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EU Scoreboard 2013 – eGovernment

The European Commission (EC) Digital Agenda for Europe (DAE) – eGoverment Scoreboard reports for 2013

eGovernment BuildingIn 2013 eGovernment services have been used by 41% of the EU28 population, down from 44% in 2012 and almost at the same level as in 2011. This set against a target of 50% of the population to be using eGovernment by 2015.

Currently only 9 out of 28 countries are above the 2015 target and only 7 countries have seen usage increasing in 2013.

The UK is ranked 14that a little over 40% just under the EU average in 13th place. Unfortunately the UK was one of the 7 countries that experienced a decrease in the use of eGovernment between 2012 and 2013.

eGovernment Use

Internet-savvy citizens often use the Internet to contact public administrations, but less so to conclude more complex interactions.

Almost three quarters (73.3%) of Internet users (in the last 12 months) who needed to contact a public authority (or to use a public service) did so online in 2013.

A quarter of these used exclusively the Internet, while the others used also other channels of interaction. 26.7% of the internet users contacted their public administrations without using the Internet at all. The preferred offline channels of interaction were personal visits (54%), telephone (50%), email (25%) and other methods (e.g. SMS, post, 20%).

However, when more advanced interaction is required, Internet users are less likely to carry this out online. In 2013, among Internet users who needed to submit official forms to public authorities, only 52% did so via Internet, down from 53% in the previous year


Users of eGovernment services are in general satisfied, while the main reason for non-use is a lack of trust.

chart-pieOnce citizens start to use online public services, they generally find the experience highly satisfying (75%), with only a minority feeling very disappointed (8%). The most appreciated feature is the usefulness of information (87% mainly satisfied), followed by the ease of finding information (84%), the ease of using online services (79%) and the transparency/follow-up (75%).

Lack of trust seems to be the main source of non-use. It comes in several forms:

  • a preference for personal contact (41%),
  •  higher trust for paper submissions (30%),
  •   concern about personal data (19%),
  •  and a lack of immediate feedback (16%).

Other main factors of non-use are a lack of skills and an incomplete digitalization of government services.

The measurement of eGovernment supply, some methodological notesItem Checked

The supply side of eGovernment is measured through a user journey approach. This is undertaken by researchers acting as mystery shoppers, that is, by posing as ordinary users of eGovernment services. The mystery shoppers simulate an event in the life of the citizen/entrepreneur requiring administrative action from the government (e.g. a marriage) and then go through public authorities websites in order to fulfil the related administrative requirements through the online channel when possible.

Seven of these life events are analysed in the course of two years (the first complete measurement is from 2012-2013) in different government domains:

  • losing/finding a job
  • enrolling to university
  • moving
  • starting a small claim procedure
  • buying/owning a car
  • starting a business
  • regular business operations

Different aspects of service provision are examined in this new methodology, but the two examined here are the following: User-centric eGovernment and Transparent eGovernment.

The User-Centric eGovernment indicator measures the availability of eGovernment services, their connectedness and their user-friendliness.

The Transparent eGovernment indicator measures the online transparency of governments on the different aspects of online service delivery, treatment of citizens’ personal data and activities of the public administrations.

Both indicators range from 0 (complete absence of required features) to 100 (all features included).

The source for the eGovernment supply data is the eGovernment Benchmark Report (see

Link to an easy view of the EU eGovernment Report

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EU Scoreboard 2013 – Internet Use

The European Commission (EC) Digital Agenda for Europe (DAE) – Internet Use Scoreboard reports for 2013.

There are some really interesting profiles developing not least in respect of the maturing App market place and transitioning that appears to be occurring between Apple and the Android platforms.


The diversification index* measuring the mean number of online activities undertaken by internet users has grown continuously of the past few years, from 5.1 in 2009 to 6.2 in 2013
This showing that as people become more experienced and confident online, they not only increase their frequency of use but also the diversity of the activities they perform.

This process takes time, and while leading countries such as Denmark and Sweden are about 4 years ahead of the EU average, internet users in lagging countries such as Romania, Bulgaria, Italy and Poland are 4 years behind the average.

The UK comes in a respectable rank of 6th which is above the EU average ranked itself in 9th place.

Online shopping is growing, but less so cross-border.

Online ShoppingThe proportion of online shoppers continues to grow, up more than 10 percentage points over the period 2009-2013 to 47% of citizens, advancing in a close parallel with the rate of internet use. As such the Digital Agenda target of 50% by 2015 is likely to be achieved.

Cross-border online shopping has also increased somewhat over this period, up to 12% in 2013 (+4 percentage point over 2009), but this pace is too slow to achieve the target of 20% by 2015.

The UK is second in the table behind Germany and one of only 9 member states that have succeeded in exceeding the EU target. In the UK over 75% of Internet users shop online.

Europeans increasingly download Apps.

App Economy continues solid growth both in Europe and worldwide.

In 2013, total App downloads from all platforms reached 90bn worldwide and 20bn in Europe. The number of downloads grew a staggering 80% worldwide in 2013. Europe showed a 68% growth, and the USA grew at a rate of 36%.

However, growth is slowing and forecasts for 2014 point to an increase of 44% in downloads worldwide, 36% in Europe and 17% in the USA.

SlidersIn 2013, App revenues (downloads and In- App purchases) reached EUR 12bn worldwide and EUR 2.75bn in Europe. Worldwide App revenue has roughly doubled in 2013 (97% growth). In Europe it grew 59% and 43% in the USA. Revenue growth is slowing down and in 2014 it is expected to grow 32% worldwide, 31% in Europe and 19% in the USA.

China’s App economy “woke up” only recently. From nearly no downloads until 2010, China has surpassed both Europe and the USA in 2013 with a total of 23bn downloads and a growth rate of 135% for that year. However, revenues have not yet caught up. While China accounted for 26% of worldwide App downloads in 2013, it accounted for a mere 8% of revenue.

