Integrated Care Systems (ICSs) and a Single Care Plan

Contents

• Information Governance (IG)
• The standard clinical information model
• Strategy Landscape
• ICS Strategies – Staffordshire and Shropshire
• Primary Care Networks
• The Single Care Plan – One Health and Care
• The Single Care Plan – NHS App
• Population Health
• Leadership and system working
• Boundary working, national strategies
• MPFT internal developments
• MPFT Care Portal
• Integration
• Our Integrated Care Systems and Single Care plan schemes will focus on
• Transformation Plan headlines
• Measures for success

Integrated Care Systems (ICSs) are the future of health and care integration in England. ICSs bring together NHS, local authority and third sector bodies to take on responsibility for the resources and health and care of an area and this is commonly referred to as a 'system'.

The aim of ICSs is to deliver better, more integrated care for citizens and they are legal entities as of April 2022.  We anticipate that in the initial transformation to ICSs and ongoing transition to normal ways of working for the new Integrated Care Boards (ICBs), a great deal of digital transformation will be required.

We have been a long-term active participant of the digital transformation agendas of wider ICSs nationwide. We have been embedded in two primary Sustainability and Transformation Partnerships (STPs) within Staffordshire and Shropshire, from which the ICSs were formed.

The ICS ambition is to give real meaning and purpose to the regional partnerships that previously identified as STPs.

ICSs will ensure collaboration between providers, commissioners and local authorities and will change the way in which budget is allocated, prioritised and spent in the interests of local community priorities.

The NHS Long Term Plan ambitions remain, supplemented by the priorities and guidance set in the NHS England document entitled “Integrating care: Next steps to building strong and effective integrated care systems across England” (Improvement, 2020). This reinforces the need for ICSs to:

• build smart digital and data foundations
• connect health and care services
• use digital and data to transform care
• put the citizen at the centre of their care

Through partnership working, we will transform the way care is delivered to local populations. We will do this through:

• reduction of acute activity
• health promotion for wellbeing and prevention
• delivery of care within community health hubs
• integrated Primary Care Networks (PCN)
• delivery of care at home

These ambitions have two things in common, they will put the citizen at the heart of their own care and they will be achieved through digital and data foundations.

“The use of digital and data to drive system working, connect health and care providers, improve outcomes and put the citizen at the heart of their own care.” - Integrating care, next steps for integrating care systems

The critical challenges in the months and years ahead are organisational:

• How will the ICSs work?
• How will they collaborate to deliver priority transformational changes at both an operational and digital level?
• How will benefits be extracted and maximised across diverse organisations?
• How can we truly connect our multi-disciplinary health and care providers with 3rd sector partners to wrap care around the individual and put them in the centre of their own care?
• How can we ensure our workforce have secure access to the data and systems required to effectively collaborate on integrated care packages and shared care plans?

In addition to the challenges, the opportunities are also more evident than ever before. The achievements from the COVID-19 collaborations have exemplified all organisations' ability to co-operate for the benefits of the localities.

Adopting innovative technologies for the better management of care has been phenomenal and revelatory to all involved throughout the COVID-19 response. There is still far more to do before we can truly declare success in connecting our ICS services together.

“Our IT is currently a barrier when it comes to being able access information between social care and healthcare”
Christine Wheeler, Service lead for Social Care Older People and Physical Disability

MPFT has invested to support the transition to ICS working. Through this strategy we will actively collaborate and align resources to the system-wide digital transformation journey required for our local populations.

We will continue leading by example with our openness, our digital systems interoperability, our network connectivity and our access for regional colleagues and our service users.

Information Governance (IG)

Information governance is central to the development and success of the proposed digital initiatives both locally and across our ICSs.

All partner organisations involved with One Health and Care, which is the Staffordshire, Shropshire and Black Country regions’ Integrated Care Record (ICR), are registered with the Information Commissioner’s Office (ICO). This means that data is processed in accordance with the current data protection legislation and any subsequent revisions.

Fair processing campaigns are conducted to raise awareness and inform population members of the initiatives and their rights to ensure the correct processing and management of personal data.

