labour attempted to deal with the obvious and major defects of the NHS, too few doctors and nurses, poor buildings, and waiting lists that would be unacceptable in other major western nation. 

While by the end of the decade there was a difference of opinion about how far the NHS could be separated from political control, the three main parties agreed that

• the NHS should remain a public sector monopoly (with the private sector contributing to its provision)

• that Labour had been right to increase spending on healthcare to European levels

• that the NHS had been too centralised

• that patients should have more choice and be treated as consumers rather than passive recipients.

Funding

Traditionally the funding of the NHS had three characteristics,

• It had been low by international standards, 5.6-6.0% of gross domestic product compared  with nearer 7% in Europe and 15% in the USA

• It was highly dependent on public finances, some 89% of total health care expenditure

• A reliance on general taxation (rather than insurance or employers' contributions)

There had been many reviews of the way the NHS was funded, generally away from the public gaze.  These tried to identify additional money to close the gap between what people wanted and what they were willing to pay for, for example private contributions to the costs, or forms of taxation that the public would pay more willingly.  There was little change until 2000, the reviews being constrained by the unwillingness of any party to question the basic principle of a universal service with comprehensive benefits based upon need rather than willingness to pay. 

Total staff in England 1996 1,056,501 1997 1,058,606 1998 1,071,562 1999 1,098,348 2000 1,118,958 2001 1,167,166 2001 1,124,934 2003 1,283,901 2004 1,331,857 2005 1,336,030 2006 1,338,779   above - source NHS Information Centre on the left - source: BMJ 2004; 328: 729 and Department of Health)

Towards a new pattern of NHS

In 1999 Frank Dobson told the NHS to adopt a single Logo within two years to imply focus and a consistency of service.  It was soon hard to remember the days when this did not greet one daily.

In each decade there are central concepts affecting the organisational pattern of the NHS.  In the seventies there was consensus management.  In the eighties the general management function.  Now, spurred by scandals in the financial sector and industry, good governance became a guiding principle. In 1992 the Cadbury Report had identified principles of good governance in organisations - integrity, openness and accountability.  This was taken further in the Nolan Report (1997) and other subsequent management orientated documents.  These principles were absorbed into NHS management. The constitution of NHS organisations was developed on this basis and Trusts would be monitored and assessed on their conformity to them.

New initiatives and new policies altered the NHS substantially, as health advisors in No 10 and economists and operational research staff in the Department of Health played a substantial role in shaping policies.  Increasingly the NHS was seen as a concept - tax funded, largely free at the point of use, but provided by a variety of organisations.  No longer was it a service where provision was in the public sector, in facilities that it owned.  The service moved from a system in which providers took no risk and patients just waited until they were treated, to one where the search for efficiency spurred a new series of incentives. 

Over the decade, to professionalism, peer review, central direction, performance reporting and accountability were added competition, commissioning (including practice based commissioning), trusts, patient choice, and payment by results.. _{Dixon J. Editorial, BMJ 2008,336; 844-5}.   The crafting of detailed financial incentives was both important and difficult.  Some policies (trusts and payment by results) had at least some effect for the good.  Others (e.g. practice based commissioning) were less certain in their effects and some were possibilities for the future, e.g. integration of capitated budgets for both primary and secondary care.

Behind the political confrontations, there was bipartisan support for many policies such as NICE, an independent quality inspectorate (the Healthcare Commission), a purchaser/provider split, foundation trusts, concentration on long term illnesses, patient choice, involving primary care in commissioning, a tariff system to pay providers and a more personal service. Some stability could be expected, irrespective of the party in government.  Both parties wished to move from a provider dominated NHS to one in which the patient had more say and to improve health service performance. 

Simon Stevens, Policy Advisor to 10 Downing Street from 2001-2004, wrote that the attempt to increase capacity, improve quality, and increase responsiveness while avoiding cost inflation was based on three parallel strategies. 

1. supporting providers by increasing their number, modernizing infrastructure and supporting learning and the improvement of the system. (Capacity would be increased through staff recruitment, public-private partnership projects and new providers.

