Joining up healthcare services and integrating with social care is now a major focus for national policy; but the IT architecture and the systems needed to do it are still being developed.

Fiona Barr hears about the growing sophistication of information and record sharing models, and about some of the different systems that are being put through their paces by vanguards and pioneers.

The desire to deliver integrated care has been around for a long time. In 2016, however, the pace of change is accelerating as it becomes a focus for national policy.

And while integrated care is far more than an IT system, record sharing capability is an essential component. Choosing the right model may not be easy, however, when it can sometimes feel as if everybody claims to have the answer – and all the answers are subtly different.

Markus Bolton, joint chief executive of Graphnet, says: “I was speaking to an organisation that put out a tender on record sharing recently and they had more than 30 responses.”

The advice from healthcare IT supplier TPP is to keep it simple. Dr John Parry, TPP’s clinical director, says: “There is a great danger in sitting down and writing a specification which is 35 pages long.

“Unless organisations start to dip their toe in the water in a simple and straightforward way then I think they are going to get left behind.”

From nowhere, to everywhere, fast

Bolton estimates that only 15% of England currently has what he describes as shared healthcare records, covering primary, community and secondary care. He predicts that will rise substantially by 2020.

“In three or four years time most people will have taken on shared records. Some will succeed and some will fail; but it is certainly a very immature market at the moment.”

Dr Shaun O’Hanlon, EMIS Group’s chief medical officer, says the NHS wants systems that will allow a patient to have a journey across multiple care environments, with most interest currently focused on urgent care and long term conditions management.

“I’ve seen more appetite for this in the last year than at any time since I’ve been involved in the industry” he says.

Policy drives change

Part of this is stimulated by the government’s new models of care programme outlined in its ‘Five Year Forward View’ in 2014. That outlined two models for re-organising healthcare systems, Multispecialty Community Providers (MCPs) and Primary and Acute Care Systems (PACS).

Broadly, one builds out from GP practice while the other builds out from hospital, but both aim to provide integrated services, with a probable end goal of being funded on a capitation or list basis. Both are being tested by a vanguard scheme.

MCPs are to consist of groups of practices covering a minimum list size of 30,000. The government wants MCPs to deliver the majority of outpatient consultations, potentially run community hospitals and have admitting rights to hospitals.

The MCP vanguards are tackling this in different ways. Lakeside Health in Northamptonshire is one of the largest ‘super-practices’ in the NHS with more than 100,000 patients.

It is using TPP’s SystmOne to support its service redesign which includes an urgent care model, an ambulatory care service to divert care from the hospital front door, a long term condition management service for the frail elderly and a GP-led complex care management service.

Devolution plays a part

Other agendas are also in play. Manchester has made waves as the first city to win ‘devolution’ for its health services, with the council in the lead.

The city is using an integrated care record for ‘at risk’ patients using Graphnet’s CareCentric. The system brings together information from practices, social services departments and hospitals into a single record and care planning application.

Bolton says: “It’s about managing patient care through a shared record that is doing something more than just looking up data – like who the social worker is.”

Bolton says the Manchester deployment is a level two shared care record on Graphnet’s four level solution maturity model. A level two system involves community-wide integration of care planning, support and management.

GPs in Manchester can access the integrated care record from within EMIS Web and the hope that it will enable better management of long term conditions, crisis management and the discharge process.

From sharing to planning

David Hancock, client engagement director for InterSystems, also sees care planning as the next step on the road to integration.

InterSystems’ Coordinate My Care is an example of this. It enables patients to set out their end of life care plans with a ‘care co-ordinator’ – usually their GP.

This information is then available to all relevant organisations, such as out-of-hours services and emergency departments. The software went live in London in November and so far has 7,500 plans uploaded.

“We are moving towards a focus of being able to tailor healthcare more to what the patients want which is at the heart of ‘Personalised Care 2020’ [the current NHS IT strategy, published towards the end of 2014, and following the Five Year Forward View],” Hancock adds.

The impact of population health management

Integration with secondary and social care is likely to prove most challenging , according to O’Hanlon. He says: “The transactional model in acute trusts with Payment by Results is getting in the way of that integration. To survive as a secondary care trust you need to have turnover.”

O’Hanlon says moving to a risk-based capitation model in the acute sector would support greater integration but argues that the data is not yet there to do that safely.

Under the Graphnet model a level four system is associated with population health management. Health and social care organisations in the Wirral are a vanguard for the PACS model of care and are taking on this population health challenge.

The PACS model aims to see hospital and GP care ‘vertically ’integrated and potentially take responsibility for the whole health care budget for a list of patients. This would resemble the accountable care organisations in the US – and the Wirral project is working with American ACO Advocate Physician Partners.

Wirral is using Cerner’s ‘population health’ technology which pulls information from health and social care organisations and combines it with risk stratification to focus interventions and improve health of the local population.

Dr Justin Whatling, vice president of Population Health for Cerner, says prevention and outcomes-based contracts are the future. He says: “You can’t just focus on the sick people with lots of long term condition because there is also the next tsunami of people who will get there if you let them.”

Cerner hopes Wirral will be an exemplar for this in the UK, following on from the US where the population health platform is now used by 70 clients covering 55 million patients.

Get IT in the five year plan

Making sure the patient, and their self-collected data, is a key player in an integrated care approach is another challenge according to Whatling. He says information collected through personal monitoring devices is disconnected from the mainstay of NHS IT and wants to see standards introduced for interface with the patient record.

Over-arching all of this are continuing debates about information governance. Dr Parry is concerned about communities spending an enormous amount of time and money developing different data sharing arrangements and says clarity is needed.

He adds: “Fiona Caldicott [the NHS national data guardian] is going to report again soon and I hope she comes up with clear standards and approaches hat make this thing much easier.”

While the NHS waits for that guidance Whatling flags up the importance of the ‘Sustainability and Transformation Plans’ that were outlined in NHS planning guidance just before Christmas.

All health and social care organisations must write these plans by June and they will be the single way to get transformation funding from 2017-18.

This suggests that aligning new service models with bids for the IT to underpin them is going to become imperative. With January already almost over, it looks like those working on integration have a busy year ahead.