Apple App Store and Google Play are the main App platforms.

  • Google Play becomes leader in App downloads.
  • Apple App Store remains ahead in total revenues.

Google Play and the Apple App store are the two main platforms for App distribution worldwide. In 2013 they accounted together for three quarters of worldwide App downloads and about 90% of revenue from App purchases (App downloads plus In-App purchases).

Theater MasksConcerning App downloads, Google Play is in the lead with 38bn downloads in 2013 versus 28bn for the Apple App Store. In terms of revenue, Apple’s App Store generated over EUR 7bn in 2013, almost the double of the EUR 3.8bn generated by Google Play.

Both platforms are in rapid expansion, whether measured in terms of App downloads or in revenues therefrom. The Apple App Store grew 45% in terms of downloads and 75% in terms of revenues in 2013. Google Play nearly doubled in number of downloads and saw a near 4-fold increase in revenue.

In-App Purchases have become the preferred App business model.

Games generate more revenue than all other Application types together.

Looking at the breakdown of revenue from the Apple App Store in Europe reveals preferred business models and types of content.

In-App purchases are the preferred App business model, over Pay per Download. In-App purchases account for close to 90% of App Store revenues in Europe in 2013. This and increase from less than 5% in 2008.

The revenue from In-App purchases was over EUR 1.4bn in Europe, versus less than EUR 200m from App paid downloads.

Games generate the largest share of App revenues, more so than all other Applications together. Games account for over 70% of App Store revenues in Europe in 2013. The revenue from Games reached about EUR1.2bn in Europe, whereas other Applications generated only over EUR 400m.

Advertising revenues are in slow recovery after the financial crisis.

Online + Mobile advertising are growing much faster than the advertising sector as a whole.

Online advertising is overtaking traditionally dominant segments in terms of revenue share.

After the severe dip due to the financial crisis and the ensuing period of near stagnation, advertising revenues have slowly started to recover. Total advertising revenues** reached EUR 75.593bn in 2013, which still represents only 87% of the 2007 pre-crisis peak value.

moneyRevenue for the whole advertising industry returned to positive growth of 1% in 2013 (+EUR 0.5bn) largely due to the Online + Mobile segments. In 2013, revenue from traditional segments decreased 5% (-EUR 2.9bn), while the Online + Mobile segments grew 18% (+EUR 3.4bn).

Online + Mobile advertising revenue shares have grown steadily since 2005. At EUR 23bn in 2013, they accounted for over 30% of total advertising revenue. By contrast, the revenue shares of the Print and TV segments have been declining, and are about to be overtaken by the online segment.

Germany, the UK and France account for over 60% of advertising revenue in the EU. The UK accounts for the largest share of online revenues.

The largest European countries also generate the most advertising revenues: Germany (23.5%), the UK (22.9%) and France (14%). The share of online revenue in total advertising revenue varies significantly across countries. The UK accounts for the largest share of online revenues (45%), followed by Denmark (39%) and the Netherlands (34.5%).

Both the UK and Germany showed growth in total advertising revenues in 2013 (UK: 9.5%, DE: 4.3%), as well as in the online segment (UK: 24%, DE: 33%). France showed some growth in the online segment (6%), but a decline in total revenues (- 1.2%). Due to the revenue from the Online segment, the UK is expected to overtake Germany as the biggest advertising revenue generator in 2014, with a forecast EUR 18.5bn in total revenue.

eCulture Conclusion for the UK

The UK continues to make solid progress in the diversification and use of internet services amongst its existing use population.

The UK’s position as the leader in securing online revenues from advertising is a marked success to be maintained going forward.

Article Links

Perhaps an area for investment focus is development of revenues from Apps and development of a strong app development community here in the UK. Critically to this however will be the need to address the UK ICT skills gap that is forecasted form the UK flagged in a previous blog article on the EU Digital Inclusions and Skills Scoreboard.

Link to an easy view of the EU Internet Use Report


*The Diversification Index is calculated for individuals that used the Internet in the previous 3 months, and is computed as the number of activities performed out of the following 12 selected activities:

Sending/receiving e-mails  – browsing for information about goods and services – reading online newspapers/news  – looking for information on travel/accommodation services – posting messages to social media  -interacting with public authorities – internet banking – telephoning or video calls – selling goods or services – purchasing content (films, music, software) – purchasing goods – purchasing services

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EU Scoreboard 2013 – Digital Inclusion and Skills

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The European Commission (EC) Digital Agenda for Europe (DAE) – Digital Inclusion and Skills Scoreboard reports for 2013 have flagged some interesting concerns with potential to quite significantly impact broader EU digital aspirations.

And critically, the UK is singled out as a contender likely to be adversely affected alongside Germany and Italy.

eCulture, summarises UK progress on this scoreboard to date and explores the potential impact a skills gap could have.

Access to the full version of the EC report published is available at the end of this article.

Internet User and Usage Growth

The EC reports that the number of internet users in the population continues to increase, with 72% of the EU population reporting that they used the internet at least weekly in 2013.

computerMore than half of the EU citizens (62%) reporting using the Internet daily in 2013. Use by disadvantaged people also continues to rise; with 57% reporting using the internet at least weekly in 2013. In both cases the rate represents a continuance of the ongoing upward trend since 2009.

Across Europe, rates of weekly internet use remain dispersed and the rankings of countries with the highest and lowest rates have changed very little over time.

In the UK, 80% of Internet users (including disadvantaged users) access the Internet at least weekly, a fairly respectable 8th place, ahead of Belgium, Germany, Austria, Estonia and France perhaps surprisingly in 14th place. The EU28 average ranks in at 16.

The highest rates of weekly internet use continue to be found in the Nordic countries, where rates are around 90% or more, with Iceland top of the league, followed by Norway, Luxemberg, Netherlands, Sweden, Denmark, Finland.

