1. Sharing information to improve patient care in Sussex Adrian Woolley Head of Strategic IT NHS Coastal West Sussex CCG NHS Crawley CCG NHS Horsham & Mid-Sussex CCG November 2014

2. Sharing information between care settings Photo: sparkle glowplug particularly for use in unscheduled care

3. Reactive, not predictive services: failure to identify vulnerable people who might then be given extra help to avoid hospital admission or deterioration / complications of their condition… Fragmented care: the healthcare system…not being considered in a whole system approach with social care… Lack of informational continuity: care records which can’t be accessed between settings... NHS England. Everyone Counts: Planning for patients 2014/5- 2018/9 NHS England describe the barriers to great care for people with long term conditions:

5. The phone…how we traditionally share information between health and social care

6. Somebody’s handbag…where to find latest home visit assessment

7. Serious case reviews – ‘familiar failings’ Poor communication between and within agencies "Professional over optimism" A lack of "professional curiosity" in questioning information A lack of confidence among professionals in challenging parents and other professionals A lack of analysis of information Shortcomings in recording systems

8. Significant diagnosis DNACPR Social Services visit daily ECG Diabetes clinic In-patient discharge letter Specialist nurse record Care providers can have ‘silos’ of information held within their organisational boundaries Dementia nursing GP practice system Social Services Hospitals Community Nursing Mental Health Admission Avoidance DES Care Plan MH Crisis Plan Contingency Care Plan

9. Significant diagnosis DNACPR Social Services visit daily ECG Diabetes clinic In-patient discharge letter Specialist nurse record Care providers can have ‘silos’ of information held within their organisational boundaries Dementia nursing GP practice system Social Services Hospitals Community Nursing Mental Health Admission Avoidance DES Care Plan MH Crisis Plan Contingency Care Plan

10. A real time Read Only viewer for use in direct patient Care, with Information derived from both Health and Social Care ROCI

11. A Virtual Integrated Digital Care Record Live data (no data warehouse) Live data (no overnight updates) Consent to view at point of need

12. Real time messaging to multiple systems – ‘send pertinent information for unscheduled care’ GP Social Services NHS No, Name, DoB Community Nursing Mental Health Integration Engine and VIPER360 portal Hospital Consent record for audit RBAC

13. a patient summary problems diagnoses medication (current, past and issues) risk and warnings procedures investigations blood pressure measurements encounters, admissions and referrals patient demographics What data could be available? From GP (via MIG): current meds allergies adverse reactions From SCR: Main Address Current Address Placement Address Allocated Worker, Open/Closed Agency Providing Care Package Funded? Emergency Next of Kin details Does the Subject Have a Carer? Is the Subject a Carer? From Social Services: recent admissions & discharges EDD From Acute Trusts : open referrals From Community Trust LC anticipatory care plans From care plan repository: Mental health crisis plan From Mental Health:

14. Patient details Examinations Events Summary Investigations Problems Procedures Risks & warnings Live data from the GP clinical system

15. Recent tests Biochemistry ECG Haematology Imaging Microbiology Cytology Others Physiology Urinalysis Potentially useful in admission avoidance

16. Mrs W is a 91 y.o. woman who has dementia. She lives with her family but they are normally out during the working day. Mrs W is quite deaf. She has a leaky heart valve and AF, she has oedema in legs; she has been reviewed by a cardiology consultant. She is diabetic. Mrs W presses her emergency button when she feels a bit breathless and wants a hand getting out of her chair. An ambulance is dispatched. Scenario 1 Ambulance crew have no background data but find a confused patient unable to remember what medication she is on. They undertake ECG and find it abnormal, they decide to convey her to A&E. Mrs W waits on a trolley in A&E, confused and a bit frightened. A&E have no background data on patient. 4 hour target looming. Decide to admit to MAU for blood tests and ECG Scenario 2 Ambulance crew access anticipatory care plan and are reassured that her condition is not acute. They decide not to convey but advise the district nurse. Scenario 3 Ambulance crew do convey, however A&E access the ROCI system to understand the medical history and admission to hospital is avoided. Case study

17. Admission Avoidance People, especially the frail elderly, can find hospital admission a frightening experience and would rather be treated in their own homes. Avoiding tests and medication If unscheduled care has access to primary care and social care information then this information can sometimes avoid repeating test or medication that have already been prescribed. As well as a cost saving, it avoids subjecting patients to test or medication that does not benefit their care. Qualitative benefits

18. Information Sharing Agreement finalised Trust Interface Engine (messaging technology) installed and operational. Pull of MIG data through system tested and working. 30 day pilot run in hospital A&E; data from 8 local GP practices. Social Services record to include NHS numbers; monthly batch tracing to start. To Include social services, mental health and anticipatory care plans in next few weeks. ROCI: Where have we got to?

19. Better Care: Proactive Care Primary / secondary care interface: One Team Duty social worker Hospital in-reach Discharge planning / Alerting Planned Care Potential applications of ROCI

20. ROCI is supported by the 7 CCGs across both West and East Sussex Population 1.6 million (Population 159,311 in 1801)

21. Thank you adrian.woolley@nhs.net Photo: garryknight

22. The classics – stakeholder engagement etc x n 2. Information Governance, legal opinion Data access. Paternalism Commercial self interest of system suppliers Finding care plans Waiting to test against Spine 2 Challenges for this type of project

23. GP Admission Avoidance DES care plans Proactive Care EoLC Plans NHS mail – special template AmbulanceA&E (ROCI) OOH GPs Sussex wide care plan database Data readers Data sources One place to find care plans = reduced conveyance by ambulance.