MPFT’s IG department are central to the digital transformation journey within Staffordshire’s ICS and an active supporter of the Shropshire ICS digital ambitions. The team are leading on the necessary reviews and upkeep of General Data Protection Regulation (GDPR) compliance, Data Sharing Agreements and Information Sharing Agreements between our ICS partners.

All of these processes are fundamental to our citizen’s digital data privacy and security.

The standard clinical information model

As of early 2021, the NHS is progressing a major initiative to support interoperability across the numerous digital systems used in supporting the health and care of the population. It is vitally important that the systems we use are as connected as possible with those of our ICS partners, without compromise on security. Through securely connecting data between our systems we can join together our health and care services and put the citizen at the centre of their health and social care journey.

The strategic ambition for data captured by these numerous systems in use across regions, is for the data to be ‘separated’ or aggregated from the platform. This means we can reduce the reliance on local systems for sharing information securely and improve the way ICSs can collaborate on care securely.

This approach is yet to be defined nationally, yet we anticipate that this will become a major disruptor in the market and is expected to release a significant new wave of activity in the digital landscape.

MPFT will work with our multiple system providers to ensure that our systems, when the time is right, are not outliers in this proposed new approach to securely consolidating and sharing data across ICSs.

Strategy Landscape

The following sections outline the high-level strategies proposed by the ICSs where MPFT operate.

The major digital transformation programmes intended to support the ICS strategies are assured in our prioritisation of resources and investment through strategically aligned initiatives. This is enabled through creation, co-design and sharing of our digital strategy with our ICS partners.

ICS Strategies – Staffordshire and Shropshire

The Digital strategy for the Staffordshire ICS outlines six key areas and associated programmes of focus:

• Empowered Patients
• Digitised Care
• Population Health
• Infrastructure & Service
• Capability & Innovation
• Invisible Boundaries

The details on delivery of these items are emerging.  MPFT are aligned and engaged with the strategic, operational and technological objectives.

In the short-term, there is a particular focus on the 'One Health and Care' system rollout that is creating a single location of view-only, clinically valuable, and patient-centric information.

“The One Health and Care Record is wonderful, really exciting. The admin team send emails requesting medical histories to GPs. This will help for referrals where it isn’t always complete, being able to triage using the ICR.”
Lindsay Cary, Clinical Lead Dietitian, Advanced Adult Weight Management & Diabetes Dietitian, Specialist Adult Dietetic Service

The Shropshire ICS digital ambitions include short term plans to provide an Integrated Care Record (ICR) for Shropshire using the same One Health and Care system used within Staffordshire.  The plan is for this to be extended to connect datasets across boundaries between Staffordshire and Shropshire for all ICS providers to utilise in the delivery of care.

MPFT’s own digital strategy aligns to the digital vision for Staffordshire which provides a clear digital transformation focus on:

• connected systems
• unified infrastructure
• simplified access
• digital upskilling
• empowering service users
• leveraging the power of our data
• Informing health inequalities and population health needs

Through ensuring full alignment between MPFT, regional and national ambitions, our digital transformation journey is assured to complement and deliver the ICS ambitions within the areas of our direct control.

Primary Care Networks

From 1 July 2019, all patients in England are covered by a Primary Care Network (PCN). PCNs are made up from groups of neighbouring general practices within a designated region. This means that GPs within a locality are encouraged to work collectively in the interests of patient needs.

The new GP contract is designed to deliver commitments made in “The NHS Long-Term Plan” (England, 2019) and PCNs have responsibility for delivering seven national service specifications:

• structured medicines review and optimisation
• enhanced health in care homes
• anticipatory care
• personalised care
• supporting early cancer diagnosis
• cardiovascular disease prevention and diagnosis
• tackling neighbourhood inequalities.

First contact practitioners from MPFT working within primary care settings will support the PCNs and co-operate through access and sharing of information between systems at the point of care.

Through close collaboration with our Clinical Commissioning Groups (CCGs) now and subsequently when they transition to ICSs, we will continue to ensure that MPFT’s services and staff are truly inter-connected with the primary care offers.  This ensures that digital supports this approach for improved access to services and seamless health and care processes for our service users.

