National Programme for IT


National Programme for IT

The National Programme for IT (NPfIT), is an initiative by the Department of Health in England to move the National Health Service towards a single, centrally-mandated electronic care record for patients and to connect 30,000 General practitioners to 300 hospitals, providing secure and audited access to these records by authorised health professionals. The Department of Health agency NHS Connecting for Health (NHS CFH) is responsible for delivering this programme. In due course it is planned that patients will also have access to their records online through a service called [https://www.healthspace.nhs.uk/ HealthSpace] . NPfIT is said by the NHS CFH agency to be "the world's biggest civil information technology programme". [cite web |url=http://www.connectingforhealth.nhs.uk/delivery/serviceimplementation |title=NHS Connecting for Health — Service Implementation |format= |work= |accessdate=]

The cost and scope of the programme, together with its ongoing problems of management and the withdrawal or sacking of two of the four IT providers, have placed it at the centre of ongoing controversy, and the Commons Public Accounts Committee has expressed serious concerns over its scope, planning, budgeting, and practical value to patients.cite web |url=http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/04/17/ncomputer17.xml |title=Patients 'won't benefit from £12bn IT project' - Telegraph |format= |work= |accessdate=2008-05-29 |date=2007-04-17] [Cite web
title = DoH: The NPfIT in the NHS - twentieth report of session 2006-2007
accessdate = 2008-05-31
url = http://www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/390/390.pdf
]

tructure and scope of the programme

The programme was established in October 2002 following several Department of Health reports on IT Strategies for the NHS. [cite web |url=http://www.connectingforhealth.nhs.uk/aboutus/history |title=NHS Connecting for Health — History of our organisation |format= |work= |accessdate=] , and on April 1 2005 a new agency called NHS Connecting for Health (CfH) was formed to deliver the programme. CfH absorbed both staff and workstreams from the abolished NHS Information Authority, the organisation it replaced. CfH is based in Leeds, West Yorkshire.

Reviews

The refusal of the DoH to make "concrete, objective information about NPfIT's progress [...] available to external observers", nor even to MPs, has attracted significant criticism, and was one of the issues which in April 2006 prompted 23 academicsSignatories of the open letter to the Health Select Committee: Ross Anderson, Professor of Security Engineering, Cambridge University ; James Backhouse, Director, Information System Integrity Group, London School of Economics ; David Bustard, Professor and Head of Computing and Information Engineering, University of Ulster ; Ewart Carson, Professor of Systems Science, Centre for Health Informatics, City University; Patrik O’Brian Holt, Professor, School of Computing, The Robert Gordon University ; Roland Ibbett, Professor, School of Informatics, University of Edinburgh ; Ray Ison, Professor of Systems, The Open University ; Achim Jung, Professor, School of Computer Science, University of Birmingham ; Frank Land, Emeritus Professor, Information Systems Department, London School of Economics ; Bev Littlewood, Professor of Software Engineering, City University ; John A McDermid, Professor of Software Engineering, University of York ; Julian Newman, Professor of Computing, Glasgow Caledonian University ;
Brian Randell, Professor, School of Computing Science, University of Newcastle ; Uday Reddy, Professor, School of Computer Science, University of Birmingham ; Peter Ryan, Professor of Computing Science, University of Newcastle ; Geoffrey Sampson, Professor, Department of Informatics, University of Sussex ; Martin Shepperd, Professor of Software Technologies, Brunel University ; Michael Smith, Visiting Professor, Department of Computer Science, University College London ; Tony Solomonides, Reader in Computer Science and Medical Informatics, University of the West of England ;
Ian Sommerville, Professor, Computing Department, Lancaster University ;
Harold Thimbleby, Professor of Computer Science, Swansea University ; Martyn Thomas, Visiting Professor of Software Engineering, Computing Laboratory, Oxford University ; Colin Tully, Professor of Software Practice, School of Computing Science, Middlesex University ] in computer-related fields to raise concerns about the programme in an open letter to the Health Select Committee.cite news | first = Tony | last = Collins
title = NHS Focus: Open Letter: Questions that need to be answered|url=http://www.computerweekly.com/Articles/2006/04/12/215323/nhs-focus-open-letter-questions-that-need-to-be-answered.htm
work = ComputerWeekly.com|publisher = Reed Business Information Limited
date = 2006-04-12 | accessdate = 2006-11-01
] cite news | first = Tony | last = Collins
title = Signatories to health committee letter |url= http://www.computerweekly.com/Articles/2006/03/14/215264/Theexpertscallingforareview.htm
work = ComputerWeekly.com|publisher = Reed Business Information Limited
date = 2006-04-11 | accessdate = 2006-11-01
] 2006-10-06 the same signatories wrote a second open lettercite news | first = Tony | last = Collins
title = Experts strike new NHS warning note | url=http://www.computerweekly.com/Articles/2006/10/10/218985/Experts+strike+new+NHS+warning+note.htm
work = ComputerWeekly.com|publisher = Reed Business Information Limited
date = 2006-10-10 | accessdate = 2006-11-01
]

