Why don’t we offer everyone the opportunity of using email for all communications with their care provider? You can access email from almost anywhere, a letter you can only access at the address to which it was posted. And email is a lot cheaper! The NHS in England would save over £125 million per year for outpatients alone.
Our recent workshop on standards for outpatient letters got me thinking about this issue and how we address it. Given the current financial challenges in health and care can we really justify wasting money on posting letters when emails are fast, cheaper and reach virtually everyone, even older adults?
88% of adults have used the internet recently. That includes virtually everyone between the age of 16 and 44, dropping to 74% of 65-74 yr olds and 39% of the over 75’s. Use by the over 75’s has more than doubled in the last 5 years. My father in law is constantly on the internet for research, youtube, iplayer, email and even has his own blog (with only a bit of assistance) – he is 86.
There were over 113 million outpatient appointment and 89 million outpatient attendances in England in the year to March 2016. 18% of these attendances were by people aged 75 and over. If half of the outpatient appointments involved posting just one letter before each appointment and one third with posting a letter after each attendance (eg to GPs or patients), that would be a total of 84 million letters. Sending letters by post costs the NHS approximately £2 per letter while an e-mail costs approximately 0.5p. If 75% of the posted outpatient letters were sent by e-mail, that alone would generate a saving of nearly £125 million.
There are many fears and anxieties about using email for sensitive information. Many people worry about data security and information governance; care professionals worry about increased workload and the legal status of emails. In 2014/15 the PRSB carried out a project to coincide with the launch of the new NHS Secure Email Standard. Extensive literature search, workshops and survey consultations found no reports of evidence of harm to individuals as a consequence of the use of email and no evidence to show that doctors’ work load was increased
The project published guidance for the public and care professionals on safe effective emailing in health and social care that addresses much of the confusion about email. Specifically it describes what is secure and what is not secure, and how the standard for secure email will greatly help in email communication between all public services. It also includes guidelines for care professionals and patients, so they can use email safely and with confidence. The information standard is in the process of being updated by NHS Digital. PRSB clinical and professional members had the opportunity to feed back to the review in order to ensure the updated standard reflects current practice.
There is no excuse for not offering every patient and care recipient the opportunity to communicate using email. And most importantly, the money saved could be better spent on care and treatment.
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.
