Clinical guidance on COVID-19 SNOMED codes

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Frequently asked questions

  • Why is NHS Digital issuing this new release now and what will it cover?
    The new SNOMED CT release is required to support COVID-19 and its management. Using consistent coding will will help improve care of individuals now as well as informing research into the best way to manage this virus across the whole population. It is vitally part of the effort to manage and combat the virus that clinicians use these new codes as soon as they are available in your local practice.
  • Are the new codes available in systems now? When should we start using them?
    The 1 April 2020 release has been communicated to all system suppliers.  Some have already implemented them, others will do so in the near future.  The new codes will be made available in appropriate data entry forms and templates as needed. The codes should be used as soon as they are available in your local system – refer to guidance from your system supplier or local management to know when this applies to you.
  • Who does this apply to?
    The guidance applies to all professionals recording COVID-19 related information. The initial focus has been on primary care systems. However, all suppliers have been advised of the requirement to comply with the new codes. If your system supports recording using the new SNOMED CT codes, you should do so.
  • How will data be shared between systems that are on different versions of the codes?
    This can happen today. Unrecognised codes will be stored as free text. NHS Digital are working to look at how any inconsistencies are managed and eradicated over time. It should not cause a problem today.
  • Why are there UK specific Covid-19 SNOMED CT codes? Why not use the international codes?
    For a number of practical and operational reasons the April 2020 release of SNOMED CT will be based on the July 2018 SNOMED International release, which does not contain the international SNOMED CT COVID-19 codes. In order to accommodate additional requirements for COVID-19 management and minimise other change impact, NHS Digital Classifications and Terminologies Delivery Services are recommending making minimal changes to include COVID-19 codes in April 2020. Scheduled changes are planned in October 2020 to phase in merger with SNOMED CT international content and Covid-19 specific content.
  • Does this mean UK data won’t be able to be aggregated with international data for research into the care and treatment of people infected with COVID-19?
    All international COVID-19 codes have counterparts in the April 2020 UK data and so can be aggregated.
  • Will there be other additional releases?
    Additional interim releases to accommodate novel COVID-19 requirements are planned. These will be to support new activities or observations, to manage new challenges specific to later waves of the disease or its recovery phases, or could be to support care in alternative settings
  • How was this list compiled?
    The current set is the result of collaboration (since January 2020) between NHS Digital terminology/clinical staff and representatives of primary care system suppliers (EMIS, TPP, Vision, Microtest), as well as extraction and analysis groups – PRIMIS and The Nuffield Department of Primary Care Health Sciences. There have so far been two ‘phases’ of work: the first produced data that was published in late February – much of this was a reworking of content developed to manage the 2009 H1N1 Pandemic. As the COVID-19 story has developed, more content has been developed to try and keep up (e.g. with aspects relating to transmission suppression) and this is included in the April data.
  • Can changes to the list be suggested?
    The current publishing process means that the current list to be released on April 1st 2020 cannot now be changed. However feedback is always welcome, released content can undergo certain controlled modifications or be withdrawn, and new content can be added for later releases.
  • What happens next?
    Further information and guidance will be provided over the coming weeks as well as new work to set out the plans to enable alignment across the whole health and care system.

Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.

CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests. 
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history. 

 

• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning. 

This links to the fifth principle that:

5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”