2. improving efficiency and reducing variation in performance by setting standards (National Service Frameworks, inspection, regulation, publishing performance information and direct intervention when necessary)

3. using market incentives for change and local accountability  (e.g.patient choice, star ratings, reforming financial flows, and commissioning)

NHS planning - a central organisation activity since 1948 -  was modified regularly as responsibilities moved as organisational structures changed.  Local Development Plans (LDPs) were introduced in 2003 and key areas were identified as priorities changed with need, demand and political requirements.  After years of negotiation, a new pattern of pay system, the Agenda for Change was introduced for all directly employed NHS staff, except very senior managers and those covered by the Doctors’ and Dentists’ Pay Review Body, to harmonize the conditions of service staff, provide a clearer system of rewards for staff working flexibly and assist in the development of new types of job.

Continual organisational change had created a structure that was as divided as the tripartite service of the first 25 years of the NHS. 

Primary and secondary care was funded and overseen by a Primary Care Trust covering the local residents.  GPs and their staff were paid under contracts negotiated nationally, but susceptible to local modification.  Hospitals received money under service agreements and many funds encouraging particular improvements.  The Primary Care Trusts were overseen by Strategic Health Authorities with wide planning functions and at top level by a regional office of the Department of Health.  Health care was not always provided by an organisation entirely within the NHS with hierarchical responsibilities to the centre.

The NHS now provided care largely free at the time of delivery, funded from central taxation, and gained access by

• contacting NHS Direct or NHS Direct Online

• turning up at their local hospital accident and emergency department where they would be assessed by a triage nurse

• booking an appointment with the GP with whom they were registered, providing acute care, care for chronic conditions and health promotion

Each of route of access might lead into the local hospital (secondary) care system.  The local hospital might be

• a university-type hospital with a wide range of specialist units or

• a district general hospital covering most normal requirements but part of a referral and clinical network involving hospitals with more specialised facilities (see the Darzi report 2007). 

• as patient choice and "choose and book" systems were expanded, the hospital might be in the private sector

In addition, more specialised services would be based on other specialised hospitals that could provide skills and experience that was not normally available

Labour, as had the Conservatives before them, looked at what could be learned from managed care organisations in the USA, such as Kaiser Permanente. The NHS took notice.  Beacon sites for particular aspects of Kaiser began to appear as far apart as Torbay and Northumbria. Characteristics of Kaiser included integration of funding with provision of service, integration of inpatient care with outpatient care and prevention, focus on minimizing hospital stays by emphasizing prevention, early and swift interventions based on agreed protocols, and highly coordinated services outside the hospital, teaching patients how to care for themselves, emphasis on skilled nursing, and the patients' ability to leave for another system if care is unsatisfactory.

An independent NHS

Towards the end of the decade, the debate about giving the NHS more independence from government resumed.  Previously the clinching argument had always been that as the NHS was funded almost entirely from taxpayers money, parliamentary accountability was essential.  The Prime Minister, Tony Blair, believed that independence would have major disadvantages, but others entered the lists including the King's Fund, and the BMA. The Conservatives proposed a NHS Autonomy and Accountability Bill, calling for an independent board to run the NHS and extension of  the freedom of foundation trusts (June 2007)

Ethics and Patient participation

Ethical problems abounded, particularly in the fields of genetic medicine and in vitro fertilisation. Legislation did not fully reflect the possibilities now opening, for example in the creation of 'rescue babies' whose stem cells could help a sibling.  People increasingly wished to be consulted on their care, and could turn to Internet.  The GMC sent doctors advice on the importance of consent, advice to patients and the ethical problems that might arise.  The Council stated in 2008 that doctors must be prepared to set aside their religious and other personal beliefs if these compromised the care of patients, instancing face veils worn by a  doctor if that was an obstacle to communication and trust, abortion or cremation. The extent to which the professions gave patients adequate information and obtained informed consent was raised in the context of a clinical trial of the respiratory management of premature babies in North Staffordshire.

Attempts were made to develop general ethical principals, for example, those of the Tavistock Group.