At the other end of the scale, countries with the lowest rates of weekly internet use (Romania, Bulgaria, Italy and Turkey) is limited to around half of their respective populations.

Interestingly the report flags that convergence is taking place; with, generally speaking, larger annual increases in rates of weekly use of the internet in counties with the most catching up to do.

EC Digital Excluded

The report highlights that of those identified to be digitally excluded the biggest barriers were:

Not having a need for access (49%)

Lack of skills and ability (37%)

And cost, with equipment (30%) and access (26%)

Interestingly all of the three reasons have become increasingly significant over time, it is cost issues that have gained substantially in significance amongst households with children and those on low incomes.

BanThe EU target set in 2009 was for halve the digitally excluded from 30% to 15% by 2015. With the ratio down to 20% in 2013 the report suggests EU members are on schedule to achieve the target.

However, the margin of improvement between 2012 and 2013 was just 2%, so this will have to be slightly improved upon going forward.

The biggest improvements were made in Croatia, Greece, Romania, Slovenia, Cyprus, Estonia and Italy, but it was noted that number of countries (Bulgaria, Portugal, Poland and Malta) with above average rates of non-users had struggled to make improvement since 2012.

Digital Inclusion and Skills Mix

The EC report adopts the newly constructed Digital Skills Indicator*, based on the Digital Competence Framework** (developed by DG EAC and IPTS on-going).

Across the EC the variation of skills ranges from 6% in Sweden with no digital skills to 50% in Romania. In ten countries (Malta, Lithuania, Portugal, Poland, Croatia, Cyprus, Italy, Hellenic Republic, Bulgaria and Romania) 30% or more of the population have no digital skills.

In four countries (Italy, Hellenic Republic, Bulgaria and Romania) rates are 40% or more. In Italy, with its large population, this equates to almost 18 million people without digital skills. In the worst cases Bulgaria (81%) and Romania (85%) most of the population does not have the digital skills they need.

Considering that to function effectively in the digital society one needs more than low level skills, almost half the EU population (47%) can be considered as insufficiently digitally skilled (having either low or no digital skills).***

The EU assessment of the UK Digital Skills rankings identifies approx.

11% of the population has no skill

31% low skills

27% have basic skills

31% are considered “Above Basic”

That means according to the EC standard described here, approx. 42% of the UK population has insufficient skills to function effectively in a digital society.

Disadvantaged People

Disadvantaged people are defined as individuals belonging to at least one of the following three groups: aged 55-74, low educated or unemployed, retired or inactive.

In the EU28 38% of disadvantaged people have no digital skills at all.

In the UK approx. 24% of the population falling into the disadvantaged class have no skills, with a further 38% identified to have low skills, making if 62% of the disadvantaged population having insufficient skills to function effectively in a digital society.

Digital Skills Amongst The Workforce

Rates of digital skills for this category fare much better as expected, with rates on average higher than for the average population rates in the EU review earlier.

In the UK the rates are approx. 5% with no skills and an additional 30% with low skills, thus 35% with insufficient skills to star-offfunction in a digital society.

In respect of information communication and technology specialist employment across the EU on average growth in the specialist skilled population has grown 4% a year since 2000.

The UK increased its share of ICT specialist employment by 4.2% to position itself 3rd in the leaders group, behind Sweden 4.8%, Finland 4.7%.

Despite this growth since 2000 the report flags the employment potential of ICT remains underexploited, with evidence showing a growing gap emerging between supply and demand.

The report goes on the highlight that the largest ICT professional skills gap to be found in Germany, with forecasts suggesting that over the period up to 2020 the ICT professional skills gap will be severely aggravated in the UK and Italy in particular. This due insufficient production of ICT graduates to keep up with strong demand.

eCulture Conclusions for UK

Of key concern will be the fact that the UK has an emerging problem with the production of ICT skilled graduates, for which a call out for assistance from the private sector for help on resolving this issue.

This approach is shared across the EU, under a proposal for the private sector to support the formation of a “Grand Coalition for Digital Skills and Jobs”.

The skills gap issue has the potential to increase in severity as the government pushes ahead with development of eGovernment, success of which is highly dependent on availability of ICT skills.

As eGovernment is especially concerned with the digitally excluded, the being for the most part primary users of government managed services such as health, social care and benefits, set to be transitioned to digital engagement models.

The digitally excluded will need assistance to become engaged, likely adding to the increase in demand for ICT skilled specialists, especially in education and training in particular.

alertWith austerity still very much a focus in the private sector as well as the public sector, there has to be a concern that if not sufficient support and assistance is secure to address the growing ICT skills gap, a much broader and negative impact is going to be felt across other programmes of work designed to increased our capabilities to contribute and compete in an eCulture orientated world.

Link to easy view of the EU Digital Inclusion and Skills report


* Measuring Digital Skills across the EU: EU wide indicators of Digital Competence

** Ferrari, A. (2013), DIGCOMP: A Framework for Developing and Understanding Digital Competence in Europe, JRC Scientific and Policy Reports.

*** To be classified as “Low Skilled” an individual has to have carried out activities from only one of the four Digital Competence domains included in the index (information, communication, content-creation and problem-solving). To have “Basic Skills”, an individual has to have basic in at least one domain. To be classified “Above Basic” the individual has to score above basic in each of the four domains.

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Patient Record Access – A Perspective 2 Years On

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peopleIn May 2012 I wrote an article (Patient access to GP Records by 2015) and offered some immediate thoughts on who would be the primary beneficiaries of this Department of Health mandate, with some thought on identifying the primary element of the patient population, access to medical information should be targeted at.

A little over two years on and with the benefit of additional insight from consultancy engagements with some very innovative and forward thinking solution providers, there remains much to be resolved if the target is to be met, especially with anything like a solution that delivers on the range of benefits that should be secured.