“PCNs are all about providing rapid access to healthcare professionals from either GP discussion or care navigator based at the GP practice. Patients can then access specialist and multi-disciplinary teams quickly getting the care they need much more efficiently.”
Wendy Hollands, AHP Professional Lead for Clinical Practice and Dietitian

The Single Care Plan – One Health and Care

Common to both Staffordshire and Shropshire, the One Health and Care record brings data together securely from the different organisations involved in health and social care. It allows doctors, nurses and other registered health or social care professionals to view relevant information and provide better and safer care across the population.

Inside the One Health and Care record is the data and tools to allow co-ordination and collaboration for care activities. Care plans will increasingly exist in a digital format and be accessible to all registered professionals supporting the individual’s care.

As ICS and PCN working becomes more defined, the new processes established will need to be supported by digital. The practicalities of how these needs will be achieved will be defined and matured over the course of this strategy.

Our First Contact Practitioners within PCNs need to be able to update both the MPFT Rio record and the GP record. Currently, this means access, training, support and updating of two different clinical systems, which will ultimately feed the same care plan and the same centralised One Health and Care record.

“Advice and guidance notes need to be streamlined to reduce duplicate data entry between systems.”
Dr. Shouma Dutta, Consultant Rheumatologist, Clinical Lead for Rheumatology

There is clearly an opportunity to streamline these working processes and the means by which each provider is commissioned.

The way reporting is requested will also be fundamental in ensuring that trust is in place to reduce reliance on data needing to be present “locally” for each Trust for activity purposes.

"The Patient record needs to follow the patient. We do a lot of duplicating and asking the same patient the same questions"
Amanda Spooner, Operational Manager Community Nursing, Newcastle and Moorlands

We also know from our discussions that the level of detail within our centralised ICR needs to be further improved.

Contacts, appointments, alerts, blood results, images and medicines are very useful and already offering benefits. However, our PCN colleagues have advised that we need to be able to see richer information including mental health and community progress note details.

Our MPFT services have expressed the need to be able to see PCN diagnosis and GP consultation notes to aid their decision making and person-centred care.

“The community nurses were calling GPs and Acute Hospitals daily, but we’re now able to see more information in the Integrated Care Record”
Angela Starkey, District Nurse, Moorlands Rural District Nursing

As part of an initial priority within community mental health, we are planning more digital transformation work with our 3rd sector organisations to allow them secure and audited access to the One Health and Care solution.

The Information Governance (IG) and digital teams are collaborating to ensure appropriate governance and security which will result in some changes to working practice.  

The benefits to this approach will be significant, with care homes, nursing homes, local charities and support groups all able to co-design, collaborate and support a centralised package of care, personalised to individual need.

The amalgamation of data is the very first step on that transformation journey.

“The one health and care record is a game changer for safeguarding and we’ve been waiting decades for this level of functionality”
Sharon Conlon, Head of Strategic Safeguarding, Nursing

Our continued adoption of the ICR also needs to be continually evaluated.

Through continued collaboration with our services and our partners across the ICS we will ensure that the right level of data, the right functionality and the benefits linked with its use are routinely captured and shared.

We have found that the ICR in its current state, whilst in its infancy has needed greater communications and awareness for our staff around the art of the possible and how and when it should be used.

We will continue working with our MPFT care groups to train and advise our staff to ensure continued use and benefits realisation through improved access to information for direct delivery of care.

The Single Care Plan – NHS App

There is an urgent need for service users to be able to access their own care plans directly, to manage their appointments more effectively and be more informed in their care pathways. This is covered in further detail within the Choice and Access theme. A key way of achieving this is through the use of the NHS App. This allows a service user to securely view their health and care record from their own personal device.

Over the coming years we will continue working as a ‘system’ to manage our suppliers in the delivery of key digital systems’ functionality to enable true empowerment of our service users through access and updates of their care record.

We aim to achieve this through use of the NHS App and ensuring that our selected ICR partner gains full accreditation to securely integrate the data within our regional ICRs with the nationally supported NHS App.