Reports by the King's Fund have also criticised the government's "apparent reluctance to audit and evaluate the programme"Cite web
title = King's Fund - Our Future Health Secured? A review of NHS funding and performance
accessdate = 2008-05-29
url = http://www.kingsfund.org.uk/publications/kings_fund_publications/our_future.html
] .

The initial reports into the feasibility of the scheme, known to have been conducted by McKinsey, and subsequent reports by IT industry analyst Ovum among others [cite web |url=http://www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/390/6062636.htm |title=House of Commons - Public Accounts - Minutes of Evidence |format= |work= |accessdate=2008-05-29] have never been published nor made available to MPsCite web
title = Another ministerial spokesperson for the NHS IT programme moves on (Tony Collins's IT Projects Blog)
accessdate = 2008-05-29 |publisher=Computer Weekly
url = http://www.computerweekly.com/blogs/tony_collins/2007/07/another-ministerial-spokespeop-1.html
] .

Costs

Originally expected to cost £2.3 billion (bn) over three years, in June 2006 the total cost was estimated by the National Audit Office to be £12.4bn over 10 years [cite web |url=http://www.connectingforhealth.nhs.uk/faq/mythbusters/the-cost-of-the-national-programme-for-it-is-spiralling |title=NHS Connecting for Health — Mythbusters: The Cost of the National Programme for IT is spiralling |format= |work= |accessdate=] . However, officials involved in the programme have been quoted in the media estimating the final cost to be as high as £20bn, indicating a cost overrun of 440% to 770% [cite web |url=http://www.telegraph.co.uk/news/uknews/1473927/Bill-for-hi-tech-NHS-soars-to-andpound20-billion.html |title=Bill for hi-tech NHS soars to £20 billion |publisher=The Daily Telegraph |format= |work= |accessdate=2008-05-31 |date=2004-10-12] .

In April 2007, the Public Accounts Committee of the House of Commons issued a damning 175-page report on the programme. The Committee chairman, Edward Leigh, claimed "This is the biggest IT project in the world and it is turning into the biggest disaster." The report concluded that, despite a probable expenditure of 20 billion pounds "at the present rate of progress it is unlikely that significant clinical benefits will be delivered by the end of the contract period."

The costs of the venture should have been lessened by the contracts signed by the IT providers making them liable for huge sums of money if they withdrew from the project; however, when Accenture withdrew in September 2006, then Director-General for NPfIT Richard Granger charged them not £1bn, as the contract permitted, but just £63mcite web | author=Kablenet | url=http://www.theregister.co.uk/2006/09/29/accenture_nhs_penalty/ | publisher=The Register | title=Accenture escapes £1bn penalty for NHS walk-out | accessdate=2008-02-28 ] . Granger's first job was with Andersen Consultingcite web |url=http://www.guardian.co.uk/society/2006/nov/12/epublic.technology |title=Health service IT boss 'failed computer studies' |publisher=The Observer |format= |work= |accessdate=2008-05-29 |date=2006-11-12] , which later became Accenture.