Current Focus Remains Narrow

Technology choice for electronic patient records (EPR’s) and patient record access is wide and varied, from traditional operational patient administration system providers, with these largely focusing on improving visibility and accessibility of clinical patient information operationally, to the more expensive and challenging to implement solutions that can integrate patient data from a wide range of operational clinical systems, from independent solution providers.

For the most parts investment in EPR technologies are currently health sector and organisationally specific, with current early phases of delivery focusing on clinical operational needs (data quality) and business performance improvement (QIPP), largely it is felt because these tend to be business case qualifications (QIPP deliverables) that are easier to define, over alternatives concerning wider benefits of patient engagement.

The technology to enable patient record access exists, and certainly with the right approach and focus, the target for enabling citizen access to at least key parts of their record remains achievable. There are however, some fundamental considerations to be addressed to move thinking beyond current operational focus, and onto the service transformation potential citizen engagement would deliver.

Patient (Citizen) Centricity

Citizen CentricA citizen view servicing “meaningful use”, requires the assimilation from multiple organisations, e.g. primary care, community care, social care, acute care and mental health, as well as systems, such as appointment management solutions, prescribing management systems, patient management systems and healthcare contact systems etc., especially when giving due consideration to the touch points across health and social care for patients for example with long-term chronic conditions.

This means that the maximum benefit to be secured by access to medical information can only realistically be achieved by a strong commissioning lead, and one that is capable of resolving the conflicting interests and competing requirements individual information host organisations will bring to the table.

It remains the case that the greatest benefit to be secured from improving patient engagement through provision of better information will be derived from engaging with those that are suffering from one or more long-term chronic condition, with which engagement succeeds in enabling patients and their carers to better manage the condition(s), to the point of reducing the numbers of calls and escalations occurring that require direct engagement of health professionals and any associated service provision.

Data Ownership Becomes a Concern

However, it remains the case that for this engagement to be most useful, the solution should provide the citizen (owner) with a mechanism by which they can consent access to the information, to members of their personal care circle (friends and family), citizens should be able to refine access according to need, i.e. allow some carers to see more of the record that others.

Inclusiveness, accessibility and security subsequently still also remain primary concerns, given the largest proportion of patients that stand to gain from engagement supported with access to health and social care information are those with long-term chronic conditions, a large proportion of which presently have limited engagement with technology.

Data Protection

Along with the issue of ownership, a further information governance concern arises from delivery of a single unified patient record, built from the assimilation of information from a multitude of operational systems managed by different organisations (data controllers), in that data moved into a new host, creates new data controller obligations and information governance responsibilities that can be difficult to align operationally.

AlertCritically new patient identifiable systems are necessary, such as a “Master Patient Index” for example, that enable different patient coding systems and identification methods to be unified, thus ensuring that data assimilated and presented is relevant to the patient concerned.

Administering a master patient index sitting in between a multiplicity of systems in different organisations would need to involve resources across all organisations, and in the process, would likely lead to an increase the range of access to patient identifiable information above and beyond current organisational focused remits.

Looking ahead, the range of benefits for all concerned increase when integration with social care information is incorporated but as before, concerns for data protection and information governance also increase.

Key to Resolving Ownership and Data Protection

DirectoryEstablishing a maintainable Master Patient Index (Citizen Directory Service) within a safe secure framework capable of accommodating the administration and multiple access requirements with the ability for the citizen to understand and appreciate the range of identifiers associated to them, with an ability to self-maintain appropriate identification attributes would provide for a solid engagement foundation from which service and bi-directional data flows could be managed.

Additional benefits to be derived from a self-maintained citizen directory include:

  • A range of health and social care data management needs that are outside of the current health and social care systems, these include:
  • Details on their personal care circle, family and friends supporting them and what level of care they provide, mentors, and additional support they may have contracted or secured privately from third sector providers and charities, support groups etc.;
  • Extending data flows for care plans, end of life plans, life stories, coping strategies, self-prescribing / medicating information;
  • Scheduling of personal health and wellbeing activities such as keeping fit activities and appointments schedules with third sector providers etc.;
  • Ability to link data associations from assisted living devices, tele-health and tele-care devices and solutions to that again may be acquired by patients by private purchases or through personal engagement with third party service providers.

These representing just some of the additional information that could be sourced directly from the citizen and / or their personal care circle that by virtue of association being known in the “citizen directory service” potentially provided back to health and social care providers to further help inform and shape the care delivery process.

Importantly, at this level the citizen (or person assigned power of attorney) is the data controller and owner of their information, thus resolving a significant data protection cost and engagement challenge for health and social care.

So What’s Likely in 2015?

The country is certainly more than one year away from securing the very significant efficiency, effectiveness and quality service improvements that could be achieved from patient access to medical information.

Perhaps not surprising given that since the announcement on patient access to medical records was made, there has been (and needed to be) a significant focus on the re-organisation of health care, that at best, patients will only be provided in 2015, with fairly rudimentary (read only) level of access to information and likely, primarily from just one source, the GP.

There is consequently the potential for a real and very significant problem emerging ironically from the re-organisation, which materialises from the devolution of control and responsibility for delivery down to a local level.

QueryThis because if it is agreed that a unified master patient index (citizen directory service) is a key foundation to progressing onto and integrated citizen centrically focused and bidirectional process of engagement, then this ought to be implemented to a national standard, and perhaps once?

Concluding Thoughts

With current technology supporting mobility for the population and rapidly emerging to support assisted living, tele-health and tele-care, the very process of caring and engaging in a patients care pathway / process is set to change dramatically.

Care closer to home is set to become a reality, technologies are emerging that can enable patient carers to become more engaged in the ongoing care process and management of conditions, along with technologies that also have the ability to increase levels of confidence for patients to live more independently.

Subsequently care, supported by the technology innovations emerging today, has the potential to become a true joint venture that engages personal care circles of family members, friends and personally engaged third sector charities or private sector providers of services and solutions with public funded health and social care service provision.