Since the earliest days of the NHS it had been appreciated that the quality of doctor/patient communication was sometimes poor. In a consumer society people expected more and Labour attempted to increase the participation of patients and members of the public both in their individual care and in the management of the NH.  The long standing Community Health Councils were replaced by a Commission for Patient and Public Involvement in Health in 2003 and this was scheduled for abolition in 2008 to be replaced by a new system, LINKs.  The views of patients were increasingly sought on the pattern of their service and the establishment of Foundation Trusts (2004) and the encouragement of local people and patients to become trust members was a further approach.

^{Medicine and the media}

The media covered health issues extensively from several points of view.

1. Thoughtful examinations of the NHS when compared to alternative systems of health care e.g.  Panorama on 26 March and 3 June, before the election of June 2001.

2. Health care as a whole;  e.g. the Sunday Times regularly featured alternative medicine, dealing with everything from allergy to cancer. Within the professions, where evidence-based medicine was in vogue, it was recognised that much information was spurious junk medical advice. 

3. Scandals in which patients had received poor care, from individuals or from a health system more generally. Criticism of incompetent doctors, of difficulties in gaining access to health care, the restricted availability of expensive drugs and clinical procedures, and the funding of the NHS as a system, was continuous.

4. Individuals with health problems were not exempt from media  interest.  Thomas Stuttaford, in The Times, frequently made the medical misadventure of a well-known personality the basis for a review of the characteristic presentation, treatment and outlook of that condition. 

Internet

The rapid spread of the Internet during the decade affected health care in many ways.  By providing people with information it became a powerful way of creating a patient-led health system. Those with serious illnesses such as cancer used the Internet as a source of information.  Typically they used a search engine to check a number of sites dealing with their specific many of the sites, they were not entirely altruistic. Some sought to improve the image of an institution, others had concerns, often finding networks of patients with their own problem. As the private sector had created a marketing orientation.  Some had an axe to grind or were off the wall. By 1998, 6 million in the UK had access to the web at home or at work and numbers rapidly grew, as did the proportion with broadband access.  While there might be much rubbish on the net, that was true of most other forms of publication and users were generally discriminating.  People might make direct contact with doctors via health web sites (c.f. www.drgreene.com).  By 2006 W 2.0 was developing, social software with public participation.  Blogs, YouTube and their compatriots were increasingly used as patients and doctors sought new methods of information discovery.  The amount of clinical knowledge on the web was so vast that doctors, faced by a difficult diagnosis and an unaccustomed group of symptoms, might find useful suggestions by using Google.

Health organisations such as the Mayo Clinic and Kaiser Permanente were early as in the field.  So was the US Government.  The UK government’s attitude was initially cautious, and health web pages in the UK were  seen more as a problem than an opportunity.  By 2000, however, the NHS, the Department of Health and the British Medical Association had effective sites and increasingly used them to publish their documents and reports.  Every significant body now had a web presence; sometimes the only way to find out about the role of the many new organisations in health care was to look at their web site.

Education also benefited. A National Electronic Health Library was developed as a resource primarily for professionals, to be followed by the National Library for Health.  In 1998 the BMJ became an open access journal, making  the full text of original research articles (along with everything else) freely available on the BMJ's website, though some restrictions were later introduced.  In 2003 the BMJ Publishing Group provided access to the evidence-based summaries available in Clinical  Evidence and in 2004 NHS Direct linked to this material. Journals increasingly offered on-line editions, sometimes free, and Stanford University's Hire-Wire Press hosted several hundred electronic versions of scientific journals and provided a search system. U.S. National Library of Medicine's free digital archive of biomedical and life sciences journal literature (PubMed Central (PMC)) aimed to digitise a complete archive of medical journals, including the BMJ, some going back more than 125 years.  On-line leaning developed progressively, for example an online course in International Primary Health Care based at University College, London..

