Informatics 98may5

Journal of Informatics in Primary Care 1998 (May):12-14


Is it time to review the Code of Connection to the NHSnet?

Dr Nick Booth, Medical Information Group

20 Springfield, Ovington, Northumberland, NE42 6EH

Tel: 0191-256 3100, Fax: 01661 830316, email:



As confirmed by the recent White Paper, the roll-out of NHSnet as the NHS corporate intranet will enter an accelerated phase. It is quite clear that this will be a key feature of an NHS with considerable reliance on information systems for both business and clinical purposes. The purpose of this preliminary paper is to highlight relationships between NHSnet and the internet, and consider communication of and access to health related information in the wider UK health service.

The original contract for the NHS network was negotiated in 1993/94, at a time when much of the impact of the internet on the general public had neither been realised nor assessed. In the light of developments and experience with this medium, it is worth reviewing the arrangements for connection to, and use of, the NHS intranet.

Current arrangements under the existing contract for NHSnet rely upon a strictly closed network which is completely inaccessible from outside; one-way communication with internet world wide web sites is possible through a central controlled gateway. Email across the boundaries is possible. Charges for connection to NHSnet and use of it (tariffs on volume) are payable and may dictate policy on level of use.

Corporate intranets (wide area networks for the exclusive use of an organisation) are common in the business world, but seem a very inflexible model for an organisation such as the NHS. They do allow wide bandwidth per user, which can be guaranteed, as external traffic is excluded. There is also a more clearly defined security risk. However, this depends on tight definitions on who is a legitimate user, which I feel is not the case in the NHS. As can be seen below, the NHS is a very fuzzily defined organisation, which, apart from being far larger than most corporate entities, has relationships with organisations which, under controlled circumstances, need to have access to specific information.

The security inherent within NHSnet has been said to depend on tight criteria for rights of use, and on an extremely tight ‘Code of Connection’. Initially, secure password access, backed up with physical tokens, would allow user access. Representations from the profession have challenged this mechanism. As the NHS domain is poorly defined, and because of an inherent finite internal security risk, key management has been a central demand. Keys will allow authentication, integrity checking, and encryption. It follows from the adoption of this type of security environment that the exclusive Code of Connection used in NHSnet is no longer required.

In particular, and in view of the currently strict Code of Connection, there is concern about the nature of access to information between NHSnet and the Joint Academic Network (JANET). It is clear that there is a considerable disquiet amongst the clinical community in universities that the symmetrical communication with colleagues on NHS sites is not easy or even possible. There is increasing use of web-based education in medical schools, and the predictable development of this is that information services will grow and include postgraduate education and CME. It is thus unclear that development of web-based information services will flourish in an environment where there are two similar though separate sources of information. The single most worrying aspect of this development is that information services developed solely on the NHSnet are invisible and inaccessible to the internet in general and to JANET in particular.

Further concern will be generated by considering the internet revolution in our society and the likely impact of this on the public. Some aspects of communication with health professionals will move to email, whilst the enormous but somewhat anarchic information resource on the world wide web will begin to have an impact on the relationship between health professionals and their patients (clients). All clinicians will be challenged by a huge increase in the clinical information available to patients.


Who needs access?

The problems associated with access to information may be further considered by first categorising according to type and audience.

1. Clinical care

  • utilisation by clinicians of named patient information
  • transfer of personal health information between appropriate clinicians
  • transfer of requests for and results of tests and investigations

2. Research and epidemiology

  • sharing of de-identified patient information

3. NHS infrastructure and administrative support – analogous to traditional commercial network activity

  • transport
  • supplies
  • equipment
  • administrative information (non-clinical)

4. Information transfer between purchasers and providers

  • contractual information for hospital services

5. Information about services

  • for clinicians
  • for patients and the public

6. Health related educational material

  • for patients and carers

7. Teaching and learning materials

  • undergraduate training
  • postgraduate and in service training of health professionals

8. Information to fulfil statutory obligations from Health Authorities and Trusts to the NHS Executive

  • Central Returns


Reasons to connect to a wide area network from a General Practitioner’s perspective

The workstation in my office should be the single information source to assist my clinical activity. It should give me access, on one workstation, to:

1. The Electronic Health Care Record

  • local
  • shared care

2. Files

  • personal
  • practice
  • clinical communities.