It is this potential that delivers the much need reform of the current health and social care model, certainly at a scale with potential to exceed achievement of £20bn of efficiency gains and savings.

Whilst there are benefits to initiatives having a local focus, so that variation in needs across communities can be accommodated there are some core elements that if not delivered as a national hub, must at least be supported by appropriate nationally agreed standards, addressing requirements such as interoperability, data / care pathway workflows to support engagement functioning across localities, however these are defined.

With that said, the patient / citizen user experience is another area for concern. With the potential benefits to be secure from engagement being undermined by patients / citizens experiences being widely different across the country, as features and capabilities vary as a result of variations in approaches.

But see, now this represents a case for some sort of nationally coordinated approach, and we’ve been there with the National Programme for IT (NPfIT), and if you believe everything you read that was a total failure, with nothing of any real benefit delivered.

But then maybe, the NHS SPINE, Summary Care Record and need for unifying the interface to offer citizens consistency in the engagement experience, if only there was an appetite to even consider the potential use of some of the NPfIT investments that did deliver?

What do you think?

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Digital Citizen Centred Healthcare Critical for Reform

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Citizen centred healthcare is part of a shift in focus which has drawn increasing interest in recent years, highlighting the importance of incorporating citizens’ needs and perspectives into care delivery. The citizen’s engagement with their care is now considered a key part of patient-centred healthcare.

Incorporation of health solutions addressing the Department of Health Digital First initiatives addressing patient engagement in particular, those identified initially with long-term chronic conditions as a first step, with delivery of health engagement solution that can reach the patients personal care circle, would provide a first significant foundation for service transformation to a patient centric service model.

As has been acknowledged in a recent Guardian article,

“Families are the biggest providers of care, yet carers can find themselves cut out of decision-making and bounced between bureaucracies.

If you care for someone and they need support, you don’t really care whether it is the NHS, a local council or nearby mental health services that provides it – all that matters is that it is the right support, on time, from a caring and well-trained professional

Better integration can solve that problem because it leads to the NHS, local councils and mental health services working better as a unit rather than as three separate entities. When services are integrated, all that matters is making sure that older, ill and disabled people and their families get continuous care regardless of their circumstances.”

The objective of integrated care is reflected in the NHS England mandate:

“An NHS for everyone, regardless of income, location, age, gender ethnicity or any other characteristic. Yet across these groups there are still too many long-standing and unjustifiable inequalities in access to services, in quality of care and in health outcomes. The NHS England Board has specific legal duties to tackle health inequalities and advance equality”.

“The Board’s objective is to achieve a significant increase in the use of technology to help people manage their health and care”.

Presently technology investments tend to be focused on filling gaps in operational information capability, electronic patient records investments being an example of note. Whilst these will make a positive impact on the operational efficiency of service providers, the focus of this investment is presently too narrow to facilitate radical transformation to a new service delivery model that better engages and supports citizens and importantly, those with long-term chronic conditions and their family members and friends operating in a carer role.


There is a large body of evidence that highlights “care closer to home” delivered by the provision of better engagement of citizen with their family and friends (carers) is fundamental to service transformation, at a scale sufficient to make a significant and demonstrable contribution across the health and social care “Quality, Innovation, Productivity and Prevention (QIPP)” agenda.

The Guardian article goes on to highlight:

“That in the worst cases, failing to support families can push them to breaking point and result in hospitals admitting both the carer and the older or disabled person. This situation is unacceptable but it is also preventable”

in a recent Carers UK survey,

“almost two-thirds of carers supporting someone after a hospital discharge said they had either been consulted late or not at all, and one in three carers caring for someone recently admitted to hospital in an emergency said that it could have been prevented if they had had more support at home”

Making The Case

This highlights one of the more significant well-being benefits to be derived from better citizen / carer engagement that can also make a very significant contribution for reductions in the cost of healthcare, by reducing for example the number of avoidable hospital admissions, a theme explored in a King’s Fund paper on (Dec 2010), which exposed a number of factors that were found to be associated with increased rates of admission, and therefore important considerations when targeting interventions with the objective of reducing avoidable admissions.

The Kings Fund report classified the consideration into the following categories:

Age; Social Deprivation; Morbidity Levels; Area of Residence;
Ethnicity; and Environmental Factors

The report recommendations that,

“Policy-makers should consider the impact of socio-economic deprivation and other socio-demographic factors when designing policy around admission rates”

The fact is these factors are equally important considerations for citizen / carer engagement.

Suggested approaches put forward by the Kings Fund paper towards identifying high risk groups focus on internal business intelligence (BI) approaches utilising the clinical knowledge base, notable threshold modelling and predictive modelling.

BI technology and capability investments are making important contributions to the remodelling of service delivery models with demonstrable progress already achieved towards Evidence-Based Health Care (EBHC), Pay for Performance (P4P), Diagnosis-Related Groups (DRG) of note, some of which are positively impacting costs through reductions in things like hospital admission rates.

The addition of a citizen centric dimension, with additional socio-economic deprivation and socio-demographic data inputs derived from engagement of citizens, their care circle and other third sector providers, charities and special interest local and national groups would greatly enhance the value of BI investments to provide a much stronger platform upon which service transformation decision making would be established.

Digital Citizen Centred Healthcare

Emergence of web and mobile app based technologies has provided a wide range of options for securing patient / citizen engagement with public services. Today a search of the Apple App Store for “NHS” will return a listing of 176 apps for the iPhone, and 44 for the iPad device, the Google Play App Store returns 155 apps for the IOS platform, some are the same apps, and some are not, a search on either App Store for “healthcare” generates a less than helpful greater return of results.

It is unfortunate however that the range of apps is beguiling, some are location or service provider specific, some relate to general information on services, some are condition specific, some are provider specific etc. etc., and makes for quite a wide and varied experience for the end user, with a wide variation in approaches addressing accessibility, presentation and most importantly privacy.

