Urgent Care and the Five Year Forward View Next Steps

A quick post picking out bits from the Five Year Forward View Next Steps paper that are most relevant to urgent care.

NHS England have just released the “Next Steps on the NHS Five Year Forward View“, which is an follow-on from the original “NHS Five Year Forward View” which was published in 2014.

Given my current focus on Urgent & Emergency Care technology, I have pulled out some of the sections I felt most likely to affect my current work, or which are relevant to the Integrated Urgent Care programme so that I can easily refer to them.

EXECUTIVE SUMMARY (Page 4)

“4. That’s why over the next two years the NHS will take practical action to take the strain off A&E. Working closely with community services and councils, hospitals need to be able to free up 2,000-3,000 hospital beds. In addition, patients with less severe conditions will be offered more convenient alternatives, including a network of newly designated Urgent Treatment Centres, GP appointments, and more nurses, doctors and paramedics handling calls to NHS 111. (Chapter Two)”

Chapter Two – URGENT AND EMERGENCY CARE (Page 14)

“Some estimates suggest that between 1.5 and 3 million people who come to A&E each year could have their needs addressed in other parts of the urgent care system. They turn to A&E because it seems like the best or only option.”

What’s been achieved in England over the past three years? (Page 14)

  • Boosted the capacity and capability of NHS 111, which now takes 15 million calls each year, up from 7.5 million three years ago.

Key Deliverables for 2017/18 and 2018/19 (Page 14)

  • Every hospital must have comprehensive front-door clinical streaming by October 2017, so that A&E departments are free to care for the sickest patients, including older people. (Page 15)
  • Enhance NHS 111 by increasing from 22% to 30%+ the proportion of 111 calls receiving clinical assessment by March 2018, so that only patients who genuinely need to attend A&E or use the ambulance service are advised to do this. GP out of hours and 111 services will increasingly be combined. By 2019, NHS 111 will be able to book people into urgent face to face appointments where this is needed. (Page 15)
  • NHS 111 online will start during 2017, allowing people to enter specific symptoms and receive tailored advice on management. (Page 15)
  • Strengthen support to care homes to ensure they have direct access to clinical advice, including appropriate on-site assessment.
  • Roll-out of standardised new ‘Urgent Treatment Centres’ which will open 12 hours a day, seven days a week, integrated with local urgent care services. They offer patients who do not need hospital accident and emergency care, treatment by clinicians with access to diagnostic facilities that will usually include an X-ray machine. We anticipate around 150 designated UTCs, offering appointments that are bookable through 111 as well as GP referral, will be treating patients by Spring 2018.

Chapter Ten – HARNESSING TECHNOLOGY AND INNOVATION (Page 64)

Specifically, during the coming two years we will implement solutions that:

  • Make it easier for patients to access urgent care on line.
  • Enable 111 to resolve more problems for patients without telling them to go to A&E or their GP.
  • Simplify and improve the online appointment booking process for hospitals.
  • Make patients’ medical information available to the right clinicians wherever they are.
  • Increase the use of apps to help people manage their own health.

Technology to support the NHS priorities (Page 66)

Urgent and Emergency Care

  • NHS 111 Online. Throughout 2017 we will be working to design online triage services that enable patients to enter their symptoms and receive tailored advice or a call back from a healthcare professional, according to their needs. We will be testing apps, web tools and interactive avatars in local areas and using detailed evaluation to define the best approach. By December 2017 all areas will have an NHS 111 online digital service available that will connect patients to their Integrated Urgent Care via NHS 111.
  • NHS 111 Telephone: Clinical decision support systems are well used throughout the health system. They have supported our ambulance services and urgent care services for many decades. The developments in technology mean these systems are improving exponentially – becoming more personalised and intelligent and able to process more data in real time. From summer 2017 we will be developing and testing new specialist modules of clinical triage for Paediatrics, Mental Health and Frailty and demonstrating the impact of risk stratification. By March 2019 an enhanced triage will be available across integrated Urgent Care, with the potential to also support Urgent Treatment Centres, Care homes and Ambulance services.
  • To ensure that patients get the right care in the most appropriate location, it is also important that clinicians can access a patient’s clinical record. By December 2017 every A&E, Urgent Treatment Centre and ePrescribing pharmacy will have access to extended patient data either through the Summary Care record or local care record sharing services. We will also have access to primary care records, mental health crisis and end of life plan information available in 40% of A&Es and UTCs.
  • By December 2018 there will be a clear system in place across all STPs for booking appointments at particular GP practices and accessing records from NHS 111, A&Es and UTCs supported by improved technology APIs and clear standards.
  • During 2017 we will begin the work with vendors to seamlessly route electronic prescriptions from NHS 111 and GP Out of Hours to pharmacies via the Electronic Prescription Service (EPS). This will speed up the supply of medicines, and significantly reduce the time and cost involved.

Note: I haven’t extracted the full sections – I’ve hand-picked specific paragraphs. If you want the full context of the material you should read them in the original document.

We need to learn from the evil suppliers (at least some of them)

Events like UKHealthCamp give you an opportunity to meet lots of cool people who are on a mission to make a real difference in healthcare using digital.

I’m currently working with NHS England doing exciting digital things but have spent a large part of my career working for a commercial software supplier to the NHS –  for this reason I’ve often been quick to fly the ‘suppliers aren’t all evil’ flag (#notallsuppliers #notallevil). A lot of the time, I’ve met a fairly defensive reaction to this.

