Dr Martin McShane, NHS England’s National Director for Patients with Long Term Conditions, explains why building care plans is so vital:
I was fortunate to participate in a course at INSEAD when I was still a GP at Moss Valley Medical Practice in Derbyshire.
For the course I had to do a change project and I decided to see if we could become proactive about emergency admissions. People kept disappearing into hospital and re-emerging, usually as a surprise, having had ‘stuff’ happen. It caused us a lot of work and it was patent that some of the ‘stuff’ might have been done better if the hospital team knew as much as we did about the individual.
Having worked in hospitals I knew the information we had about people could be invaluable but it was locked in our computer system. I decided the first thing to discover was when people were admitted as emergencies and set up an admission alert system.
I had a chat to our District nurse. Fiona cheerily told me that she was notified daily about who had been admitted. We agreed she would stop shredding the fax and we would collate the information to use as a team. We then arranged to review all patients over the age of 65 who were admitted, on a weekly basis, and decide what information would help the ward team. This quickly became structured as their medical, prescribing and social information.
What started as a small meeting with me, Fiona, a social worker and practice manager quickly grew into a standing room only meeting. We cared about people and liked solving problems. Knowing who had acute problems was a great focus for team working.
The feedback we got from the hospital staff was also incredibly positive. It really helped them and we were ready and prepped when patients were discharged, because of better communication.
This was all brought back to mind in a recent meeting with the Summary Care Record team.
As of May 2015 over 95 per cent of people in England have a Summary Care Record. Over 40,000 are being viewed every week. The functionality of the system is being improved to provide more information (with the patient’s consent).
This ‘Additional Information’ functionality means it is now potentially possible to include not just medication, past history and procedures but also upload anticipatory care information, communication preferences and end of life care information from the GP system.
In 2013-14 one million bed days were taken up by people under the age of 40. People over the age of 85, alone, used seven million. We know that our success in addressing the problems of health care in the twentieth century has given us new problems for the 21st. We need to work with people to shape health and care around their goals as well as their needs and draw upon the assets in their communities and value their carers.
This can be achieved by co-producing and care planning with the patients, with this information able to be updated and viewed by all involved in their care. There are already examples of these local ‘integrated care record initiatives’ that enable co-ordination of care, such as the Leeds Care Record and Bristol Connecting Care. Where this has been done in palliative care it has had staggering results: improving quality of care and reducing costs in the system.
It feels to me that we are at a moment of huge potential where the NHS can continue to lead the world.
By working with people with long term conditions we can make sure they have a care plan, agreed with them, available 24hrs a day in case of emergency; for out of hours, 111, ambulance and hospital services.
We have the potential to make continuity of information business as usual, improving care and making it person centred. Collectively we can make it happen.