In an organisation as far-reaching and wide-ranging as the NHS, complete digital transformation has remained a challenge for the past decade. With so many people now using a multitude of different services to meet their needs, cohesive and connected information sharing has never been more important. But it’s not easy to achieve.Â
A new report by the National Audit Office, which was completed before the start of the COVID-19 crisis, has analysed the current state of digital readiness in the health system, highlighting some of the key challenges. It stressed that while progress has been made in some areas, there is still a considerable way to go before we achieve a truly digitised landscape. In addition to many trusts not having up to date technology, healthcare data is extremely complex and there are many governance and privacy issues to consider.
Interoperability, the seamless sharing of information between systems, has also been flagged as one of the most important cornerstones of the digitisation process.Â
We fully back the report’s recommendations that standards for information sharing must be set and adhered to by national bodies, and that coded structures for digital patient records will be an integral part of this. PRSB has already developed a number of standards that can support trusts in recording the information they need to deliver better and safer care. The next stage is to encourage wide-spread implementation and we will fully support all efforts to make this a reality. As well supporting professionals with adoption through our support services, we’re also developing online tools and guidance to help ensure that everyone can use standards- even those at the early stages of digital development. By acclimatising themselves to standardised data sharing, it will make it easier to put the information sharing into practice when systems are revamped.Â
Another key challenge that was identified as a barrier for all types of digitisation was professional buy-in and involvement. In 2011 the National Programme for IT (the Programme) was stopped early and didn’t deliver ket benefits. According to the report, this was partly due to the lack of clinical and stakeholder involvement in the IT development process. At PRSB we are extremely aware that digitisation can only be effective if frontline professionals are onboard and engaged. That’s why all of our standards for digital information sharing in healthcare are developed with the people who will actually be using them- which includes doctors, nurses, patients, carers and many others. This was also reflected in the findings from The Doctors Download consultation in late 2019, where we worked with The Academy of Medical Royal Colleges to interview 420 practising doctors. As well as fixing the basics of technology in health and care environments, they pointed out that clinicians should play a key role in shaping digital transformation. They also expressed concerns that too many different technology solutions were a barrier to improving care. Moving forward it will be important to reduce day-to-day friction in the use of technology to support healthcare service delivery, which means working collaboratively.Â
In some places we are seeing improved pockets of interoperability where our standards are being used. For example, trusts who have implemented our e-discharge summary standard have reported greater efficiency within their teams. Sharing of information digitally has also reduced errors, leading to safer practices for both professionals and patients. Meanwhile the impact of COVID-19 has demonstrated how technology solutions can be fast-tracked and adopted when people are less risk averse. In some areas of practice, virtual consultations are transforming the working lives of clinicians and proving more convenient and accessible for the people who use them. Learning from the positive outcomes of the COVID-19 crisis will be important so that we don’t lose momentum.Â
At PRSB we’re already starting to see the difference that standards can make to clinical and patient outcomes. We’ll continue this mission of not only developing standards, but also encouraging implementation, cultural change and championing the success stories.Â
For more information on our standards and how you can get involved, contact us on info@theprsb.org
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.Â
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.Â
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.
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.