Health service information systems

This was the decade in which an effective country wide NHS information system centred on clinical need, was under development. Appropriate technology was at last becoming available.  It was recognised that a complex and inefficient paper based system, attempting to share clinical information between organisations and their medical staff, would slow the improvement of the service.  The assessment of the quality of care, and contracts that required information about who had done what for whom, increased the importance of IT.  Finally, new services such as pharmacist prescribing and walk-in centres made a coherent IT system essential. An NHS Information Authority was established to manage the development of national health information systems.  It oversaw the introduction of the NHS number, new numbers for babies, payments for GPs and national screening programmes.  It was later phased out to be replaced by the NHS Connecting for Health and the Health and Social Care Information Centre (2005).

The quality of health service information, particularly patient activity information, had long been a source of concern.  From the earliest days of the NHS financial allocations depended upon its accuracy. The introduction of Hospital Activity Analysis in the 1960s and the work under the chairmanship of Edith  Körner in the 1980s were early examples of attempts to improve matters. Yet in 2002 the Audit Commission still found grounds for concern in its report Data Remember: Improving the quality of patient-based information in the NHS.  

In 1997 Labour inherited a strategy for NHS IT dating back to 1992 which had taken some fundamental steps, for example a unique identity number in a standard format for every patient, and a NHS-wide data network.  However the problems that had been experienced, general practice computing being a notable exception,  reduced support for the programme.  In 1998 a white paper,  Information for Health, created new momentum and shifted the emphasis to the clinical from the administrative.  It committed the NHS to provide life-long electronic health records for everyone with round-the-clock, on-line access to patient records and information about best clinical practice for all NHS clinicians.  Computerised medical records and prescriptions, electronic referrals and hospital test results, and arrangements with community support would all become quicker and more reliable.  Using NHSnet every GPs would be connected by 2000, but though the principles were agreed to be sound, targets were generally missed.

A new impetus followed a  seminar in Downing Street in February 2002 attended by industry representatives, and the Wanless Report in April 2002 which criticised NHS IT as piecemeal and poorly integrated. In July 2002   Delivering 21st century IT support for the NHS was published. An unprecedented investment in IT began, which would cost some £18 billion over ten years (though early estimates were far smaller).  It was the world's largest and most ambitious health programme, creating comprehensive electronic health records compiled at the point of care, and to be made available to users in primary, secondary, tertiary and community care.

The programme's details emerged in the summer of 2002 and a National Director was appointed in October that year, Richard Granger.  Procurements stressed speed, competition and payment to contractors only if they delivered working systems. In April 2005 the programme was renamed NHS Connecting for Health, but it talked as if the NHS were just another industry for which a standard system was practicable. The programme was handled in a top down fashion to overcome the previous piece-meal approach. The service was organized in two parts, a national spine and five local service providers that aggregated the health service into five regional clusters. In 2004 BT was awarded the contract to provide the national infrastructure (National Application Service Providers [NASPs] ), as well as the contract to be one of five Local Service Providers (LSPs) responsible for local level services.  Three other firms won contracts to provide services in four other areas. (see map below).  LSPs were responsible for IT systems and services used locally, such as GP and trust systems. They would also make sure local applications can ‘talk to' and share information with the national systems. The programme would connect 30,000 GPs and 270 acute, community and mental health trusts.

National Application Service Provider contracts were awarded to BT for the NHS Care Records Service, Atos Origin (formerly SchlumbergerSema) for Choose and Book (The Electronic Booking Service), BT for N3 (the New National Network). BT would act as a system integrator, and BT Syntegra for new software to manage information and payments under the Quality and Outcomes Framework.  The system would involve

• Broadband connections to all NHS sites - contract placed in February 2004 - and renamed N3 as opposed to NHS Net.

• An Electronic referral service which expanded first into electronic booking and later into Choose and Book.  Patients would be able to choose which hospital they would like to attend at a date and time to suit them, enabling them to exercise choice at the point of referral to hospital from their GP.  In October 2003 a £60 million contract was signed to provide the national electronic booking system.   Software would be available to 30,000 GPs, connecting them to some 270 acute hospitals and community or mental health hospitals. The programme fell at least two years behind the target of universal electronic booking by the end of 2005, there were major problems over confidentiality, and the Parliamentary Health Committee decided to enquire into the electronic patient record (February 2007).