Deliverables

The programme is divided into a number of key deliverables. These are:
*The NHS Care Records Service (NHS CRS)
*Choose and Book, an electronic booking service
*A system for the Electronic Transmission of Prescriptions (ETP)
*A new national broadband IT network for the NHS (N3) (see also [http://www.n3.nhs.uk external link to BT N3 website] )
*Picture Archiving and Communications Systems (PACS)
*IT supporting GPs including the Quality Management and Analysis System (QMAS) and a system for GP to GP record transfer.
*NHSmail – a central email and directory service for the NHS. NHSmail was renamed to "Contact" in late 2004, [cite web |url=http://www.e-health-insider.com/news/item.cfm?ID=889 | publisher=E-Health Insider| title=Contact lost as NHS e-mail relaunch misfires |format= |work= |accessdate=2008-05-31] before being reverted to NHSmail in April 2006. [cite web |url=http://www.e-health-insider.com/news/item.cfm?ID=1849 |publisher=E-Health Insider |title=Connecting for Health fails to lead on Contact |format= |work= |accessdate=2008-05-31]

The Spine (including PDS & PSIS)

The Spine is a set of national services used by the NHS Care Record Service. These include:
* The Personal Demographics Service (PDS), which stores basic demographic information about each patient and their NHS Number. Patients cannot opt-out from this component of the spine.
* The Personal Spine Information Service (PSIS). This is a summary of patient's clinical information, such as allergies and adverse reactions to medicine.
* The Secondary Uses Service (SUS), which uses data from patient records to provide anonymised and pseudonymised business reports and statistics for research, planning and public health delivery.

The Spine also provides a set of security services, to ensure access to information stored on the Spine is appropriately controlled. There are, however, already suggestions these security measures are inadequate, with leaked internal memos seen by the "Sunday Times" mentioning "fundamental" design flaws [cite web | url=http://www.timesonline.co.uk/tol/news/uk/article391090.ece | author=Jonathan Carr-Brown | publisher="The Sunday Times" | title=Computer loophole hits hi-tech NHS trial] . In addition, government spokeswoman Caroline Flint failed to dispel concerns regarding access to patient's data by persons not involved in their care when she commented in March 2007 that access would be granted to "in general" only those staff who are working as part of a team that is providing a patient with care, that is, those having a legitimate relationship with the patient, will be able to see a patient's health record."

Exceptions

The NHS in Wales is also running a national programme for service improvement and development via the use of Information Technology - this project is called Informing Healthcare. A challenge facing both NHS CFH and Informing Healthcare is that the use of national systems previously developed by the NHS Information Authority are shared by the both these organisations and the Isle of Man. Separate provision needs to be made for devolution, while maintaining links for patients' travelling across national borders.

NPfIT is currently focussed on delivering the NHS Care Record Service to GPs, Acute and Primary Hospitals, medical clinics and local hospitals and surgeries. Whilst there are no immediate plans to include opticians or dentists in the electronic care record, services are delivered to these areas of the NHS.

Clusters and Local Service Providers

The programme originally divided England into five areas known as "clusters": Southern, London, East & East Midlands, North West & West Midlands, and North East. For each cluster, a different "Local Service Provider" (LSP) was contracted to be responsible for delivering services at a local level. This structure was intended to avoid the risk of committing to one supplier which might not then deliver; by having a number of different suppliers implementing similar systems in parallel, a degree of competition would be present which would not be if a single national contract had been tendered. However, in July 2007 Accenture withdrew from the project, and in May 2008 Fujitsu had their contract terminated, meaning that half the original contractors had dropped out of the project.As of May 2008, two IT providers were LSPs for the main body of the programme:
* [http://www.cscalliance.com CSC Alliance] - North, Midlands & Eastern (NME) cluster
* [http://www.btplc.com/health/ BT Health London] (formerly BT Capital Care Alliance) - London cluster
* [http://www.accenture.com Accenture] had full responsibility for the North East and East/East Midlands clusters until January 2007, when it handed over the bulk of its responsibilities to the [http://www.cscalliance.com CSC Alliance] , retaining responsibility for Picture archiving and communication system (PACS) rollout only.
* [http://uk.fujitsu.com The Fujitsu Alliance] - had responsibility for the Southern cluster until May 2008, when their contract was terminated. Ownership of this cluster from that date remains uncertaincite web |url=http://www.guardian.co.uk/business/2008/may/29/nhs |title=Second contractor drops out of £12bn NHS computer upgrade |publisher=The Guardian |format= |work= |accessdate=2008-05-29 |date=2008-05-29] .

