For our recent panel, we spoke with Max Carter, programme director in outpatient transformation at North West London ICB; Dr Paul Wright, GP and deputy clinical director/IT clinical lead at NHS Greater Manchester and CCIO at Manchester and Trafford Local Care Organisation; David Ezra, managing director at integrated patient referral management platform NEC Rego; and Lee Rickles, CIO at Humber Teaching NHS Foundation Trust.
Contextualising the primary and secondary care interface
To set up the discussion, we asked our panellists to talk a little bit about the context surrounding the primary and secondary care interface.
David began by noting that the advent of integrated care boards and systems has “blurred the boundaries now – everyone’s in it together. Beforehand, organisations worked in silos – you had your acute trust working one area, community providers and primary care, and the commissioning structures largely reflected that. However, things have changed, and I do think that’s for the better; people have realised that healthcare and the delivery of healthcare isn’t straightforward. It needs everyone to collaborate, and at the heart of this has to be the patient. We feel very passionate about that – if possible, we want to be able to move patient data rather than move patients, whether that means optimising the referral management process, or ensuring that administrative processes are enhanced.”
Paul commented that defining the primary and secondary interface is key, because “effectively at locality level, it’s probably the crack that people tend to fall into, or the thing that stops patient care from happening as you hope it would. When those interface conversations are taking place, there needs to be a focus on the inbound workload, and on optimising of advice and guidance.”
Max shared his perspective from North West London ICB. “The biggest thing for us right now is our journey to get all four acute trusts onto the same EPR, and we also have the One London shared care record. Our challenge is that we have two different GP IT systems in place across our population, so there’s some natural fragmentation there.
“We’ve done a massive amount of work to implement the Vantage Rego advice and guidance platform,” Max added. “We’ve used it as a way of opening up some of those interface conversations, such as how we can make it really easy for a GP to get specialist advice from a consultant in the hospital or in the community, for example. There are challenges around how we improve processes around call and recall, consultant-to-consultant referral, and most importantly make sure that everyone out there in the system understands them. The interface is so critical and so crucial – we need to get to a point where we can deliver the level of seamless care that patients expect, because they receive it in every other consumer transaction they make.”
Lee noted that one key challenge is that the public don’t get much insight into how fragmented the system actually is, and explained what is happening at Hull and Humberside regarding the interface between primary and secondary care.
“We have some nice tools that are helping us – we use OPTICA (optimised patient tracking and intelligent choices application) with the Federated Data Platform, we are one of the pilot sites. We’re also working on our virtual ward and command centre, and we’ve got a solution which is basically an Azure database for population health management. Then there’s the shared care record which helps with quite a lot of the workflow in terms of alerting, real-time messaging, sending data and care plans to patients – all sorts of good stuff.”
With regards to the ICS itself, Lee raised other issues in this area, including affordability and disruption, the other challenge, he said, is that of the four acutes in the region, two work closely with each other and the other two work closely with trusts in other ICSs. “So the synergy of moving data across is very little in some cases.”
Lee emphasised that the biggest challenge, however, is culture. “At this point in time, we’ve got an ICS that is now under severe pressure; we’ve got providers that are struggling around budget and resources; and we’ve got quite a few transformation pieces that are going on, so we’ve got a lot of change within people’s lives. How do we make that a more positive experience for the public, but also for the staff involved in that process? They’re the key movers and shakers to make that happen. I don’t think we are totally getting that right in our patch at the moment, but we’re going in the right direction.”
The technology challenge and the supplier perspective
David shared his opinion on what is working well and challenges, from a supplier and a technical perspective.
On the first, he said: “Taking the example of Max’s area in North West London; in that ICB we’ve got four major trusts using the system, tens of thousands of referrals and advice and guidance requests being triaged every single day; we’ve got eight CCGs with all their 400 GP practices sending referrals every day through the system. So it’s operational, and it’s yielding significant benefits. I think it’s fair to say that maybe not all of the benefits have been realised so far, because obviously there’s a bedding-in process as people get used to it, but essentially we’ve been able to demonstrate significant amounts of referrals being converted to advice, and we’ve seen that there’s been an elimination of administrative process that existed beforehand.
“What Rego facilitates, for example, is the downstream of information at various different trigger points to the clinical systems within the trust that didn’t exist beforehand. Reporting data that comes out of that is extremely powerful. Everything that comes through Rego is a data point and then can be reported as such, and that allows you not only to understand what’s going on in real time, but to be able to act on that information.”