NHS Care Records containing basic patient information and health details. The information on the NHS Care Records would grow over time and eventually people would be able to access their record and all their health information, and be more involved in making decisions about their own care and treatment.  GPs were anxious because the main system in use in their surgeries was not adopted by the new national groupings. The National Electronic Library for Health, later the NHS Library for Health, designed with the NHS employee, doctor or nurse in mind.  Access to the private NHS Intranet (NHSnet) or registration is necessary to use the full facilities, but substantial sections of the library (and its links) have public access.     The public and patients were asked to use NHS Direct.   By 2006, however, the programme was not only behind schedule, sometimes by years, but might not work.  Many hospitals had to upgrade ageing systems as the long term solution was not in sight.  GPs, for example, were given permission to continue to choose one of a wide range of existing systems, rather than being forced onto a national standard that was not available.  Contracted suppliers were facing facing major losses and in September 2006 Accenture gave up a £1.9 billion contract, passing it to CSC amid fears of further delays. In parallel public anxiety about the security of personal information was increased by a series of security breaches, including the loss in 2007 by government of 25 million personal records relating to child benefit.

Richard Granger left the programme in 2007.  By that time the NHS spine was in place, ensuring that basic data, name, address and NHS number, were correctly recorded.  The summary medical record and its transmission between providers remained a far off dream.  Electronic appointment booking was, however, making progress, though electronic prescriptions were slow to come on stream. The Department established a review to establish the problems and found failures right at the top, no one seemed to "own" the big picture on information, there was no system to translate policy into business requirements, and a shifting of responsibility for IT around the Department..

Computerisation

In general practice, the cooperation of the BMA and the RCGP that worked together with government to introduce financial incentives to encourage GPs to computerise their practices, had led almost all to use computers in their consulting rooms for prescribing and other clinical purposes. By 1996, 96% of general practices were computerised and about 15% now ran "paperless" consultations. In hospitals computing was treated as a management overhead, and doctors had few incentives to become involved.  There are several reasons why it was technically easier to computerize general practices than large hospitals, and all are related to scalability. What works for a small practice does not work for a big hospital or across the primary-secondary care divide. For twenty or more years GPs had used PCs; hospitals at least initially could not go down that route.  The sheer size of the hospital sector and the way in which technological advance rapidly outpaced information technology in the NHS, led to substantial difficulties.  The structure of patient records that differs substantially from specialty to specialty, terminology, varying computer standards, security and rapid technological advance all make for problems. (Benson T, BMJ 2002: 325,1066-9 &1090-93)  Conventional email  easily outpaced developments in the NHS intranet that might be more secure, but was less easy to use. 

By 2003 doctors, both in hospital and general practice, were taking to hand-held computers and using their personal digital assistants for similar activities - personal and professional scheduling and, at the point of care, for information access and support for clinical decision making. PDAs were being used to access  drug information and clinical decision support systems, prescribing, medical records and laboratory results.  At Ohio State University Medical Center, over 3000 PDAs were issued to staff who synchronized  them each day before seeing patients.  Wireless connection was also being used.

Examples of common uses of handheld computers Point of care assistance—drug information, clinical guidelines, decision aids, patient education Patient information—patient tracking, clinical results Administrative functions—electronic prescribing, coding, tracking schedules Research activities—data collection, participant education Medical education—lecture notes, presentations, photographs and diagrams Source  McAlearney A S et al., BMJ 2004: 328: 1162-5

NHS Numbers

In 1995/6 a new NHS number was issued to all patients on GPs' lists.  These numbers formed a database on which, ultimately, electronic patient medical records might be developed.  However the data base was soon used for a  National Strategic Tracing Service (NSTS) to provide the NHS with accurate patient administrative data.  Pilot trials showed that the data base was useful in waiting list management.  Based on a secure database of all people born, or who had been registered with a GP in England and Wales, by 2001 it provided on-line access to over 60 million records covering all GP registered patients.  It included:

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