Population Health

Population health data will help us to understand, at a regional and national level, where our priorities to improve health and care are. Over the course of our increasing ICR maturity, our plans are to utilise the ever-increasing aggregation of local health and care data to serve our population health needs.

The solution is already capturing basic health and care activity data, conditions and outcomes and this information is essential to inform population health needs and priorities across our ICSs.

Working in collaboration with our colleagues and our ICR strategic supplier partnerships, we will look to ensure that the ICSs can make informed, data-informed decisions.  Decisions will include where to prioritise funding, resources and future digital innovation needs. These decisions will be based upon what we know today, and what we may need in the future.

Leadership and system working

Leadership will be a key success factor as we co-ordinate across different organisations that contain differing cultures, challenges and operational arrangements.

Relationships will need continued development and nurturing while retaining focus on the citizen at the centre of all our ambitions and the corresponding delivery of service enhancements.

Aligning the core competencies of each organisation and understanding the skills available at a regional level will enable greater opportunities. We will ensure we will not work in silos, tackling common problems and innovation together with the right knowledge rather than working individually.

"Authentic and honest leadership is important, we need digital leaders without the spin"
Carolyn Gavin, Clinical Care Director, Specialist Services

The ICS presents an opportunity to fundamentally shift the behaviours of our leaders across the health and social care sectors nationwide. Through alignment of strategies, pooling of resources and delivery against a common set of shared ambitions, we can ensure that our regional digital leaders act as an effective team.

“Focus on a shared purpose”
Matthew Gould, Chief Executive Officer, NHSx

Boundary working, national strategies

MPFT has many services that have patients visiting health and care providers that are not within our immediate ICSs.

The availability of care data for those citizens outside of MPFT’s services is already  difficult for many MPFT teams within an ICS boundary, yet this is further compounded through cross boundary activity.

In discussion with MPFT services that operate in the South East of Staffordshire, we are caring for service users that could be visiting anywhere up to seven different hospitals and have registered GPs within up to four different ICSs.

While progress has been made through use of the ICR within each ICS to ensure we no longer operate within provider trust silos; we need to be able to join this information together across multiple ICS boundaries for our service users and staff.

“In Community Intervention Services in Burton, Lichfield and Tamworth we cover Burton Hospital, Good Hope Hospital, New Cross Wolverhampton Hospital, Walsall Hospital, Cannock Hospital, Stafford Hospital and occasionally Stoke Hospital. These hospitals all use different systems and we don't have access to the information from the acutes without phone calls and emails. Getting the information in a single place would make a huge difference. We need results in integrated care records that cover all local hospitals."
Vicky Mee, Community Matron, Community Integrated Services, Lichfield and Burntwood

The development of Local Health and Care Records (LHCRs) across ICS boundaries will ensure that the right information is available by the right health and care professional at the right time, no matter which provider offered care last or which GP practice they are registered to.

An example is the need for MPFT to work closely with our colleagues in University Hospital Derby and Burton and Royal Wolverhampton Trust.  There is a requirement for MPFT staff to have secure access to x-ray images, blood results and other diagnostic reporting from our local acute hospitals.  

We plan to collaborate closely with the Black Country and West Birmingham ICS to ensure that when ICR plans are formed for their region, the needs of our communities are taken into account.  This will ensure that access to vital primary care and acute data from these boundary areas is maintained.

Further afield, we will work with our ICS partners across other areas of our service provision, ensuring that, for instance, our Substance Misuse Services in Buckinghamshire, have seamless, digitally enabled results reporting available from Stoke Mandeville Hospital.

This is just one example where our Trust, regardless of its geography, will establish agreements and service level arrangements to ensure we can routinely and reliably access the services we need from our health and social care colleagues, regardless of the localities from which they may be based.

MPFT internal developments

MPFT is growing and enhancing its internal digital maturity through a broad array of programmes that will enable more comprehensive integrated working in the years ahead.

An example of this type of programme is the integration of our main clinical system, RiO, with the ICR. This integration has been developed to collect, consolidate and display shared health population information in a web-browser or mobile application.

