Why decentralisation is a prescription for inconsistency

Public information health sites in the UK reflect the country’s famed National Health Service: a mixture of the good, the bad and the indifferent. But the complaint seems to be a universal one – due most likely to a generic lack of coordinated managem

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The UK’s health websites are a mix of the excellent, the mediocre and the terrible, and are almost completely uncoordinated. That will be no surprise to anyone who has had anything to do with the system. What is surprising is that other countries’ efforts seem to be no better.
Health services are complex at the best of time. The UK’s are particularly byzantine, with responsibility shared across a patchwork of doctors, hospital trusts, other trusts, local and national government. The potential for chaos is terrific, but if one medium can hold the whole lot together, it is the web. Trouble is, this is almost impossible to achieve without some central control. And the whole point of the National Health Service structure is that it is decentralised.

Close examination reveals ills


The main National Health Service site starts well. Here you can find your local doctor, dentist, optician, pharmacist or hospital. The “Are you feeling ill?” link leads to the self-help site NHS Direct. You can also check the star ratings and waiting times for any hospital. This last is particularly impressive (if depressing) – it can tell you how long it will be before any named consultant might possibly see you.
But the site flatters only to deceive. It fails miserably as a route to comprehensive information or to the rest of the NHS. Why, for example, can you find a hospital on the Local Services page but not through the Local Services dropdown box on the home page? Why can you find a link to hospital websites in the “star ratings” section but not in the main hospital directory? Why are there no links to Primary Trust or local authority health sites? Why does the site give the addresses of surgeries but not of their sites?
I found my way by search engine to the Guildford and Waverley Primary Care Trust . It looks neat enough but the detail is poor: under Public Meetings, “the next Board meeting is scheduled for 19 February 2002”. The first picture link is labelled “Pyschiatric (sic) care of the elderly”. And while the site offers a link to “find your doctor, dentist or optician”, the search engine is quite different from the main NHS one. Not least because it doesn’t work. I searched for “doctors surgeries” in Guildford and was shown two. I know this is wrong because 13 practices are listed in the Local Services section; some even have their own websites.

Wide variations in quality


So, the health websites are uncoordinated. On quality, the story is more complex. There are many appalling sites. Some seem to be looking for a role and failing to find one, like the vacuous Surrey Hampshire Borders NHS Trust. Others are just bad. The Southwark Primary Care Trust consists largely of Adobe Acrobat documents, which have to be downloaded and printed out. Not much commitment there.
But there is also excellence. NHS Direct has improved greatly since I wrote it up three years ago. This is a self-help site designed to take pressure off doctors and works alongside a telephone service. I criticised it in 2000 for being difficult to use, failing to generate much even when fed with a simple search term such as “migraine”. Now, “migraine” takes you through to a series of useful pages, including several pieces from the site’s own Health Encyclopaedia. The Self-Help Guide uses an admirable ‘needs-driven’ approach. First, click on the bit of the body affected, select a complaint, and answer a set of questions to determine whether you should ring the emergency services, NHS Online, treat yourself or do nothing. My main criticism of the site is that it is coy about providing links to external sites. For example, it gives a reference to a British Medical Journal article in its homeopathy section, but does not link to the site where it can be read (www.bmj.com). A lack of links to non-UK material limits the pool of valuable knowledge that might be fished.
At the local level, the two Guildford surgery websites I looked were first rate. The Guildowns Group Practice has news stories, advice on common illnesses and a doctor-by-doctor appointment schedule. It was built by one of the doctors. The Wonersh Surgery goes further, allowing you to order repeat prescriptions and read the doctors’ biographies. Both sites have prominent links to NHS Direct, though not to any of the other health sites.

Weaker standards world-wide


Were they better organised, the UK’s health websites would add up to an impressive presence, perhaps the best in the world. Three years ago I contrasted the US government’s Healthfinder site favourably with NHS Direct. But the site has not moved on. It is a specialist medical portal linking to a wealth of articles and resources, including online check-ups. But some of the navigation is poor. Would you think of clicking on D to find a tool that tells you how much (drinking) water you should glug each day? And the articles are not, as NHS Direct’s are, written for the impatient web user. The first piece on “migraine” comes from the Food and Drink Administration and contains an indigestible 2,600 words.
The American Medical Association site is aimed mainly at physicians, though it does have a Doctor Finder for patients. It also links to the useful Medem service, which has a large library and a locator for doctors on the Medem network. Medem doctors each have a simple site built on the same template. A useful feature, available to registered users, is a secure link that allows them to offer online consultations with their patients. This, I suppose, is the equivalent of NHS Direct.
The famously efficient French medical service appears to be an offline beast. The central site, www.sante.fr, links through to various public departments but has nothing for the patient. Health Canada is a good-looking if somewhat nannyish site telling citizens what they should and should not eat, drink and do. It also gathers together government statements on SARS. But as a source of health information or contacts, it is weak.
It may be of course that other countries do have good sites, but that they are as uncoordinated as the UK ones and I have failed to find them. Perhaps online disorder is a universal illness in the heath world? Let’s hope they find a cure for it soon.

First published 02 July, 2003
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