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plicit. One of the positive aspects of a formally accepted plan is the fact that it introduces a standardized way of thinking about the goals of the organization. A dialogue needs contributions from all participants. The decision-makers are primarily responsible for the content - what should be known - other experts for methods and techniques. In order to participate in the dialogue, the health statistician and other experts should learn to understand the problems of decision-makers. The information produced should naturally be reliable and relevant but these terms are not, in this connexion, identical with scientific exactness and scientific value. Measurements at the right time, even if relatively crude but in principle correct, are often more helpful than exact results available later. Discussion of the optimal organizational structure is one where very different opinions can be defended. Introducing the concept of 'system' to information services can be helpful here. The goal is not a unit, office or department but a functionally coordinated system which fulfils the expectations of decision-making bodies. An information system reflects the basic principles of a management system and the two cannot be discussed in isolation. Requirements set upon the quality, type and timeliness, with participation or dialogue, dictate to a marked extent the structure and location of information services in the organizational hierarchy. In each organization or society decision making is a specific process, and planning is accordingly different. A planning process, which is shown to be suited to one society, cannot serve as well in another, except when the decision-making procedure as a whole is modified accordingly. The same is in principle true of information services, but there are numerous principles which are valid in all circumstances (WHO 1974). Evalution in the health field is generally difficult and in most instances based on subjective impressions. This is of courses true in relation to the value of information. My personal impression is that it is difficult to find any activity in the field of health where a relatively small input would give such a valuable output as in the planned development of information services. REFERENCES Bernard J (1976) In: Decision Making and Medical Care: Can Information Science Help? Ed F T de Dombal & F Gremy. North Holland, Amsterdam; p 3 Bodenham K E & Wellman F (1972) Foundations for Health Service Management. OUP, London Harb A S (1972) Methods of Information in Medicine 11, 1 (1976) In: Cross-National Sociomedical Research: Concepts, Methods, Practice. Ed M Pflanz & E Schach. Thieme, Stuttgart; p49

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Johnson R A, Kast F E & Rosenzweig J E (1973) The Theory and Management of Systems. 3rd edn. McGraw-Hill Kogakusha, Japan Land K C (1975) International Social Sciences Journal 27, 7 Nordic Medical Statistics Commission (1973) Planning Information Services for Health Administration, Decision Simulation Approach. Mimeo, Stockholm Purola T, Kalimo E & Nyman K (1974) Health Services Use and Health Status Under National Sickness Insurance. A: I 1/1974. Social Insurance Institution, Helsinki World Health Organization (1971) WHO Technical Reports Series No. 472 (1973) Report of the Technical Discussions at the Twenty-Sixth World Health Assembly, Geneva. A 26 (1974) WHO Technical Reports Series No. 559 United Nations (1975) Towards a System of Social and Demographic Statistics (ST/ESA/STAT/SER F/18). United Nations, New York

Dr M A Heasman (Information Services Division, Common Services Agency, Scottish Health Service, Edinburgh) Health Information Services: a View from Scotland

Health information services are first and foremost a service - if they are not that then they are nothing; and in considering their structure and purpose this has to be kept in the forefront of the mind. Their task is to provide those with an interest in the problems of morbidity, mortality and delivery of health services with the data they require, whether this be for planning, administration, management, epidemiological or socioeconomic research, for education, political interest or just sheer curiosity. There may be different priorities on these various uses of health information, and these priorities may vary from time to time, but all have to be met. There is now a move, particularly at an international level, to extend the definition of a health information system to include all types of information used in health service management, but this paper considers only the statistical and computing services as suggested by Knox et al. (1972) and by Bodenham & Wellman (1972). The paper also draws upon my experience in Scotland. I shall first discuss some matters of general concern before going on to consider the information services as organized in that country. Routine Statistics and the Needfor Flexibility Despite the modern tendency to dispute the accuracy and usefulness of routinely collected official statistics, they form the cornerstone of health information services as they have done since the time of Farr. Vital statistics, data on hospital inpatient treatment, cancer registration and nu-

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merous smaller schemes, together with data on provision and use of resources, are the bread and butter of health information. Although vital statistical data has a much longer history, most of these schemes have been developed since the inception of the National Health Service. All of them are used for a multitude of purposes, although their original purpose was almost certainly much more restricted. It is now recognized that the flexibility of use of routine statistics is fundamental. The health statistician of today is continually developing new uses for his data in response to requests for information. His task is, first, to ensure the speedy collection ofdata in as accurate a form as possible; secondly, to understand that data and particularly its many imperfections; and thirdly, to be ready to assist an enquirer to use the data in a way that most nearly fulfils that individual's requirements. To maintain flexibility it is necessary to store data, as far as is feasible, in disaggregated form, i.e. relating to individual patients, staff members, individual institutions, etc. The greater the summarization the less the

