Special Report: Integrated Care

The way in which patients move across the NHS is changing with people often having to move across regions in order to access care, placing greater emphasis on the need to have seamless care. Jennifer Trueland investigates whether national programmes and the coronavirus pandemic have changed attitudes towards integrated care.

When NHSX chief, Matthew Gould, said that shared care records should be in place across England by September 2021, he admitted that this was a tough ask. Speaking to MPs on the Public Accounts Committee in September 2020, he said that reaching the point where data could flow between care settings was a “stretching target, but we will do our best to give systems the support they need to reach that”.

It’s hard not to be cynical when looking at any targets related to joining up health and social care, especially if they relate to the ability to share information digitally.

Yet it would be unfair to suggest that there has been little or no progress in reaching the goal of integrated care, where NHS organisations and local authorities in England join forces to co-ordinate services around the needs of individuals – while at the same time gathering data vital to understanding population health needs.

Greater awareness

So are these national programmes having an impact on attitudes and awareness of the benefits of integrated care?

Ben Wilson, INTEROPen board member and product specialist lead with Orion Health, believes there is, and the Covid-19 pandemic has served to make the case stronger.

He points to Wessex, a LHCRE site, where the Dorset Care Record has been gathering traction throughout the pandemic and has also adapted to work with the way that patients actually travel through the health and care system.

According to Wilson, between 30-40% of patients admitted to Yeovil Hospital cross the boundary from Dorset to Somerset. This can create difficulties for clinicians when it came to accessing medical records.

“The clinicians at the hospital didn’t have access to the shared care record so they were quite blind in terms of how they were treating the patient because they couldn’t see the GP summary which meant they couldn’t see the patient’s history,” Wilson says.

“So, one of the things that Dorset did was give access to the professionals working in the hospital to the Dorset care record so that patients could be treated more effectively.”

One key lesson from the Dorset Care Record has been to make it as easy as possible for users, Wilson says.

“Clinicians understand the benefits now of shared care records, which I don’t think they necessarily saw a few years ago,” he adds.

“One of the things we found really important was for clinicians to access the shared care record frictionlessly. By that I mean, not to introduce a new system, where they have to log into it separately and learn how to use it.

“It has to be made really simple to use and intuitive so that they can access it in the context of the patient they are looking at in the system they use on a day-to-day basis.”

Turning vision into reality

So with the vision of joining up regions laid out in the LHCRE programme, how do they turn it into a reality?

For James Hodgin, solution director (EMEA) with Allscripts, there is more work to be done still, especially when it comes to population health management.

“We were involved in a number of procurements and generally speaking what was being asked for was the right thing – that was a technological capability to take the data from multiple services, including obviously acute, primary, mental health, social care – and put that in a central repository where that data could then be used for multiple other purposes,” he says.

“I think that sentiment was absolutely right. But what we saw happen, and there were multiple reasons for this, was the people were tending to steer to the names and solutions they already had in place and extend contracts with those providers.

“This fulfilled one of the criteria in terms of harvesting certain amounts of data and presenting that back. But what it didn’t do was take that data and normalise it in such a way that it could be reused for multiple other purposes such as analytics for population health, and to be consumed into other systems so that data can be used as a frontline resource.

“That, for me, is a missed opportunity.”

Changing attitudes

For many areas of life, the events of 2020 have changed people’s attitudes and technology is no exception. Elaine O’Brien, senior health network strategy executive with Cerner, believes that the circumstances of the pandemic have helped changed attitudes towards technology more generally, including the value of shared information.

“People realised that they could work remotely because technology and information was available to allow them to do that,” she says.

“Before [the pandemic] it was there, but they didn’t really have a driver to do that. But the fact that people weren’t allowed to move, made them start to investigate and to look. They pulled themselves as opposed to stuff being pushed on them. There was a change in people’s attitudes that I think has made some great differences, and that in turn has made people more curious about what technology can offer.”

Attitudes to the risks of information sharing are also changing, adds O’Brien.

“The risk of not sharing was greater than the risk of sharing – that was the shift, if you like,” she says.

Matt Cox, managing director of Better UK & Ireland, echoes the argument of shifting attitudes in 2020.

“Probably in the last 12 months, I’ve seen more embracement [of integration],” he says.

“It may be down to Covid; it may be down to the way that systems had to mobilise and make change faster. We have had a lot more conversations this year than in previous years around open platforms for regions and what you can achieve with getting data brought together from lots of settings.”

Discussions about open platform approaches and open architecture that isn’t wedded to a single application or vendor have “exploded” in the last year, he adds.

Still work to be done

Despite good progress being made towards integration, there is still more work to be done and full integration could still take time. However, events such as the Covid-19 pandemic could provide a helpful push.

“I think the tipping point for any change is that there’s a will, and a direction that’s set, so I have to say that with respect to the pandemic crisis, there’s a realisation of the need to integrate, to share information on a national level, but manage the situation on a local level,” says David Eccles, associate partner with Solidsoft Reply.

“In some ways it’s the best case study you could ask for.”

Creating an integrated network

Going back to the national LHCRE programme and the impact it has had, Brian Waters, CEO of Graphnet, believes the programme has created an integrated network of clinical, technical and transformation leadership. He adds that such teams are working across wider regions, tackling cross-border issues to deliver lasting change in a way not seen before.

“These teams are able to leverage common practices, data and applied technology to improve integrated care,” he says.

“The benefits of record sharing are well-established – eg safety, quality of care, and the integration of services around the needs of the patient, regardless of the care setting. However record-sharing across a much wider regional geography such as a LHCRE obviously brings additional benefits.”

These additional benefits, according to Waters, include larger pools of data for analytics and understanding the health of a population, and the fact that larger record-sharing geographies mean an individual’s health and care information is available as they move across borders and between different parts of the health and care system.

Again, Waters also argues that Covid-19 has helped make the case for integrated health systems.

“Even pre-coronavirus, there was widespread understanding about the need for integrating care and workflows around the needs of the patient,” he says.

“The focus on establishing integrated care systems country-wide and evidence of progress in existing ICSs make this clear. However, Covid-19 really has thrown into sharp relief the long-standing structural and funding problems affecting the NHS and social care and the urgent need to integrate the activities of the two.”

In an immediate sense, Covid-19 has provided a real-world demonstration of the value of record sharing data programmes in providing integrated care, Walter adds.

While in a more strategic sense, it has highlighted the importance of data and data-sharing in terms of prevention and improving the health of a whole population.

“We have all now been made much more aware of the potential in a new level of integrated working, involving central and local government, the individual and all parts of the health and care system,” Waters says.

Looking ahead

So what lies in store for integrated care in 2021? You cannot hide from the fact that Covid-19 has changed attitudes towards healthcare and how it is carried out, especially when it comes to digital services.

These changing attitudes couples with national programmes such as the LHCREs show that integrated care is on the agenda but there is still more work to be done.