Local ownership

In the first half of 2007, David Nicholson announced the "National Programme, Local Ownership programme" (known as "NLOP") which dissolved the 5 clusters and devolved responsibility for the delivery of the programme to the ten English Strategic Health Authorities (SHAs) [cite web |url=http://www.e-health-insider.com/news/item.cfm?ID=2552 |publisher=E-Health Insider |title=Hunt spells out local ownership moves |format= |work= |accessdate=2008-05-31] . Connecting for Health retains responsibility for the contracts with the LSPs [cite web |url=http://news.zdnet.co.uk/itmanagement/0,1000000308,39287578,00.htm |title=NPfIT to go local by August |publisher=ZDNet.co.uk |format= |work= |accessdate=2008-05-31 |date=2007-06-15] .

Under NLOP, staff employed by CfH in the Clusters had their employment transferred to the SHAs, with some being recruited to revised national CfH posts.

National Application Service Providers

In addition to these LSPs the programme has appointed "National Application Service Providers" (NASPs) who are responsible for services that are common to all users e.g. Choose and Book and the national elements of the NHS Care Records Service that support the summary patient record and ensure patient confidentiality and information security. As of October 2005, the NASPs are:
* [http://www.bt.com BT] - NHS Care Records Service and N3
* [http://www.atosorigin.com Atos Origin] and [http://www.cerner.com/public/global.asp?site=uk Cerner] - Choose & Book
* [http://www.cw.com Cable and Wireless] - NHSmail

Changes to service providers

In March 2004, EDS had their 10-year contract to supply the NHSMail service terminated. [cite web |url=http://www.e-health-insider.com/news/item.cfm?ID=676 |publisher=E-Health Insider |title=Granger terminates EDS's NHSmail contract |format= |work= |accessdate=2008-05-31] [cite web |url=http://www.e-health-insider.com/news/item.cfm?ID=677 |publisher=E-Health Insider |title=National programme says NHSmail was 'unacceptable' |format= |work= |accessdate=2008-05-31] On 1st July 2004, Cable and Wireless were contracted to provide this service, which was initially renamed "Contact". [cite web |url=http://www.cw.com/media_events/media_centre/releases/2007/06_07_2007.html |publisher=Cable & Wireless |title=Press release:NHSMail Service To Transition Onto Microsoft Exchange Platform |format= |work= |accessdate=2008-05-31]

IDX Systems Corporation was removed from the Southern Cluster Fujitsu Alliance in August 2005 following repeated failure to meet deadlines. They were replaced in September 2005 by Cerner Corporation.

In early 2006, ComMedica's contract for supply of PACS to the North-West/West-Midlands cluster was terminated, and they were replaced by GE Healthcare.

In July 2006, the London region started the contractual replacement of IDX (which had been bought out by GE Healthcare in January 2006) as its supplier. Systems for secondary care, primary care and community and mental health services are proposed by BT to be provided by Cerner, [http://www.inps.co.uk INPS] (formerly In Practice Systems) and [http://www.cse-servelec.com/ CSE Servelec] respectively. [cite web |url=http://www.e-health-insider.com/news/item.cfm?ID=2037 |publisher=E-Health Insider |title=NHS officially told of London Cerner switch |format= |work= |accessdate=2008-05-31] . This is subject to contractual negotiation known as 'CCN2'.

In September 2006, the CSC Alliance, Accenture and Connecting for Health signed a tripartite agreement that as of January 2007, the CSC Alliance would take over the responsibility for the majority of care systems the North East and Eastern clusters from Accenture, with the exception of PACS. As part of the handover process, around 300 Accenture personnel transferred under a TUPE process to CSC, and CSC took over the leases for some of Accenture's premises in Leeds. Accenture now retains only a small presence in the city for the delivery of its PACS responsibilities.

In May 2008 it was announced that following the failure to conclude renegotiation of the contract for the Southern Cluster, CfH terminated the contract with Fujitsu. [cite web |url=http://www.e-health-insider.com/news/3798/fujitsu%E2%80%99s_%C2%A3896m_nhs_it_contract_to_be_terminated |title=E-Health Insider :: Fujitsu's £896m NHS IT contract to be terminated |format= |work= |accessdate=2008-05-31]

