Author: Holly Kearn

New PRSB member spotlight: CIO Network

Lee Rickles

PRSB is delighted to welcome the CIO Network as a new member. The organisation brings together chief information officers to support their development as clinical information leaders, and promote their involvement in advancing health and social care services. Lee Rickles, Yorkshire & Humber Care Record Programme Director and CIO Network Advisory Board Member, perceives standards […]

Nuance looks to PRSB standards to help ease the burden on NHS staff

Nuance

Although electronic patient records are essential to improving joined-up care, documentation can be a burden to hard-pressed health and care professionals. Marrying the AI-powered speech recognition of Healthcare AI technology pioneer, Nuance, and PRSB’s Standards Partnership Scheme is the kind of smart problem-solving that could help clinicians using Nuance technology provide more time to care. […]

Epic becomes a PRSB partner

Epic

Electronic health records supplier, Epic, is the latest organisation to join the PRSB Standards Partnership Scheme. Epic develops software to help people get well, help people stay well, and help future generations be healthier. More than 300 million patients have a current record in Epic. Epic’s decision to join the Standards Partnership Scheme was driven […]

Reaching new heights with highly personalised care

A guest blog by Rob Hardisty, Solution Director at Graphnet Health. What is integrated care’s next big move? I believe the obvious next step is using digital tools to help people record and share what they and/or their families consider their most important information while they are being cared for. Using IT as an enabler, […]

The role of standards in delivering integrated care

The health and social care sector is currently experiencing a ‘boom’ of digital innovations, harnessing the power of data, increased connectivity and greater integration across different systems and settings, to improve the delivery of care. While it may seem that digital technology is key to driving these changes, it’s only a part of the solution. […]

Using standards to optimise personal health technologies

Mobile health, also known as mHealth, has undoubtedly revolutionised healthcare and self-management, providing health data within a short space of time, or even in real time. However, while personal digital technologies seem like a huge step forward in health and care, there are still some elements to consider to make sure we utilise their full […]

Overcoming barriers to successful implementation of the About Me standard

The NHS estimates that personalised care will benefit up to 2.5m people by 2024. During an era in which almost every industry harnesses the ability to provide services that would suit individual requirements, it’s equally the right time for health and social care providers to abandon the one-size-fits-all approach, and start focusing on the needs […]

EMIS joins the PRSB Standards Partnership Scheme

One of the UK’s primary suppliers of health software solutions, EMIS, has now become a PRSB partner. Operating for more than 35 years, the products offered by EMIS are developed with a strong clinical focus to support and deliver connected healthcare, and EMIS Web is present in almost 60% of GP surgeries across the UK. […]

“If someone’s been working for a period of time, in a form of therapy, for instance, where there’s an agreed plan for the locality when they may present in an emergency situation … then it’s really important for us to be able to see that that information and be able to act appropriately according to that because, you know, there isn’t and there shouldn’t be a stock response to that. These plans are designed to be individualised and personalised.  All services should be giving that personalised approach to care wherever possible. And a standard such as [PCSP standard] definitely moves us closer towards being able to do that. [Not acting on agreed plans] is a key finding in terms of emergency responses over the years where responses have been inappropriate.” – Mental Health Nurse

“Following a particular plan that’s been put into place will result in much better outcomes and prevent the sort of poor outcome which would otherwise be leading to an unplanned hospital admission.” – General Practitioner

Successful teams have the functional skills to lead a task, benefit from diversity, and are led in a way that creates time and space for reflection; the ability to take stock periodically, of the task and of the way in which the team is engaged in delivering it. Your stakeholder analysis [HYPERLINK] should help you assemble the most appropriate team and identify how the team interacts and relates to other stakeholders like sponsors, services users, etc.

The variation in the size, both in terms of population served and numbers of constituent organisations, and of complexity, between Integrated Care Systems, precludes the possibility of any prescriptive guidance on the way in which this team is assembled.

Engeström’s expansive learning cycle of learning actions explains how there are 7 stages of learning actions;

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.