Our final HTN Now event of 2022 focused on all things digital integrated care systems, and we were joined by a team from Apira for a discussion on the lessons learned from their digital ICS experiences.
Apira, a digital healthcare consultancy, supports organisations on a national, regional and local level to buy and deploy clinical systems. They support the whole system lifecycle journey, from justification of investment through to realisation of benefits.
The team joining us for this session included David Corbett (Director of Client Engagement), Alan Brown (Director of Professional Services), Richard Scowen (Managing Consultant and Procurement Practice Lead), Kiran Dave (Senior Consultant and Requirements SME) and David Thompson (Senior Consultant). The Apira team were also joined by Kevin Briggs from NHS Digital (Frontline Digitisation Business Case Review Service Lead).
Business cases: costs and benefits
Alan started the discussion by posing a question: “What is it going to cost for a joint EPR system?”
He pointed out, “We’ve got so much information about a trust buying an EPR, but when it comes to buying it for two, three or more trusts and cross-care settings, it’s much less certain.”
Richard replied, “It’s an interesting point. There’s a bit of a myth in the EPR space that there is going to be a substantial discount if you suddenly bring in multiple organisations. Typically, that’s not how this works. Yes, you’ll see some discounting, judging by what we’ve seen so far over the past 12 to 18 months, but it’s not massive. We’re looking at somewhere between five and ten percent. The idea that you’re going to be able to roll this out and it will cost you 50 percent more is quite challenging.”
This is less true when you’re talking about things like Picture Archive and Communication Systems (PACs), Richard added, where the majority of the cost depends on the size of the images that you are taking and storage use.
Another question here is around benefits. “What benefits do you get from having a joint procurement?” Richard asked.
“We can talk a lot about benefits in general – we can see much better patient experience from a system going across trusts, where patients don’t have to keep repeating information throughout their journey,” Alan replied. “But when we do a business case, we also have to look at which benefits are going to save money. It’s difficult to say how it’s going to save money by sharing the same system. Across the system, there’s maybe an ongoing five to ten percent reduction in costs, but where are the big savings? We hope that there will be less repeat tests, but I don’t believe that this is always the case.”
Richard supplied another question: “What about if you were sitting in an ICB, looking across the ICS, and you’ve got a classic mix of demands – you’ve got acute trusts, primary, community health, mental health. Some of those trusts might be integrated, as well, to deliver both acute and community care. How can you make a case to go out and buy an ICS solution that covers all of those domains?”
“Let’s take acute and mental health,” Alan said. “It’s a well known fact that patients with mental health problems have lower life expectancy, and it’s not because of their mental health problems alone – it’s because of a combination of factors. When they are in a mental health setting, the trust is focusing on their mental health, and their physical health can suffer. So that’s an example of how joining up would help those different settings.”
It remains a challenge, Alan acknowledged. “We’re working on a few joint business cases and we’re still having those discussions. We know the benefits for patients but even when it comes to staff – with acute and mental health as the example, you don’t get that much cross-working so you don’t get quite the benefits of sharing staff experience. Are we saving staff hours of time?”
“Maybe the main focus here isn’t perhaps on the cash releasing benefits,” David said. “It’s on clinical quality and patient safety benefits that come from having all organisations on the same system. If it happens in an area where there’s a trust that’s local to another trust with both of them on the same EPR, you are more able to move staff around those organisations so they don’t have to become trained on lots of different systems, and they can also start to provide care for patients as soon as they walk into the other trust.”
On that note, Alan asked, “Is co-location of teams easily done when you are all on the same system and therefore are there space saving benefits?”
David replied, “I think this is the role of the ICS – looking at opportunities to standardise processes and at resources across organisations and seeing that there are better ways to move staff around those organisations.”
Lessons learned from the South West
David Thompson joined the conversation at this point to offer his views from the topic from experience in the South West.
“The key to it really is shared care records, to be able to share information across multiple stakeholders and the wider health and social care community,” he said. “They’re a very important part of that overall strategy.”
In terms of his own experiences in his region, he continued: “We had six ICSs with about 4 million patients. The ICSs were at various stages of maturity and roll-out of the shared care records. We had four ICSs that had shared care records and two that didn’t, so the initial strategy was to bring those two up to the same level as everyone else. So a lot of the work went into those two ICSs around procurement, specification and business case, through to selecting the supplier and moving onto planning and deployment. They’re live now – it took around 18 months.
“If I was to offer advice to anybody who was about to start this journey, I’d tell them to look at the scope. How big is the programme? Make sure you take into account all the stakeholders in your area, look at their digital strategies, and phase those around the implementation of your shared care records. For example, if they’re in the middle of deploying a large EPR, they won’t want to be the first to join a shared care record so you’d have to schedule them in a bit later.”
A key activity for the start of the timeline, David continued, is to “look at the baseline of all the systems – you want to know what data is available, what can be shared and what can’t be shared. Start small. Potentially start with GP data first, then if you can move onto admissions discharges and transfers which is particularly useful information for community teams.
“Another key area is to make sure it is clinically led and get the GPs on board. Attend GP meetings and training sessions, engage with the LMC and go and meet them to get them on board at an early stage.”
Information governance is an important factor in this, David noted. “It does take a long time to get through, there’s a lot of stakeholders to get involved and signed up to it. So it’s definitely worth starting that at the earliest stage you can.”
David also recommended focusing engagement work on the comms team to help with any concerns from the public on how their data is going to be used and how secure it is, and staff teams too.
“From a technical side, you need to make a few key decisions up front,” David added. “Are you going to persist the data up front and store it somewhere centrally or are you going to live query all the systems? That will need to be given consideration. A lot of areas go for a hybrid approach, persisting and holding some data but live querying others.”