Criticisms of the programme

Data security risks

NPfIT has been criticised for inadequate attention to security and patient privacy. In 2000, the NHS Executive won the "Most Heinous Government Organisation" Big Brother Award from Privacy International for its plans to implement what would become the NPfIT. [cite web |url=http://www.privacyinternational.org/bigbrother/uk2000/ |title=The 2000 UK Big Brother Awards |format= |work= |accessdate=2008-05-31] In 2004 the NPfIT won the "Most Appalling Project" Big Brother Award "because of its plans to computerise patient records without putting in place adequate privacy safeguards". [cite web |url=http://news.bbc.co.uk/1/hi/technology/3933679.stm |publisher=BBC NEWS |title=Privacy foes named and shamed |format= |work= |accessdate=2008-05-31]

The balance between the right to privacy and the right to the best quality care is a sensitive one. Also there are sanctions against those who access data inappropriately, specifically instant dismissal and loss of professional registrationFact|date=September 2008.

More worryingly, a January 2005 survey among doctors indicates that support for the initiative as an 'important NHS priority' has dropped to 41%, from 70% the previous year. [cite web |url=http://www.publictechnology.net/modules.php?op=modload&name=News&file=article&sid=2414 |title=Doctor's support of NHS National Programme for IT declines, says new survey |publisher=PublicTechnology.net |format= |work= |accessdate=2008-05-31] There have been concerns raised by clinicians that clinician engagement has not been addressed as much as might be expected for such a large project.

Concerns over confidentiality, and the security of medical data uploaded to the Spine have also led to opposition from civil liberties campaigners such as NO2ID the anti-database state pressure group and [http://www.nhsconfidentiality.org/ The Big Opt Out] who provide patients with a letter to send to their doctor so that their records are withheld from the database.

Reservations of medical staff

As of August 5 2005, research carried out across the NHS in England suggested that clinical staff felt that the programme was failing to engage the clinicians fully, and was in risk of becoming a white elephant.

Surveys suggest that two-thirds of doctors will refuse to have their own medical records on the system [cite web |url=http://www.dailymail.co.uk/news/article-1022920/Daily-Mail-Comment-The-NHS-great-white-elephant.html |title=Daily Mail Comment: The NHS and its great white elephant |publisher=The Daily Mail |format= |work= |accessdate=2008-05-31 |date=2008-05-30] .

Impact on IT providers

The programme contracts have become a substantial element in the UK activities of many IT providersFact|date=May 2008. According to the Daily Telegraph, the head of NPfIT, Richard Granger, 'shifted a vast amount of the risk associated with the project to service providers, which have to demonstrate that their systems work before being paid.' The contracts meant that withdrawing from the project would leave the providers liable for 50% of the value of the contract; however, as previously mentioned, when Accenture withdrew in September 2006, Granger chose not to use these clauses, saving Accenture more than £930m.

The programme's largest software provider iSOFT has been seriously affected by this process and is under investigation by the UK Financial Services Authority for irregular accounting. [Daily Telegraph, 28 September 2006, 'IT providers left in the debris of NHS's 'Big Bang'] On 28th September 2006, the consultancy Accenture announced its intention to withdraw from £2bn of 10 year contracts with NPfIT, which were taken over in January 2007 by the [http://www.cscalliance.com CSC Alliance] - both Accenture and CSC laid blame with iSOFT, although CSC has said it will be retaining iSOFT as its software provider for all its clusters. [Daily Telegraph, 29 September 2006, 'Accenture pulls out of NHS deal'] Earlier in the year Accenture had written off $450m from its accounts because of 'significant delays' in the programme.

Implementation

The first trusts in the London & Southern Clusters to implement the new Cerner system found it problematic, with hospital trust board minutes revealing a catalogue of errors. Difficulties with the system meant thatcite web | url=http://www.guardian.co.uk/society/2008/aug/10/nhs.computersystem |publisher=The Guardian |author=Jamie Doward |date=2008-08-10 |accessdate=2008-08-11 | title=Chaos as £13bn NHS computer system falters] :
*2007: Enfield PCT were unable to obtain vital data on patients awaiting operations and were obliged to delay 63 patients of the Barnet and Chase Farm Hospitals. Further, 20 patients were not readmitted for treatment within 28 days towards the end of the year because the surveillance system for tracking them "was not operational in the new ... system". Buckinghamshire Hospitals NHS Trust found that problems with the system had meant potentially infectious patients with MRSA were not isolated for up to 17 days, requiring six weeks work by staff to update them manually.
*April 2008: Enfield PCT found that the system had failed to flag up possible child-abuse victims entering hospital to key staff, "leaving the responsibility to the receptionist"
*May 2008: Enfield PCT found that 272 elective operations were cancelled at the last minute for "non-clinical reasons"
*May 2008: Barts and the London PCT blamed their failure over the preceding six months to meet targets for treating emergency patients within four hours on staff not being familiar with the new computer system. The same report cited "breaches of the two-week urgent cancer access guarantee" and delays in assessing 11 patients with possible cancer as being due to the computer system.
*July 2008: the Royal Free Hampstead NHS Trust said 12,000 patient records had to be manually amended over a three-week period due to the system, and noted that "The outpatient appointment centre has experienced a significant increase in the time taken to process individual patient appointment bookings. This has had a consequent and negative effect on call-answer performance."