On the Internet the experience is just as varied and beguiling, and from an engagement perspective, services such as mainstream social networking platforms (Facebook, Twitter, LinkedIn etc.) are not able to offer the assurances on privacy and data protection required to underpin and maintain engagement, sufficiently to be utilised as collaboration tools on healthcare, beyond generalised messaging.

Exploiting Technology for Better Engagement

Unquestionably technology, and in particular web and mobile services are key enablers for engagement, service transformation, and the ability to offer a “choice for method” for engagement has some value. There is however merit in the unification of approaches, if the full benefits of engagement via mobile, internet and social networking services are truly to be secured, and at scale, quickly and for the long-term.

For this to happen, a digital citizen centred focus needs to be incorporated into technology investment considerations. This is important not only from the perspective of ensuring technology investment decisions are appropriate and aligned where necessary to engagement aims, but that also requirements concerning data protection and information governance, necessary to secure and maintain citizen and carer engagement, are also addressed appropriately going forward.

To be successful, any technology solution must also be highly scalable, flexible enough to support multiple healthcare transformation initiatives across multiple organisations and communities, seamlessly integrate multiple partners (interoperable), low cost and leave the public health and care providers in control.

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UK GDS Identity Assurance

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Identity and access management is one of the most challenging aspects of securing citizen, and from a National Health Service perspective patient, engagement on-line with services and information. This especially important when the engagement extends to on-line access to highly personalised information specific to individual citizens.

As the government digital service (GDS) makes progress on the digitisation of services it is pleasing to see that the team leading the development of services are engaging with experts to advice and guide on the development of key engagement protocols.

However whilst the current scope is concerned with the one to one relationship between citizens and government services, the real challenge to come for GDS identity assurance will be that of on-line engagement between citizens and healthcare service provision.

NHS Digital First

With the NHS Digital First initiative, on-line patient access to medical records, at least those hosted by the GP, are expected to be available by 2015. Other health initiatives such as the Delivery of Assisted Living and Lifestyles at Scale (DALLAS) is thinking beyond traditional health and social care, to consider how new ideas and technology can be used to improve the way people live.

From a healthcare perspective, it is widely acknowledged now that technology has significant potential to radically transform, and consequently improve the care delivery model, this especially so for the 15 million citizens in the UK presently living with one or more long-term chronic (LTC) conditions, and just as importantly the extraordinary individuals that provide care support to those suffering from LTC(s) that are typically family members and or friends.

And here is the catch, realistically the benefits to be derived from digital engagement with patients with LTC(s), encompassing tele-health, tele-care and assisted living technologies with access to medical information, will increase considerably if engagement becomes extended to the patients care circle, this largely taking the form of family and friends.

Extending Access

A patient’s personal care circle can often feature a wide number of different individuals, performing a range of different roles, for example:

A friend living close by might have a mentor role on diet and / or medication, a family member might be designated as the primary carer, and be the driver for GP and hospital appointments, another family member living further away might want access to assisted living device monitoring information and thus have an arm’s length role in care provision.

The biggest benefits subsequently and frequently argued to be so, are to derived from the provision of better support to the millions of citizens providing care, sufficient to enable them to more confidently undertake better informed interventions to head of negative escalations of a condition that can easily be avoided, and thus referral to a GP, or worse hospital.

Critically for these benefits to be realised quickly, Health and social care engagement needs to be capable of reaching the carer circle in the most appropriate way, identifying these individuals and the care roles they are undertaking is a key first step, with the capability to support citizen / patient consent to access appropriate health and social care information to their personal care circle, a vital second step.

Bigger Brief for Identity and privacy Management

Consequently, Identity and Access Management investment in solutions for the digital agenda needs to be capable of addressing more than just the requirements on the basis of a single citizen or patient. It needs to be capable of accommodating and managing information on relationships between citizens and their family / friends and from a health perspective, the roles that these additional individuals may be undertaken on behalf of the patient, and of course patient consent to access their information, to whomever they choose!

Article Link

Computer Weekly Article

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Health and Social Care Act 2012: fact sheets

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As the new health and social care bill comes to fruition the government has published a updated a series of useful fact sheets that help explain different elements of the reform bill for those interested.

Link to the very useful fact sheets…


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Communications Data Bill published

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The UK Government has just published is proposed Communications Data Bill, a new regulatory framework refreshing the old Regulation of Investigatory Powers Act (RIPA) to ensure law enforcement agencies maintain the ability to tackle crime and terrorism as criminals use modern technology and new ways of communicating to plan and commit crime.

The main point of concern already being raised is that the powers will ensure that all data communication sent via mobile phones, emails and other Internet based means will be recorded for all citizens, and stored for a period of time.

Whilst tracking and storage of all communications might actually be necessary to identify those elements of society undertaking or planning to undertake criminal or terrorist activity, the safeguards that are to be in place to ensure the privacy of the law abiding citizen is protected, are not detailed enough to close this debate.

The publication website offers the following summary on the proposed bill, that new legislation will help ensure police can stay a step ahead of the criminals. But it will not:

  • enable unfettered access by the police to data about everyone’s communications
  • provide the police and others with powers to intercept and read your emails, phone calls or check your contacts lists
  • create a single government database containing your emails and phone calls to which the police and agencies can get unlimited and unregulated access
  • weaken current safeguards or checks in place to protect communications data
  • allow local authorities greater powers

The site goes on to provide commentary from a number of senior law enforcement professionals under the heading “protecting the public”, including:

  • Association of Chief Police Officers crime head Jon Murphy chief constable of Merseyside Police
  • Child Exploitation & Online Protection Chief Executive Peter Davies
  • SOCA Director General Trevor Pearce

One cannot help that an additional heading entitled “Protecting the Publics Privacy” with statement from the likes of the Information Commissioner and perhaps one or two privacy pressure groups on the basis of their being briefed and satisfied that privacy controls being implemented in support of the bill would do a lot to head of concern.

