I've now made so many unsuccessful and partially-successful attempts to
get my head round the Blockchain concept that I'm starting to think I
might have some form of early dementia.
However, there's one field in which I dimly understand what the
implications might be: namely, the health service, where I work. Since
the Labour government introduced the 'Payment by Results' system into
the NHS about fifteen years ago, and then the Conservative government
put groups of GPs (clinical commissioning groups, or CCGs) in charge of
local health budgets, there's been no end of muddle about how to get
good reliable statistics out of the system as regards which patients are
being treated where, what they're having done, how much it's costing,
and which health authorities they belong to. The blockchain is probably
an answer to this problem.
Let's say a patient rings 999 one weekend because he's having a
heart-attack. The ambulance takes him to the local A&E department at the
Tunbridge Wells Hospital. He gets investigated, and after investigation
he gets transferred to St Thomas's Hospital in London for a triple
bypass. Then he's discharged to a Cottage Hospital in Hawkhurst, and
eventually back home.
At each stage of the journey he has incurred costs. First of all the
ambulance trust charges for transporting him (once to the Tunbridge
Wells Hospital, then from Tunbridge Wells to the St Thomas' Hospital,
then back to the Cottage Hospital). Then his A&E attendance and
investigations in Tunbridge Wells will all incur costs (via the
Maidstone and Tunbridge Wells Hospital Trust); then his treatment and
stay in St Thomas's (via the Guys and St Thomas' Hospital Trust); and
finally his stay in the Cottage Hospital (which comes under the
Maidstone and Tunbridge Wells Hospital Trust again).
Now, all of these costs and data about what treatments were carried out,
length of stay, drugs dispensed to the patient while in hospital, etc,
are supposed to find their way into our local health informatics system,
which is a big 'data silo', so that if we want to (or, more to the
point, if the CCG wants to) it's possible to 'drill down', as they call
it, and find, under the Cardiology costs for a particular financial
year, the treatment and costs for that particular patient as a result of
that particular health episode. The difficulty is that the information
has to be pulled in from various different trusts - our local hospital,
the hospital in London, and the local ambulance service - and compliance
varies from trust to trust. So the information from our local hospital
trust will probably be available more or less straight away, the
information from the ambulance trust a bit more slowly, and the
information from London a bit more slowly again. Things can get even
more complicated if our patient has his heart attack while he's on
holiday in Dorset - because all the costs he incurs should still come
back to the area in which he is a registered patient, but of course a
hospital in Dorset feeds back information much more slowly to Kent than
it would to its own health authority. And things can also get more
confusing if parts of the patient journey, while still chargeable to the
NHS, are carried out by one of the private hospitals - let's say the
patient, instead of having a heart attack, has a cataract operation at a
private hospital, which is doing cataract operations on an NHS contract
as part of the Any Qualified Provider arrangements. The private hospital
may not have good arrangements in place for feeding back data into the
NHS system.
A big part of the problem is that you've got all these different
organisations operating within the NHS - hospital trusts, ambulance
trusts, CCGs, individual surgeries, private hospitals etc. - and they've
all got their own bespoke computer systems with their own bespoke ways
of recording patient data, and it's a constant struggle to get them to
talk to one another. A blockchain distributed ledger would surely be an
improvement on the existing system. You'd just have to enter a
transaction onto the blockchain every time you performed some kind of
service for a patient - anything from a prescription for paracetamol to
a hip replacement - and as soon as the transaction was recorded the
information would be available from one end of the system to the other,
with the costs correctly allocated both to that particular patient and
to the patient's own health authority. Of course you'd also have to
record the same event on the patient's clinical records, in order to
keep an accurate clinical history, so you'd either have to enter it
twice, once on the clinical record and once on the blockchain, or (much
better) you'd have to get every clinical system in the country to
communicate with the blockchain, which would probably be a lot easier
than trying to get them all to talk to each other.
So far so good. However, what do you do in the case of a patient where
you can't discover the NHS number, so you can't accurately say who the
patient is, where he's registered and where the costs ought to be
allocated? Let's say somebody's been run over in the street and is taken
to hospital unconscious, with no identification. Or let's say it's
somebody from abroad, or a refugee or illegal immigrant who has never
registered with a GP in this country. One option is to issue a dummy NHS
number and have some kind of 'miscellaneous' budget against which the
costs can be allocated. But the other option is to use the system as a
means of identifying people for whom the NHS doesn't have to accept
responsibility, and thus excluding or rejecting them. The refugee, the
illegal immigrant or the person from overseas, who couldn't produce any
evidence of valid NHS registration, wouldn't be refused emergency
treatment - not unless there was a really dramatic change of philosophy
- but if it was anything less than life-threatening they might be turned
away, or told that they could only have treatment if they paid for it.
And that's one of the potential effects of the blockchain, as I
understand it: it's so efficient, that if you set the rules up in a
certain way at the outset, you'll end up disenfranchising people who are
misfits of one type or another. If you don't build some leeway into the
system, you can simply make it impossible for certain types of people to
get anything out of it. Presumably the same thing could happen to the
benefits system. And this, in turn, is likely to encourage a black
market. If you haven't got an NHS number, and therefore you can't get
treatment, the way round the problem is to steal somebody else's identity.
- Edward
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