Collaboration between all the clinicians within the organisations has taken time, he noted, adding that his team is “grateful for the support we’ve received from IT leads, service managers, incredible people in the community who have been forward-thinking and helped this to work.”
David also commented that North West London ICB is “streets ahead of other ICBs, and that’s full credit to the people on the ground. The biggest challenge has been the limitations of existing solutions that we’ve been asked to integrate with – often the APIs that have been provided need heavy customisation, and that has taken time. The other thing we realised is that when you give people something good, and it works, then the next question is what can happen next? That’s also a challenge in itself, being able to manage expectations of users – they want to go further, they want to do more, so another key challenge is prioritising development work that needs to be done for them.”
Data in outpatient transformation
The discussion moved on to data and how it can be used to make changes or improvements from an outpatient transformation perspective.
“We know that in primary care and in secondary care, the most precious thing we have is time,” said Max. “Time lets us use these systems and tools, to work with clinicians to redesign processes, and not to just do what people have done historically, which is buy a new system and try and put the old process into the new system. It gives us space to ask the fundamental questions – how we can make sure that I’m not saving three minutes for myself, only for someone further down the line to have to put an extra 15 minutes in? How do we make sure that patients are getting consistent answers quickly, for what are quite often fairly straightforward questions? How can we support the GP in building that relationship of trust with their patient? Likewise, how can we use the data that comes out of David’s system to understand where we need to do some learning, and whether issues are across the entire ICS or a couple of PCNs? Do we need to parachute in with some detailed training and support in a specific area?”
It comes back to time, Max said, emphasising the importance of getting people to recognise that this might be a digital project but ultimately it’s about delivering a patient service and making best use of the time that is available.
“There’s more we can do around designing user experience and workflows, and that only comes from using the system,” Max continued. “As David said, the minute we put users in front of these systems, they can start coming up with clever ideas of what can we do next. Sometimes I have to reign people in a little and remind them that we need to get the basics sorted first. But actually, we do have a massively different digital portfolio today compared to even five years ago, and we can build on that. Five years ago this conversation would have been about interoperability, interoperability, interoperability. I’m not going to say we’ve cracked it, but if one one positive came out of our COVID experience, I think it was the recognition that not only do we need to make systems interoperable, we can make them interoperable.”
Moving on to talk about advice, impacts and his thoughts on whether the solution works better for particular specialties, Max said: “It absolutely works better for different specialties. There might be challenges in a speciality where a clinician needs to do a physical examination on a patient, for example, but it works amazingly in specialties that are data-based – clinical haematology, for instance. We’ve seen examples of 80 percent of referrals being sent back as ‘advice only’ in that space.”
Max added a caveat: “There is no such thing as an unnecessary referral; there’s an avoidable referral, but every referral is necessary, because a patient has identified there is a need. It’s important to be clear about what we are trying to achieve – it’s not about not helping the patient, it’s trying to avoid referrals becoming putting patients on long waiting lists.
“I think that’s one of the messages that we’ve pushed really hard in North West London – that a referral being for advice rather than a practical action doesn’t mean the need or the work goes away. These are still patients who require care, they are just getting care in a different setting, and that’s the bit that we have to remain really conscious about as we talk about the interface. The danger is that this becomes seen as secondary care dumping activity on primary care, and they are already really busy.”
For advice and guidance referrals, there has to be work around enabling multidisciplinary care, Max continued. “How can we support GPs who are operating at the top end of their license to ask questions, to get support on the sort of things that GPs would historically do by phoning up the person they went to medical school with 40 years ago? We aren’t in that position today – I know here in North London, we are seeing general practices with 20-25 percent locum-based staff, and they don’t have the links. So with these solutions we need to make sure we’re keeping a focus on making it equitable for any GP to access any specialist and get expert opinion.
Paul picked up on this point. “We had an advice and guidance workshop last week, and everything that Max has just said completely resonates,” he shared. “I think there’s a real opportunity here to rebuild communication with GPs and specialists in a different way. We’ve got dedicated consultants looking at advice and guidance referrals, responding within one or two days. To have that closer connection with your local trust, with your local consultants, is really valuable.
“I think one of the challenges in the software is that we’ve got these foundational blocks that are enabling us to do things, but then the core clinical systems don’t interact with those foundational blocks in a way that really delivers that efficient care. I also think that the explosion of robotic process automation and the need for middleware is really a result of the lack of the core clinical systems’ ability to deliver the efficient processes that we need. There’s more work to be done on building that community of practice and building engagement both from a primary and secondary care perspective, to build those relationships.”
Key learnings and takeaways from digital transformation
Next, David shared some of his key learnings from his journey to date.