flexibility. The Decreasing Importance of Formal Publication In the pre-computer era a health statistician's reputation depended upon the quality of his formal publication, and by his own manipulation of that data. Percy Stocks was the shining example of this and his work is still an object lessen to all today. Nevertheless, health information priorities are now different. Formal publication remains important, partly as a form of advertisement, partly as a means of wide dissemination of data of general interest and partly as a return for the effort of data collection, but the health statistician who relies on this is not fulfilling his main remit. He lives by cooperation and direct communication with his customers. With the increasing use of health statistical data, published data is hardly ever comprehensive enough to meet the needs of customers and this, together with the latter's lack of expertise, means that it is the responsibility of the health statistician to turn a customer's needs into something that more nearly meets his requirements. Often the basis of such further analysis is published material, but the unpublished material usually held is just as important, as is the facility for ad hoc analysis facilitated by the flexibility of computers. Again, flexibility of response is the keynote. Uses of Routine Statistics One can classify the various uses of routine statistical data into four types not too clearly distinguished, but sufficient for the basis of discussion. They are: (I) data-driven uses; (2) theory-driven uses; (3) case finding; (4) supportive uses. Data-driven uses are those where the data itself

is the source of the enquiry. The scanning of routine data for trends and its use in monitoring are both examples of data-driven uses. In general, the responsibility for monitoring lies primarily with the user rather than the producer, although the latter must produce information in a suitable form. The values of automatic scanning of data remains an open question. The theory-driven uses include those where hypotheses are formulated and data used to test them. Alternatively, data may be required to assist the planning process, or to create projections. Model building and simulation are also an important component ofthis class of use. Ad hoc analyses are frequently required from routinely collected material, or special surveys may be needed. A prime requirement is teamwork between the customer and the statistician to produce information in an optimum form for the particular purpose. An increasing use of routinely collected material is in providing workers with a means of access to case records or patients for the purposes of research. In Scotland there is a national hospital diagnostic index which can be used to provide assistance to two classes of user. First, it is a simple task to provide research workers with lists of patients possessing particular characteristics, usually but not exclusively related to disease. In this instance, for reasons of confidentiality, the names of patients are not given but only case reference numbers, and if the research worker wishes more information he has to obtain the consultant's permission. The second and very important category is where the research worker already knows the names of the individuals concerned. Because personal identification data are collected, it is possible to link names with any held in the data bank and thus provide follow-up material which otherwise would be very difficult to obtain. This obviously raises problems concerning confidentiality, and both this and the general topic of record linkage as discussed later. Finally, an important and frequent use of information services data is in providing supportive statistics as an introduction to other material, e.g. press releases, in answer to parliamentary questions, as an introduction to scientific and other papers. To fulfil all these uses, total coverage of appropriate health events would be desirable. This is an impossible objective, and an important function of a fully developed health information service is either to organize ad hoc or sample surveys or to have access to an organization that does. Information and Time Restraints A problem arises here, however; the great virtue of routine statistics should be their flexibility and the readiness with which they can be used for ad hoc analysis. Nevertheless, however good the infor-

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It should also be a high priority to bring about mation service, there are times when the information required is neither available nor capable of closer liaison between financial statistics and other being estimated from routine data. To set up ad hoc health information services. Although the historicollection of data takes time- and very often too cal reason for the separation of these sources of long for those who wish to use the material. Health data in the British NHS can be understood, it has administrators are not noted for their foresight in done a lot of harm. The growth of interest in costtheir information requirements and they usually benefit and cost-effectiveness studies, resource only request data when the need forces itself into allocation problems, the increasing interest in the their consciousness. A statistically respectable sur- economics of health care, the development of programme budgeting and management accounting, all vey cannot be negotiated, mounted and carried out in under six months and usually takes much longer, create an unanswerable argument for the closest by which time the administrative decision has had possible liaison between the two sources of data, to be taken and the data are no longer required. It even if their complete unification is impossible. It is this as much as anything else which led the is for this reason that the health data bank is to be Scottish Home and Health Department to attempt preferred as a source of health care information. There is a need to obtain an increased familiarity to unify control of administrative - including with the 'quick and dirty' study so that data financial - computing under information services. collection and analysis can be undertaken within a This is a move which has not been greeted with time-scale that is relevant to the customer's re- universal acclaim and is still viewed with suspicion quirements. It is these time-scales which have done by many treasurers. so much to render the randomized control trial of limited value in short-term health care research. Health Information Services in Scotland The same factors may be at the root of the Having dealt thus far with some of the general unhappiness of the service role of university principles underlying the provision of health infordepartments of community medicine and may also mation services, the concluding part of this paper be the cause of some of the shortcomings of considers some aspects of health information services in Scotland. community medicine training. The Neutrality of Health Information This paper opened with a statement which emphasized the 'service' in health information services. A further aspect of that service should be mentioned, namely its neutrality. If it is accepted that health information is basically a neutral commodity then it follows from this that available information should be supplied to anybody who requires it. Customers should be aware of the cost of the analysis they require and should consider that cost in the light of its potential value. Further, information services staff should consider the eventual result of a particular request for data, but they should not allow their opinions to influence unduly the acceptance or rejection of a requestalways assuming it is within the capability of resources to meet that request. Health Service Resources Any paper on health information services would be totally unbalanced without reference to data on resources. The most important of these is manpower. At this time medical manpower data are widely used for resource planning purposes, although still too much at the mercy of migration. Nurse manpower planning is growing rapidly but much of the rest of manpower forecasting is still almost nonexistent. More intelligent use of manpower forecasting and modelling techniques ought to be a high priority for health information services today.