Whilst there can be little doubt of the need to ensure investigation and intelligence capabilities need to be able to keep pace with technology developments, however the lack of up-front assurance aimed at addressing what should be reasonably anticipated, specifically concerns on privacy, is somewhat perplexing?

Article Link

UK Gov Communications Data Bill publication

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Patient access to GP records by 2015

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The government ‘digital’ plans to provide patient access to GP records by 2015, raise a number of important questions, not least would access to just GP be of significant value to the patient on it’s own?

To explore this fully it is necessary to perhaps try to qualify who would most likely be the initial beneficiaries of online access to medical information, and in the process what, information would be of most value.

In the first instance patients can arguably be categorised into three broad health aware groups:

  1. The Less Active – The rest of us that are not ill, but then not necessarily especially healthy, and only take to visiting the GP under duress from a family member or loved one!
  2. The Pro-Active – Those that have an interest in their health, and contribute greatest to the Lycra industry, frequent exercisers that keep a (reasonably) close eye on their diet to try to remain in a healthy state, can frequently be seen jogging and or cycling.
  3. Long-term Chronic Condition Sufferers – Those with one or more condition, estimates for the number of patients in this category stand at approximately 15 million for the UK.

The Less Active

Hands up all those that feel they fall into this category?

If you could access your medical information online, would you?

Would on-line access to your medical information in itself influence a change in your attitude toward your own health and well-being?

The answer to at least the last two is unlikely, unless access to our information is delivered with something else to secure positive and on-going engagement, a good proportion of this population group might only ever access information out of curiosity.

Stress Free ExcerciseThat is until the transition into the Long-term Chronic Condition group, which a great many would be very likely to do, as a result of their indifference to matters concerning health and wellbeing in the earlier stages of life, when there is time and energy to do something positive about it (NOTE the author falls into this group)!

Pro-active and educational engagement on health and wellbeing as opposed to access to specific health information is perhaps more key for this group, potentially for these to be reached via social networking as the demographic tend to fall into the computer literate group that frequently access the Internet and communicate online.

The Pro-Active

RunnerThis group may access their medical information online, indeed they may want more in respect of an ability to add information into their records themselves, to enable them to track their own improvement derived from their personal investment in trying to stay fit and healthy.

If an individual in this category is unfortunate enough to succumb to illness, worse case the onset of a long-term chronic condition, then they will likely need the least encouragement to engage and make use of medical information online.

Long-term Chronic Conditions

The first group are the prime candidates most likely to derive benefit from improved access to their medical information, especially if this information can be shared and / or accessed by those of their personal care circles, typically made up of family and friends.

The catch with this group is that their touch points with healthcare frequently numerous, as well as having on-going engagement with their GP and other health professionals within the practice. Their care in a great many cases will be more closely monitored and managed by other health and social care organisations, this could include, community care NHS trusts, social care providers and / or dependant on conditions, mental health trusts too.

WheelchairThe GP practice to which the patient is registered may only actually be engaged infrequently; consequently the GP record will not necessarily be the best and most up to date source of all information that is important in respect of helping a patient (and their carers) to manage their condition.

Consequently, access to medical information for this group really needs to encompass all of the potential many touch points they have across health and social care services to be truly effective and beneficial.

However, for this to be achieved a raft of challenges to be overcome, just scratching at the surface on some of the more obvious one:

Assimilation – appointments represents a good and simple example of an assimilation challenge, given the scope of a long-term chronic condition suffers touch points across different health care service providers, the provision of access to an effective online schedule for a patient requires interaction with a wide range of different appointment and scheduling systems.

Contextualisation – to be useful the information presented to the patient needs to be meaningful and understandable, and context represents an important consideration, especially if in the ideal, access to information  helps the patient to understand the need to take appropriate pro-active action to avoid worsening of their condition.

Accessibility – a great many of the current demographic category fall into the group of more senior citizens that are not computer literate and unlikely to have access to the Internet. Consequently it is more likely that it will be younger family member(s) or others (friends) operating in carer roles that will be more pro-active with the patients information online. The issue of consent, privacy, information governance and shared access becomes key concerns to be addressed.

Presentation – will be key if again the information presented is to be usable and accessible, whilst a great majority of senior citizens will not have any inclination to become computer literate and familiar with the ways of the web, there are other ways these individuals can be encouraged to become part of a digital society, some will have smart phones whilst others would be comfortable with using a touch screen tablet device.

Making online medical information accessible across a wide range of devices should be a prime objective, with due consideration given to accommodating impairments, disabilities and multi-language capabilities to ensure no citizen is excluded due to disability, race or culture. Consistency in look feel and approach is also vitally important, otherwise the need to learn a new system every time a patient moves from one locality to another will only serve to undermine engagement and the benefits this should bring with it.

Online Engagement Today

Emergence of web and mobile app based technologies has provided a wide range of options for securing patient / citizen engagement with public services. Today a search of the Apple App Store for “NHS” will return a listing of 176 apps for the iPhone, and 44 for the iPad device, the Google Play App Store returns 155 apps for the IOS platform, some are the same apps, and some are not, a search on either App Store for “healthcare” generates a less than helpful greater return of results.

The range of apps is beguiling, some are location or service provider specific, some relate to general information on services, some are condition specific, some are provider specific etc. etc., and makes for quite a wide and varied experience for the end user, with a wide variation in approaches, addressing accessibility, presentation and most importantly privacy.

On the Internet the experience is just as varied and beguiling, and from an engagement perspective, services such as mainstream social networking platforms (Facebook, Twitter, LinkedIn etc.) are not able to offer the assurances on privacy and data protection required to underpin and maintain engagement, sufficiently to be utilised as engagement and collaboration tools on healthcare, beyond generalised messaging.