Staffordshire CCG commissioned the ICR and MPFT is one of the partner organisations who have agreed to share data to benefit the population of Staffordshire and Stoke-on-Trent.

We are working with our partners and suppliers to ensure that the appropriate information sharing agreements and security is maintained and continually reviewed to facilitate cross organisational sharing of information.

The ICR is currently in development and is an ongoing project. Once fully populated with data from all clinical Electronic Health Records (EHRs) throughout the region, it will provide a single view of the patient record across the whole system.

Despite the relatively short time the One Health and Care record has been available to staff, the feedback has been extremely positive. The ICR is working well for our users and has provided an enhanced patient record. This has saved time for our clinicians who, in the past, would have phoned other care providers for information.

MPFT merged two separate instances of the RIO EHR in 2018.  The community and mental health systems are now residing in a single primary EHR which has been in use across the organisation since November 2020. Whilst there is still another 30+ key systems in use, the merger of the Rio systems was fundamental to ensuring the continued sharing of information to our regional colleagues through the ICR, while also providing immediate benefits to our staff across MPFT.

Over the next few years, the MPFT Digital function will focus on maturing our primary EHR solution to improve its effectiveness and workflow processes, described in more detail within the Workflow, Processes and Paperless Operations theme.

“Seeing updates from psychologists and mental health teams within a consolidated RiO record has been very useful for Community Intervention Services, it enables us to see wider than just physical health concerns” - Vicky Mee, Community Matron, Community Integrated Services, Lichfield and Burntwood

To assure the quality of the data being shared with our ICS, MPFT has a strategy for each of our clinical and care systems, this includes collating and sharing of information. Where security allows, we will make sure that our data is available for partnership working, our service users and any voluntary arrangements where there will be a benefit.

MPFT Care Portal

Alongside the ICR, the MPFT Digital Application Development Team have developed a locally developed bespoke MPFT Care Portal. The MPFT Care Portal works in a similar way to the ICR in that it provides a single lookup for MPFT patient data. 

The MPFT Care Portal has additional benefits over the ICR currently as it is available for teams who work in remote locations or do not have access to the ICR platform through core systems.

This is especially useful for colleagues working in prisons through our Health in Justice services and who are unable to access systems via the health and social care network (HSCN).  

The MPFT Care Portal will continue to be developed and maintained. It will introduce data sets from the Trust’s other key systems such as psychological therapy services data, diabetic retinopathy data and dental data. Sexual health data will be excluded from the MPFT Care Portal due to the confidential nature of the records that the service holds.

The sharing of this information into the local MPFT Care Portal will accelerate our ambitions for a single care plan for MPFT services, whilst we work in partnership across our ICSs on the maturing data sets available within the ICR.

The local MPFT Care Portal also serves as a business continuity platform which is available to colleagues when core systems may become unavailable, or critical systems fail.

Integration

The MPFT Digital team actively procure systems that have open Application Programming Interface (API) and interoperability standards. Our bespoke development team’s integration leads are working with suppliers to enable the sharing of data between systems. This integration will reduce the duplication of data entry and the burden on staff.

Integration will not only provide us with faster flow of data between systems and improved digital transfers of care, but also enable us to fully utilise the initiatives that we already have in place.  For example, eReferrals (eRS) for digitised referral processes, Deprivation of Liberty Safeguards (DOLS)/Liberty Protection Safeguards (LPS), DocMan Hub for digital correspondence with GPs and digital sharing of care plans and crisis plans with ambulatory services via the National Record Locator Services (NRLS).  

Over the next five years the Application Development team will be developing more API based bespoke developments.  This will not only enable links to commercial platforms that offer APIs, but also offer open APIs from our own bespoke developments. 

Through this approach, will safely connect our systems together to provide seamless care for service users and improved workflows and availability of information for our staff.

“With us all merged on to one system it has been so much more efficient, with us all on one it has been a massive advantage to see access to the mental health and seeing updates particularly with dementia colleagues. For example, seeing an update from a dementia colleague on the same system and then using Teams to network with those other MPFT services is a massive advantage.”
Gillian Findlay, Occupational Therapy, Falls Service South Staffordshire

Measures for success