It’s worth clarifying that this is absolutely not a post in defense of big software suppliers, and the message is not intended to be “big suppliers are the answer to our digital health needs” (likewise it’s not saying they can’t be) – it is simply acknowledging the fact that they are a significant and established part of our digital health economy. Sometimes, when we’re trying to change things in a big way,  ‘the behemoth suppliers’ become only a representation of what we are desperately trying to get away from, and their place in our discussions doesn’t extend past a punching bag for our criticism and utter disbelief.

If you talk with many of the people who are trying to change things in their field/sector/locality, their stories often feature a chapter like:

We’ve asked our current supplier to make some changes – they said they would do it but two years later it still hasn’t happened.

We tried talking to our current supplier but they just weren’t interested and it wasn’t a high enough priority for them to do anything.

Unsurprisingly, people are disappointed by this, and it just leaves people even more determined to do something better in spite of the suppliers.

Hardly any large software suppliers have entered the NHS market within the last 5 years, maybe even the last 10. The systems that are now handling millions of patient encounters have years’ of development behind them – years of code, years of complexity layered on previous complexity, and at least 3 significant rounds of NHS re-organisations requiring renaming or translation of entire database schemas because a table labelled

tblPrimaryCareTrusts

in hindsight should have been labelled

tblGenericFluidlyNamedNHSLocalisedWithVaryingLevelsOfCommissioningResponsibilityEntities

This is absolutely not to suggest that all long-running systems are long-in-the-tooth – far from it in a lot of cases – but anyone who has created or maintained complex applications will relate to the fact that the longer an application has been evolving for, the more history there is to consider.

None of this excuses how hard it is to change things – definitely not in fact – but we do need to be careful about dismissing their collective experience.

@lexij pointed out to me:

“You have a great idea to solve some problem, and so you solve it, and then someone with that problem wants to pay you to solve it for them, and now you have a paying customer and a contract, and then more people want you to solve the problem for them too, and now you have more paying customers and more contracts, and then someone’s problem changes slightly and they want you to change how you’re solving their problem, and you ask them to complete a change request so that you can control the impact of the change, and now you’re an evil supplier.”

Every supplier, at some point, started by doing something different and solving a problem for someone.

The NHS is starting to understand how important it is to properly discover the problems that need solving – what is the user need? Pockets of (what I consider to be) better practice are appearing all over the digital health community, and high profile digital projects such as the NHS.UK Alpha are demonstrating how better practice can be applied to real needs. This helps to establish a legitimacy for these practices that in turn provides cover for more pockets of better practice to appear. As part of this important research we accept that we need to understand both what and why and I believe that to help answer the why we need to learn from those who have been at the cutting edge before – those who are already trying to solve the problem and getting there. They may well know why they can’t respond to these needs. So as a suggestion, how about we have some conversations asking:

“Why can’t you change your system to meet our need? Do you agree that it is a valid need? If not, why not?”

“What would have to happen so that you could change your system to meet our need?”

“What things stop you from being able to rapidly adapt? Why aren’t you getting ahead of the curve?”

I think we’d probably get some answers including phrases like “fixed contractual deliverables, contractual penalties for not delivering x and y, too many higher priority requirements already in the backlog, no clear return on investment, no clear sign that people need it…..” and many more. Surely all suppliers aren’t just so lazy that they all work from the same list of ‘excuses’ are they?  There’s more for us to understand here – we might just be responsible for creating this inflexible environment.

Clever people are looking after these well-established products, and as @lexij also pointed out

“they’re just people – people who just happen to work for a commercial software supplier”

I’d be surprised if they didn’t have some useful perspectives on this stuff, and if we can try and capture some of that experience in our discovery we will almost certainly be more successful in changing things for the better.

Some thoughts from UKHealthCamp 2015

IMG_4457

On Saturday 28th November it was UKHealthCamp 2015 – a free ‘unconference’ for everyone interested in digital, design, technology and data for health and care following the style of the successful UKGovCamps.

It was organised by @sheldonline, @thatdavidmiller, @puntofisso, @aliceainsworth, @drcjar and @tonyyates and hosted at the London School of Hygiene and Tropical Medicine – they did a fantastic job and I could feel the buzz from everyone at the end of the day. 

A couple of things stuck with me whilst I was on the train home so I’m capturing them before they get nudged out by my next shopping list or I get distracted by some animated GIF.

I attended @GlynRJones‘ session titled ‘What do we know?’ – a discussion about how we can best share what we’ve learnt within the digital health community – I feel events like this are one of the best ways we can do that.

We need to learn from the ‘evil suppliers’ (at least some of them)
The ‘big NHS IT suppliers’ may not be the answer to delivering our next generation digital services for the NHS, but I do believe they need to feature in our discovery work so that we make sure we learn from their years of experience.

I blogged more about this here.

People really care about data sharing and data protection, but it’s not the only conversation we need to have
In no way should the conversation around data ownership, privacy, and protection be minimised. However it’s become the default conversation when the topic of data sharing within the NHS is raised; people feel really strongly about it but it can sometimes hinder conversations about doing things differently. 

I blogged more about this here.

Integration within health and care is all over the place and there is a disconnect somewhere (and I don’t mean the one between the systems)
Integration and interoperability are hot topics in the NHS at the moment. Most people accept that neither one-size-fits-all systems, nor disconnected ‘best-of-breed’ systems are the answer to a joined-up NHS. People providing care in the NHS want the systems they use to be more joined up yet there are tools which have existed for 5 years or more that still haven’t been utilised (e.g. the Summary Care Record). Why is that? Is it too hard to do? Is it too expensive to do? Or is in fact the benefit not real? 

I’m going to write a bit more about my thoughts on these things over the next few days.