There is clearly much less of an appetite for a national approach towards systems with the current government than there was with the previous. However, without some standardisation and change in focus on approaches, the citizen / patient engagement process will continue to evolve through a disparate array of solutions that will only serve to disengage and disenfranchise the majority.

computerThe technology exists to achieve the requirement within the target timescales set forth, with a bit more focus, and setting of standards, the opportunity to transform the health and social care engagement model is within reach. What is needed however is more focus on the production of requirements that set out common standards for engagement solutions that is sufficient to guide the wide range of third party innovators and ensure consistency in approaches.

Patients don’t need (and arguably don’t want) full access to their medical records online, to secure benefits from a digital online engagement process, some of the primary information requirements initially that could / should be available online include:

  • Access to discharge notices and any supporting information necessary to ensure transition out of hospital and servicing of after care is effective and undertaken accordingly.
  • Access to details on prescribed medicines, with perhaps the ability to add additional details on self-prescribed medicines so that this may be validated by a health professional (i.e. to confirm that adverse reactions may not be encountered).
  • Access to care plans and associated information to support wellbeing and management of conditions.
  • Access to a unified schedule of appointments, providing details of those with any health and or social care provider.
  • Integration and meaningful presentation of information from tele-health / tele-care and assisted living devices that help the patient to stay safe and well in their own home.
  • Contact details of primary NHS professional carers and support personal, with the means to communicate electronically on general issues.

And above all else, the ability for the patient to consent access to this information to members of their personal care circle, so that these become better engaged and informed on care needs and provision of assistance working collaboratively with NHS and social care service providers.

The benefit, all round would unquestionably result in improvements in quality of care and confidence that the needs of the patient are better understood through engagement of not just the patient, but those that know them best, their personal care circle.

Most significantly these benefits can be realised alongside significant reductions in costs with a substantial return on investment possibility, but only if the current disparate investments are bought together to address the requirements for consistency and uniformity in approaches that secure economies of scale.

About the Author

Presently in category 1, should be transitioning into category 2, but needs a big push and on-going encouragement, likely to become a member of category 3 in the next 10 to fifteen years.

In his late forties, married with two children and a grandson. Not a heavy drinker, but unfortunately was until recently a smoker (ugh, but now 6 months smoke free!). Grandparents deceased, one from cancer, another sadly suffering decline in later years as a result of dementia.

Was witness to family member’s sufferance of despair trying to care for the dementia patient home until it became no longer possible. Whilst the support services from the NHS and Local Authority cannot be described as poor, they could have been considerably better. Unquestionably online access to help services with better collaboration on health and care planning and service delivery could have been hugely beneficial.

Tele-health / tele-care services and assisted living devices would have offered much too, in terms of respite through reductions in need for 24/7 monitoring and on-hand attendance when conditions permitted.

Would like to see current service transformation to better patient and personal care circle engagement happen as quickly as possible, especially given that the scope of significant benefits extend right across the Quality, Innovation, Productivity and Prevention (QIPP) agenda.

Article Links

E-Health Insider Article

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eMail Highlights a Data Protection Conundrum

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eMail poses some interesting challenges from the information governance perspective, challenges that have been carried forth since the birth of personal computing and early misjudgements made in establishing this new computing concept.


Personal, or moreover the personalisation of user access and assignment of rights in a corporate setting being the issue, that has become an challenge for organisations trying to wrestle back ownership of corporate data, through the introduction of identity and access management solutions, and most importantly role based access control models (RBAC).

It is a fact that a great many users perceive the allocation of a user logon ID (usually some representation of their name) and the subsequent allocation of email, as something that is personal to them, and not just the means and tools provided by the corporation to help them perform their duties.

This is not helped in some respect by the right to privacy in the corporate setting automatically assigned by law, when in truth (ignoring personal use for the moment) the first claim on the corporate data contained within an email is surely with the employing organisation?

Data Protection Conundrum

eMailThis conundrum is perhaps best illustrated by the NHS own provision of a national (cloud type) email offering (NHSmail), founded on the principle of the NHS staff being allocated and email address for life! A concept that creates some potentially major information governance challenges and issues.

e.g. nurse A, works for a trust in the GNU clinic, and routinely handles sensitive and private information, not all granted necessarily in a patient identifiable form via email, but for the sake of argument assume that she has a function that warrants the use of email in this way.

Nurse A leaves the trust, and takes up post in another trust, in a difference less sensitive business function, she according to the policy for NHSmail takes her mail account with her. Unless the first trust has a very robust starters and leavers admin and management process (a great many do not), any data (unless archived off by the user), goes with her to her new post, that’s information governance issue one.

The second information governance issue concerns the loss of continuity, that arises is the fact that her replacement (and this is largely true of any mail system) will most likely never get sight of their predecessors communications.eMail Open

Many staff, because they use email for personal purposes as well as business purposes, will typically clean their mailbox down, this being more about protecting their personal privacy, as opposed to protecting those individuals information they may have been privy too.

Even is a user bothers to sort and sift in deletion, to subsequently leave behind relevant info for the person following into the role, the second information governance issue of disconnection still occurs, because likely as not the mailbox never gets reassigned, instead the new user gets a new mailbox.

Of course email is just one example of a number of personalisation issues that came into existence, personal file shares, user based permissions, are other significant information governance concerns affected by the starters and leavers process.

Identity Assurance

Until identity and access management, and importantly the evolution toward RBAC takes a hold, organisations will continue to experience these issues and more that are less about breaches of privacy, and more about the perhaps less tangible aspect of discontinuity, that results in inefficient and costly working practices, of learn it all again, every time a staff role change occurs.

eMail ForwardThe commercial corporate world is moving fast with the adoption of identity assurance and RBAC solutions, because they recognise the cost and downside of not doing so, and in health of course the sterling work of the CfH Identity Management Team and NHS Spine implementation of RBAC to national apps provides a model for health, time now for this to be adopted at the local level.



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