“I think the most important thing is having a clear objective that you’re trying to to reach,” he stated. “It’s very important to have everything workflowed in advance; to say this is what we’re trying to do and how we’re going to get there. It’s essential not to reinvent the wheel – if something exists, optimise it. Don’t give up on existing systems that are there, optimise and try and make them better. It’s much harder to move people away from a system they’ve been using for a long time than trying to improve it. A classic example is that we didn’t tell anyone to move away from ERS – ERS is important, it’s essential, and we used the key components of it and integrated it within Rego, so as far as anyone’s concerned they’re still getting the benefits of that great system, but through a better interface with lots of tangible benefits.
“I think the other thing is to be ambitious – don’t limit yourself and don’t replicate what was there beforehand in a digital format. One of the things that has been hugely successful in the dental world, and in other areas such as North East London, is using algorithms at point of referral to automate the triage process. I’ve seen that being highly effective in lots of different specialties, again for example in Barking and Havering, for their MSK referrals. The algorithms do effectively what the clinicians would have been doing if it came to them on a piece of paper. One of the most exciting elements within our system is being able to up-front that advice and guidance to decision support straight away.”
What “good” looks like and future plans
Lee kicked us off by talking about what he considers “good” looks like in this area, and his plans for the next 12 months.
“Good looks like a really positive experience for the people involved in using the technology,” he said. “A really good experience will generally lead to a better quality of service, which by default will be more efficient and more effective. I think there’s a tendency to focus on technical requirements and technical needs, but we need to be looking at the holistic in-person experience.”
What does that mean for his patch? “Realistically there is a big piece of work on user-centred design and getting back to basics, on how we focus on the person and how we deal with the culture change,” he said. “Also, we try to remove the word ‘digital’ from the conversation – as soon as it’s digital it’s the CIO’s problem, rather than being everybody’s responsibility, the same way patient care is everybody’s responsibility.”
Lee also raised the importance of staying realistic. “Big ideas are brilliant, but everybody will remember if you make a lot of technical promises but they’re still struggling to log onto their machines, and they’ve got 47 passwords to switch between. Sometimes the simple fixes are actually more powerful. It’s all about experience, and I think that’s where the commercial market is doing it better – we tend to get fixated on numbers rather than people.”
Paul was next to give us his outlook: “Like Lee said, it’s about experience. Good looks like the patient journey feeling seamless to them, because the interfaces aren’t apparent to the person who is experiencing the care pathway.”
In Manchester, the next year will focus on “building the community of practice we have, bringing forward the advice and guidance, the education, the shared pathways which we’ve established. Over the next 12 months, we want to be developing that brilliance; but we do need the data to see things like an increased volume of referrals going in, and whether that results in a decreased number of appointments being given, for example. What does it mean from a general practice perspective if we’re able to deliver more timely care, or does that actually reduce the volume of work in general practice? Also, we’ll be focusing on things like pathology – we’ve got ongoing work with the pathology interface to really maximise the efficiency of communication, and we’ve got virtual wards which is going to be a massive part of that interface as well, because that’s all about that transfer of care between primary and secondary.”
Max praised the idea of moving away from the idea of ‘digital transformation’ and focusing simply on ‘transformation’. “We need to build the hearts and minds of all our staff, in primary and secondary care, and our patients. Then, I think, we’ll have achieved ‘good’. We’re getting there slowly, but we are still a way off, because we know that there’s so much more that we can do in terms of that idea of seamless transfer of information and taking away those little niggles that annoy GPs and practice nurses every day.”
In terms of what North London will be looking at over the next year, Max said: “We want to see how we can try and avoid patients going into their GP and asking after their referral, feeling like they’ve been forgotten. If we can crack that, that’s a massive amount of time in general practice that suddenly gets freed up to spend on care rather than on tracing a bit of virtual paper that’s got stuck somewhere in the system. We’re also going to do a lot of work with David and his team around protocolisation. We want to get to a point where we are streaming advice into the right buckets; so if we’ve got a protocol in place, let’s provide that information right up front. If it results in a referral, can we make sure that referral goes to the right place, to try and compress pathways, improve experience and take away all of the stumbling points that drive people to distraction every day.”
Finally, David wrapped up the panel discussion by saying: “I think my colleagues have articulated it what good looks like beautifully. I would add that the definition of good changes throughout the process – what was good three years ago isn’t necessarily what good looks like now. I think we also have be mindful of the fact that perfect is the enemy of good. We would struggle to get to a perfect state, but we can always get better.”
Many thanks to Max, Paul, David and Lee for joining us.
