PRSB welcomes the government response to the Paterson Inquiry

By Professor Maureen Baker CBE

Openness is critical for safe healthcare and all consultants should be writing directly to you to ensure that you have the right information to make informed decisions about your health, treatment options and care. This is one of the recommendations made by the Paterson Inquiry, accepted by the government today, for improving practice and preventing medical malpractice.

In 2017, former surgeon, Ian Paterson, was sentenced to 20 years in jail for ‘wounding with intent’ hundreds of women by performing unsafe and often unnecessary operations for breast cancer.  In some cases, women were subjected to surgery even though they did not have breast cancer. The inquiry analysed not only how his actions were allowed to happen but how they were able to continue for so long and it became clear that organisations weren’t sharing information which may have raised questions about his work.

The Inquiry recommendations call for a culture shift in the NHS and independent sector, recommending that all consultants write to people, outlining their condition and treatment plan, in simple language, and copy this letter to the person’s GP, rather than writing to the GP and sending a copy to the person, as is common practice now. 

PRSB’s CEO, Lorraine Foley, have been advising the Inquiry since 2018 and have specifically stressed the importance of writing directly to people, a practice we have long been advocating. In 2018, AoMRC published its ‘Please, write to me’ guidance, which supports consultants in writing directly to you in language that is commonly understandable to non-clinicians, and then copy this letter to your GP. The PRSB fully supported this guidance and all PRSB standards, in particular the outpatient letter information standard, emphasises the importance of writing to people in a person-centred way.

Writing directly to you doesn’t change the content of the information in your care records, it will just ensure that the information is written in plain English. By doing this and then copying the letter to your GP, your care records will contain all the detail necessary for your GP to administer high quality care but the information will be transparent and clear, ensuring that you have greater understanding and control over your health and care information and can ask questions and spot issues before problems occur.

Writing directly to people is a practical way of meeting the NHS’s goals of personalising care and making you active participants in your own care. As a doctor, I am reaffirming my commitment to this practice and calling on all fellow doctors to drive this culture shift within the profession towards making writing to people the norm. PRSB recommends the full implementation of the Paterson Inquiry recommendations accepted by the government today, for safer care and better patient outcomes.

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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.