Here's an idea for relieving this winter's inevitable NHS bed crisis: don't put patients in intensive care after their operations - send them home. It's already happening in the US. Diann Martin, a community nurse at the University of Chicago, says that discharge within 24 hours of serious surgery is now routine, with home care taking the place of hospital. "We're doing things at home that five years ago were done in intensive care," Martin told a recent conference in London.
What makes this possible is the emerging technology of "telecare". In Chicago, wound-care specialists monitor patients' progress over the internet. An electronic device in their home collects data such as blood-pressure and respiratory rate and takes regular snapshots of the wound. If all goes well, the rest of the patient's care can be done during a daily visit by a community nurse.
Home care is the fastest growing sector of America's trillion dollar health industry. It's easy to see why: a day in hospital intensive care costs an insurance company $2,500, says Martin, but a visit by a district nurse is $100, and a routine "teleconsultation" is $35.
Telecare is also coming - somewhat patchily - to the NHS. Since summer last year, the North Manchester primary care group has cut average waiting time for a dermatology appointment from 18 months to 17 days with teleconsultations. Nurses working for a specialist contractor visit GP surgeries, photograph patients' skin ailments with a digital camera and store electronic images on their laptops for downloading to specialist dermatologists who can decide which patients need further treatment. It may not be comparable to what is happening in the US, but it is a start.
Providing targeted medical advice over the internet is about the highest level yet of what the government calls the electronic delivery of public services. Tony Blair has committed the government to delivering 100% of government services electronically by 2005 - two years later than the target in the US.
At one level, the British target is patently absurd. Whatever advances take place in computer technology between now and 2005, it will not be possible to deliver meals on wheels down the internet. But because it is a prime ministerial target, it has to be met. The Cabinet Office has even counted how many individual government services there are (457 of them) and is ticking off those that are delivered electronically. The suspiciously precise figure so far is one-third.
The snag is that the further you go from the Cabinet Office and the closer to the front line of delivering public services, the less confident people are about delivering services electronically. A survey by Mori for BT found that, in central government, more than 77% of officials were confident they would reach the 2005 target. In health and local government, however, barely more than a quarter were confident - and most were not.
Malcolm Wylie, head of IT at Cambridge city council, says the picture is more subtle. "Technically, if we just set out to put the tick in the box, we could do it within a year. But to get the real benefits is much more difficult. The jury's still out."
But on the front line of care, IT is beginning to make a difference. The key is where it allows the joining up of services. One example is Suffolk social services, which has developed an electronic customer record on computer, allowing care professionals to call up a complete history of their clients.
Joan Miller, Suffolk's head of information management, says that, as with the telecare example, the technology can cut demand for hospital beds. "In the case of a request for an older person needing help, the system would say if they already have a home care service. Our professionals can make a better decision on that basis, and maybe avoid a hospital admission."
But running an electronic customer record is a major undertaking. Persuading staff to change from pen to keyboard "has taken a long time", Miller admits. And that's only the beginning of the process, as care workers need to change the whole way they work. Computers force care workers to enter records consistently and in a structured form - a good thing for generating management information, but a new skill that has to be learned.
And in some cases, a computer is out of place. Miller says: "A social worker's job is talking to people. In some cases, technology will get in the way." In highly emotional circumstances, the last thing a worker wants is to pull out a laptop.
Part of the problem is that today's portable computers are too heavy, run down their batteries too quickly and are too attractive to muggers. Even the IT industry admits that the right gizmo isn't there yet. "It's all to do with size and convenience," says Alan Jones, of CSW Health, a company specialising in electronic health record systems. The solution, he believes, is a palmtop computer with web access, just coming on to the market in the US. "We're three or four months behind," says Jones.
Three other obstacles lie in the way of the government's vision of joined-up electronic service delivery.
• Confidentiality. For health and social care, the next challenge is to join up health records - currently held by GPs - with social care records, held by local authorities. This enters a minefield of questions about confidentiality and access. The Department of Health has published a consultation document, Information for Social Care, which suggests solutions to some of the issues. Consultation is open until December 15.
• Reliability. Public sector IT projects are notorious for turning into disasters. The latest to go off the rails is the probation service's £100m case recording system, which is being abandoned after only 16 out of 54 probation services took it up. Another project which has gone awry recently is "government gateway". This is supposed to be the system which joins together separate local government and health databases, while ensuring that only the right people have access. The system is due to be up and running in 2001. But in October, talks with the prime contractor, Compaq, broke down and a successor has yet to be found.
• Resources. In September, Tony Blair promised £1bn funding for electronic government as part of his "UK online" initiative. Local government will get £350m. Few on the front line regard this as generous. Local government is "90% of government's face to most people", says Chris Haynes, head of the information society programme at Knowsley council, Merseyside, one of the pioneering local authorities in IT. And at Suffolk, Miller says that experience shows the real problem is not the cost of computers, but of training. For every £1 spent on IT, twice as much again goes into training and new procedures for staff.
"The 2005 target is a nonsense," concludes Haynes. "Our real target is getting people in the community to benefit from the e-society."
• Michael Cross is news editor of www.kablenet.com Information for Social Care is at www.doh.gov.uk/scg/information.htm