Information services as a national structure: The first point to emphasize is that health information services in Scotland should be regarded as a whole, involving both the central Information Services Division and the organizations set up by the health boards to meet local requirements. Much of the initial design of the service was undertaken by Bodenham & Wellman (1972). The Central Information Services Division: The Scottish Home and Health Department (SHHD) has no information service of its own. With the reorganization of the health service in 1974 the decision was taken to set up an Information Services Division within a health service body known as the Common Services Agency. Civil servants formerly in SHHD were transferred to the National Health Service and from 1 April 1974 became NHS employees. There were several reasons for this: (1) Independence - the placing of health information services in a position apart from both the Health Department and tle Health Boards was a symbolic and a real act of recognition of the neutrality of health information. (2) Removal of the 'us and them' complex. Related to this independent position is the ability to be seen as part of the organization that is actually collecting the data. Much background work is involved with fostering cooperation and unifying the service. Relationships with health boards and with medical records staff have noticeably improved as a result

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of this. (3) The establishment of NHS career structure in information services. With the central organization in the civil service and the peripheral organization in the NHS, it is inevitable that a feeling of frustration is engendered on career propects in the periphery. With information services totally within the NHS there is a theoretical progression to top posts - or at least to more influential ones. In Scotland a much better career structure for medical records officers has been established although much improvement is still necessary for health statisticians. These three reasons were the ones that led to the establishment of the Information Services Division within the.health service. Since then, however, a fourth has become increasingly important. This is the fact that, as a health service body, the Information Services Division is one stage removed from government and thus not under direct ministerial control insofar as the holding of confidential medical data is concerned. One of the largest fears of invasion of privacy is the misuse of data by a corrupt government. To remove health data by one stage and to place it under nongovernmental control has already proved to be an important point in discussion with sections of the medical profession in Scotland, and has also been commented on favourably by the Royal College of Psychiatrists (Baldwin et al. 1976). The Information Services Division itself consists of two closely-related parts, one dealing with computing and information processing and the other with statistics and research. A total staff of about seventy includes computer professionals, community medicine specialists, statisticians and social scientists.

Peripheral information services: In those health boards where the fullest development of information services has taken place a similar structure exists with an information services officer responsible for both computing and statistics, working very closely with the community medicine specialist in information services. In Scotland the policy has been to set up five information services consortia bringing together fifteen boards on a geographical basis so that each information service covers a population of approximately one million. Every health board, except the Island boards, has a community medicine specialist devoting at least part of his time to health service information. As might have been expected, it has not been easy to achieve this objective, nor indeed is it always desirable to upset longstanding arrangements, but the last three years has seen significant growth in the development of information services and, what is more important, in their use and in appreciation of their value, both locally and centrally. A most important element in

Scottish information services policy is that primary processing of data should take place peripherally and usually at health board or consortium level. Where this occurs there is a marked improvement in the quality of the data and in the speed of turnround. Liaison and coordination are essential but these have, to date, been fairly successfully achieved. Record linkage: Record linkage has been an important aspect of information services development in Scotland. A crude but relatively effective means of linking most of the centrally collected patient data has been developed - based upon name, initials, sex and date of birth. Some further work is necessary on tidying up the linkage process and much further work on developing routine and ad hoc uses. These uses lie in the field of health services and epidemiological research, in providing a follow-up service for clinicians and epidemiologists, and in the detection of long-term effects. It is hoped that with the establishment of the Data Protection Committee, and whatever successor it may have, this can be given a high priority with the privacy and confidentiality aspects safeguarded and under the supervision of a 'privacy' committee, recently established with both lay and professional representation. Conclusion The last few years, just prior to and since health service reorganization, has seen a tremendous growth in the use of health information. Information Services Division dealt with over six hundred ad hoc requests for data during 1976, varying from relatively small to large studies such as those that are being undertaken for the Scottish Working Party on Revenue Resource Allocation. This is quite apart from the use made of published data or by local health information services from their own resources. In Scotland a relatively larger amount has been invested in information services than has been the case in England. This is an investment in every sense of the word and a full return is still awaited on that investment. At this time of economic stringency information services have come in for their share of attacks, but it is just at this time that they are most needed, for the decisions that are made now are going to have to be lived with for many years to come. Health information has its part to play in making those decisions more rational. REFERENCES Baldwin J A, Leff J & Wing J K (1976) British Journal of Psychiatry 128, 417 Bodenham K E & Wellman F (1972) Foundations for Health Service Management. OUP, London Knox E G, Morris J N & Holland W W (1972) Lancet ii, 696

Health information services: a view from Scotland.

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