3. Web

  • practice intranet
  • NHSnet
  • internet

4. Email (SMTP/MIME)

  • NHS
  1. Trusts
  2. Health Authorities
  3. NHS Executive
  4. Department of Health
  • other agencies
  1. Social services
  2. DSS
  • universities
  • patients

5. Wider internet

  • international colleagues

6. Structured clinical messages

7. Information about my own patients

8. Information on other patients I care for

  • emergencies
  • temporary residents

9. Educational resources for patients, whether provided by me or by other organisations or individuals.


Who will require access* to my practice network in certain controlled circumstances?

1. Doctors

  • to whom I have referred patients
  • who are otherwise caring for my patients
  1. in hospitals
  2. whilst they are away from my practice area
  3. GP out of hours co-operatives
  4. other urgent or emergency circumstances
  • in shared care
  1. in hospitals
  2. outreach clinics
  • in the private sector

2. Core team

  • nurses
  • midwives
  • health visitors

3. Extended team

  • attached social workers
  • professions allied to medicine

4. Patients

  • on the practice premises
  1. interactive workstations
  2. access to information on health education
  3. access to information on available services
  • from home
  1. email to practice staff
  2. access to practice website
  3. access to appointment booking system?

5. Patients and the public

  • from external internet connections
  1. access to information on health education
  2. access to information on available services
  3. other health information

6. System suppliers

  • for system maintenance

*Access in the context of a network containing identified clinical information is a particularly sensitive problem in terms of security. In using the word access here the author has in mind that the arrangements for obtaining information will be particularly strict, and may mean that defined individuals may only obtain information using targeted queries rather than true physical connection.


Who might have legitimate access to elements of information with prior agreement (usually stripped of identifiable markers)?

  • administrative organisations
  • Health Authorities
  • secondary care Trusts
  • NHS Executive
  • Primary Care Groups / Trusts


Principles of access

Thus the idea of a closed intranet is becoming increasingly difficult to rationalise (or even envisage), and therefore five principles of access are presented which it is hoped might help the debate about how we can maximise the clinical usefulness of a dedicated network for the NHS.

In the suggested framework, it would be possible to envisage a number of levels of access to information. At the most basic level, health information in the public domain might be accessible in areas where any member of the public could look. File areas might also exist for download of leaflets and references. At another level, information about services provided by the NHS might exist. At a higher level, access to local NHS waiting lists and appointment systems might be only accessible to appropriate health personnel. Higher still would be more sensitive NHS corporate information sources. And at the ultimate level would be specific, patient-identified health information, which would depend upon legitimate access using appropriate cryptographic means of identification and right of access.

1. We should encourage a transition to a more open network with more rigid intrinsic security from local firewall technology and the use of cryptographic keys to provide:

  • authentication of identity
  • integrity
  • encryption

2. The network can behave as an exclusive and comprehensive service provider for "consenting NHS personnel".

  • This will allow high quality and high speed levels of service between users of NHSnet.
  • Non-NHSnet users of NHS services can, under controlled circumstances, have access to appropriate NHSnet resources even if not contracted to NHSnet.
  • They will not enjoy guaranteed levels of service.
  • They may as a default be excluded from certain parts of the Intranet

3. Current tariffs based on cost per message and cost per byte should be phased out and replaced with tariff based on guarantees of service level based on:

  • bandwidth of connection
  • performance
  • reliability

4. Close contractual and practical ties with JANET are essential.

5. The UK public cannot be excluded from the network at every level.


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