He also raised data quality as a consideration. “You won’t be able to share data if the quality isn’t there, and don’t forget business as usual – it’s not just a case of going live and walking away from it. There will be ongoing issues of sorting data quality issues out if users find them, there could be mismatches in data, and then there’s the usual starters and leavers information to manage too.”
A question was posed: if a region has got a good shared care records system in place, is there a need for all organisations to potentially converge onto one EPR?
“Even if they were to converge onto one EPR, it wouldn’t necessarily give you the same sharing capability as a shared care record,” David replied. “You’ve got social care, nursing homes, other third party suppliers – they can potentially use and benefit from having access to the shared care records but they wouldn’t necessarily need access to a main acute system.
“I think the fewer systems you’ve got, the better. If you were to converge onto one IT system across multiple trusts, that’s one less data feed to get in. So the convergence agenda is very important – the fewer systems you’ve got to connect, the simpler it is to roll shared care records out.”
Working together on requirements
To Kiran, David C posed a question around requirements. “If organisations are going out together to a single enterprise-wide EPR, how easy is it for those organisations to get to a point where they have one single set of requirements?”
“We’ve got to work together,” said Kiran. “That’s the key. All trusts need to work together, they need to make sure that they agree on the requirements. A lot of the EPRs out there have their gold standard that they offer, which is traditional EPR; anything on top of that, from a design perspective, is something that the trusts have to agree to. You have the opportunity to look at localisations per trust, but when you get to deployment stage, your designs and workflows are going to be the same. That can be challenging, because everybody works a little bit differently, but there will have to be some form of compromise.”
“How are those compromises reached when there are multiple organisations?” Alan queried.
“If you’re looking at your clinical functionality or even your PAS, for instance, you do need everyone present to agree and justify why you think your process is a better way of working than somebody else’s. That is difficult because every trust works slightly differently, but people have to talk it through to reach the compromise.”
David C offered, “From my experience, you need to have shared governance across the organisations. We are currently working with some trusts in the south that have a very strong governance set up and the ICS is very much involved. In terms of signing off business cases and requirements, you can’t get literally every single person involved in the organisations to review and sign off, but having an agreed governance structure means everybody knows what the rules of the game are.”
He added, “One of the important aspects is that some organisations do feel a bit exposed. They can get into a procurement and think they’ll lose their seat at the table, for example a small trust might be concerned that a bigger teaching hospital could end up taking over. We’ve seen that it can be really helpful to have that co-produced specification and co-produced procurement structure.”
“There is a role for the ICB in holding the ring on that conversation and ultimately acting as a slightly removed further party in this,” Richard said. “When there are strong opinions, the ICB can play the role of the neutral umpire.”
It’s also worth taking advice from the suppliers themselves, Kiran pointed out. “When it comes to the design work, they know their systems very well. On a positive note, if gives you the potential to improve your workflows, maybe learning from somebody else and making yours better.”
On that note, Alan added: “Pre-procurement is the point in time when you can have an open conversation with suppliers and discover what their experience is in this area, what their products can do, in a very open, non-evaluating way. You can get a feel for the marketplace. Equally, you’re also sending signals to the marketplace about the direction that you want to take, which helps influence suppliers to develop their systems for the multi-care setting.”
At this point, the team continued their discussion by taking answers from the audience, beginning from 30:57.
At 45:47 , Kevin Briggs from NHS Digital joined the team to answer questions on his work.
“On the topic of ICBs and ICSs potentially taking a role where they may secure a system for a whole area and receive funding for that, is it your expectation that we are going in that direction?” David C asked. “Do you think that could be a good thing, or do you have thoughts to share on any particular challenges?”
“We haven’t got many examples of that through the frontline digitisation programme so far,” Kevin acknowledged, “but the one that springs to mind is Norfolk and Waveney ICS. They’re on the verge of going out to procurement for a system for the whole ICS. Obviously, the challenges are down to the individual trusts being in different places in terms of progress and digital maturity. It involves a lot of alignment for trusts in terms of the planning and the will to progress together at the same time to a joint procurement. It’s complex, but it will hopefully mean that the ICS as a whole land on the same solution.”
“I suppose if you’re a clinician in a trust who is seeing this procurement activity taking place, there may be some natural anxiety that they are not necessarily going to be able to influence the outcome of which system gets purchased,” Richard noted. “Have you come across that Kevin, do you think that’s a valid concern?
“What we are keen to ensure as part of the frontline digitisation programme is that clinicians are fully involved in those decisions,” replied Kevin. “I think it’s important that clinicians are brought in through the chief clinical information officer and the chief nursing information officer and so on, and that they are engaging from day one. Quite often, a good way to bring about that engagement is to engage them in the business case development. Let them contribute to that. Organisations also need to make sure that clinicians are a key part of the actual procurement and evaluation of bidders. They need to be able to influence the choice of solution as far as the clinical decisions and clinical capabilities are concerned.”
“That’s a good point around engaging people early in the business case development process,” David C said. “I think one of the challenges that we find is that if you engage people really early, it’s great, but sometimes they aren’t going to see the system deploy for two and a half years from when the business case is started. I suppose there’s a compromise between engaging too early, engaging too widely and engaging too late.”
“Yes – it’s crucial that clinicians are involved in that choice of solution, but there will be other factors in the cost risk benefit analysis, obviously,” answered Kevin. “I think it’s up to clinicians to really push back on what is clinically critical. Of course, clinical safety is a key aspect of that, so it’s very important that it is effectively a tool for clinicians.”
Watch the full webinar below.
