A welcome plan, but delivery is key

In quick succession in recent days, the Government published two strategies for digital transformation and use of people’s data for health and care planning and research (A Plan for Digital Health and Social Care and Data Saves Lives). The digital agenda is central to plans for the future of the NHS and social care, and standards are a critical part of that narrative, finally gaining the traction they deserve.

The lessons from the pandemic have made digital transformation unstoppable: witness the massive public uptake in use of the NHS App, remote consultations and virtual wards increasingly the norm and the development of federated data platforms to support care planning, research, the life sciences and economic recovery.

Standards are key to so much of the change and improvement envisaged in these plans. The health and care system is poised to see a huge shift as more and more success stories emerge of organisations that transform care and efficiency by embracing standards and digitisation, so much so that others will want to copy them. But bringing all parts of the system up to a passing grade, let alone best in class, demands that we understand why we’ve failed in the past and how we learn for the future.

A Plan for Digital Health and Social Care contains a clear analysis of many of the challenges that have bedevilled the digital transformation of services: the poor deployment of purchasing power, no clear route map for standards that suppliers can rely upon, a lack of vision for aligning levers and incentives across the system to support digitisation at a professional and organisational level backed up by enforcement of standards and little support for social care.

As the authority on record standards and the body representing the front-line users of standards, PRSB believes that standards could be a catalyst for radical, transformational change and improvement but that will only happen if change is looked at in the round and we don’t make the mistake AGAIN of treating this as solely a technical problem. Reviews from Wachter to Topol to Heifetz and the National Audit Office have drawn this conclusion repeatedly. PRSB was created for precisely this reason – not only to develop the standards that have wide support from professionals and people but also, with our members, to play an important role in getting them successfully landed in routine practice.

We welcome the greater clarity, consistency and de-duplication promised by the creation of the NHS Transformation Directorate. Our members and key stakeholders tell us that it has been extremely difficult to untangle the threads and work out what they need to do to implement standards and interoperability so this should make things easier.

We also welcome the focus on digitally immature organisations where the capacity for improvement might be greatest. Provider organisations will need a lot of practical advice and support – much of it at the very basic level. The plan’s focus on funding for IT systems and training to support professional staff are absolutely the right direction of travel.

With care spread across different teams, settings and services, sharing vital information about the people who are accessing services is not simply a record-keeping task or afterthought of care. In today’s world, information is care. It is great to note the attention on upskilling all professionals. Too often, people talk about standards in purely technical terms which is far from the reality of the several million front-line professionals and people who use them daily to document care, and work closely with PRSB to define them.

At the same time, strengthening the enforcement of standards through meaningful independent assessment of supplier conformance will drive positive change. PRSB’s own experience of assessing supplier conformance with record standards through our Standards Partnership Scheme has helped suppliers differentiate themselves in the market based on quality, and let providers know unequivocally what they are getting. Our partner suppliers tell us that aligning their systems to PRSB standards is an essential step toward interoperability and more importantly to better quality care, and they value our developmental approach to conformance assessment.

There is a growing recognition of the importance of engaging and activating people in their care through tools such as the NHS App and PRSB is actively promoting widespread use of the About Me standard to enhance personalised care. Our #CareAboutMe campaign is supporting people, professionals and suppliers to adopt its use and we would like to see it taken up by the NHS App.

I am also pleased to see that the role of system-wide levers and incentives is recognised as critical to driving transformation. Getting everyone to do the basics well, like sharing structured, coded transfers of care using PRSB standards, may seem pedestrian but from a safety and quality perspective, this would be game changing.

Regulation by NHS England and the Care Quality Commission are rightly identified as key to signalling that digitisation is a must and certain standards are non-negotiable. If we are to realise the potential of digital transformation, embedding it in the regulatory framework is fundamental. There has long been consensus that it is desirable and we would plead that it is given the priority it requires to see it through this time as one of the most potentially impactful changes in the journey to standardisation.

PRSB welcomes the funding announcements in the plan, but social care remains the poor relation to health care when it comes to finance. The reality is that there is no integrated care without social care. If we are to achieve genuine integration within Integrated Care Systems, we need to address the digital challenges in social care with as much rigour as those in the NHS.

Read more news
Read more blogs

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.