Management team

The NHS appointed a management team, responsible for the delivery of the system: [cite web |url=http://www.connectingforhealth.nhs.uk/about/whoswho/topteam |title=Top Team — NHS Connecting for Health |format= |work= |accessdate=2008-05-31]
* Richard Granger - is the former Director General of IT for the NHS. He took up his post in October 2002, before which he was a partner at Deloitte Consulting, responsible for procurement and delivery of a number of large scale IT programmes, including the Congestion Charging Scheme for London. In October 2006, he was suggested by "The Sunday Times" to be the highest paid Civil Servant, on a basic of £280,000pa - £100,000pa more than former Prime Minister Tony Blair [cite web |url=http://www.timesonline.co.uk/tol/news/uk/article665113.ece |title=Fat cats of the public sector take top pay |publisher=The Times Online |format= |work= |accessdate=2008-05-31] . Granger announced on 16/06/2007 that he would leave the agency "during the latter part" of 2007 [ [http://www.e-health-insider.com/news/item.cfm?ID=2784 E-Health Insider :: Granger to leave in transition by end of 2007 ] ] . Granger finally left the programme in February 2008 [cite web |url=http://www.e-health-insider.com/news/3454/granger_era_ends_as_dg_leaves_cfh |publisher=E-Health Insider |title=Granger era ends as DG leaves CfH |format= |work= |accessdate=2008-05-31] . Granger's credentials were questioned by his own mother, a campaigner for the preservation of local health services in her area, who expressed her amazement at his appointment, critcising the whole scheme as "a gross waste of money".
* Gordon Hextall - Chief operating officer for NHS Connecting for Health. A career civil servant. On Richard Granger's departure, Hextall assumed overall responsibility for the programme.
* Richard Jeavons - Senior responsible owner for service implementation. Previous posts include being CEO of the West Yorkshire Strategic Health Authority.
* Harry Cayton - Chair of the Care Record Development Board.

References

ee also

*Megaproject
*Megaprojects and risk
*National Identity Register
*Citizen Information Project
*Cost overrun
*Universal Child Database
*Medical privacy
*Health Informatics

External links

* [http://www.connectingforhealth.nhs.uk/all_images_and_docs/NPfIT%20brochure%20Apr%2005%20final.pdf "A guide to the National Programme for Information Technology" (PDF)] , NHS Connecting for Health, April 2005
* [http://www.connectingforhealth.nhs.uk/delivery/programmes/ Programmes and Systems Delivery] , NHS Connecting for Health, retrieved October 30 2005
* [http://www.connectingforhealth.nhs.uk NHS Connecting for Health NPfIT site]
* [http://www.connectingforhealth.nhs.uk/aboutus/history NHS Connecting for Health History Page]
* [http://www.btplc.com/health BT Health] , Delivering three major contracts to the NHS as part of the NPfIT
* [http://society.guardian.co.uk/e-public/story/0,,1799088,00.html June 2006: NHS risks £20bn white elephant, say auditors]
* [http://www.timesonline.co.uk/newspaper/0,,2710-751992,00.html Times Online: Patient records go on database]
* [http://www.timesonline.co.uk/newspaper/0,,176-1358226,00.html Computer loophole hits hi-tech NHS trial]
* [http://news.bbc.co.uk/1/hi/health/4745915.stm NHS IT upgrade success 'at risk']
* [http://www.nhsconfidentiality.org/?page_id=9, The Big Opt Out] , Advice to patients - How to opt out


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