I am reminded of many days sat around conference tables with colleagues from each of the local health and care organisations as we tried to storm our way through the latest centrally required mandate to work together. In those days, the phrase ‘sovereign organisation’ would be mentioned at some point in every meeting. There was a wariness to how we worked together and understanding where the boundaries were was important.
By the start of 2020 sovereignty was a rarely heard word in digital health terms, and increasingly the talk was of collaborating in ‘communities’, ‘place’ and ‘system’. When the COVID-19 pandemic hit it quickly became clear that if one falls, we all fall. The boundaries between primary and secondary care, mental and physical health, health and social care were shown to be artifices of our own creation that quickly dissolved when we all united in a common purpose. Amongst the heroic efforts of staff in all our care settings, digital teams worked tirelessly to help staff work remotely, support reconfiguration of hospital sites and deliver years of innovation in a matter of weeks. Perhaps less noted is the way in which they supported each other, sharing and gifting equipment, staff, knowledge and crucially support regardless of which badge you wore or what your email suffix was.
In the UK multi-organisational project teams stood up Nightingale Hospitals for COVID-19 patients in a matter of weeks. However, these regional hospitals could only operate as part of a combined strategic response to the pandemic. County level plans that allowed for some hospitals to operate without COVID-19 patients in order to make the best use of bed and staff resources, showed not just system thinking but system action. Dr Rob Dyer, Lead Medical Director for Devon, described this as playing for your country as well as for your club.
In November NHS England published a paper Integrating Care which set out options for accelerating collaborative ways of working between partners in health and care in Integrated Care Systems (ICS). It proposes removing some of the legislation that mandated competition and introduces a duty on organisations to “better health for the whole population,” not just their own patients. National finances will start to be allocated at the level of ICS, not organisation.
In doing so they are following a model that has seen success elsewhere. In New Zealand the Canterbury District Health Board has been using this type of integrated care model to refocus activity away from hospital settings for many years, whilst in Alzira, Spain integrated primary and secondary care services have been operating under a single budget (and single EPR) for almost 20 years. Health and care leaders have known for some time that the old model of delivering services was not sustainable. There was not the money, capacity or staff to continue. This was a current that could not be out-rowed.
Clinicians had already started forming networks of care at county and regional level. Care pathways spanned organisations and care sectors as they focused on supporting the citizen beyond the traditional boundaries. Teams and even departments were being shared between organisations as they sort to make best use of the limited resources. For all of this to work we are starting to see a clinical alignment that pools the old ideas of ‘sovereignty’. The Nightingale hospitals showed that shared facilities have a key role in a system approach and the broader response to the pandemic that our staff and facilities work best when deployed at scale in a coordinated way, that there is not just collective responsibility but collective ability. The national change to ‘system’ gives confidence that change will be supported.
The value of working together and sharing information
So in an environment where the focus becomes the citizen and their care pathway, what of the IT systems that have been built around the existing organisations? How can a clinician work effectively across hospital sites in different organisations if they must contend with different software each time, and cannot access information freely? Increasingly communities are taking the next logical step and moving beyond aligned procurement to single procurement, of clinical systems that span organisations.
In October we saw the Lancashire and South Cumbria ICS set out plans for a core clinical system, common departmental systems, and a single data orchestration layer across their 5 NHS Trusts. They are the first, but more are in the pipeline. Some organisations are now being asked to review their local EPR decisions to consider the broader system needs and we can expect to see more of this as ICSs set out their plans for Shared Care Records and Population Health Management.
The pandemic has shown us that we work best when we work together, but it has also shown the essential value of information being shared quickly and seamlessly, at both a citizen and population level. We were already on a journey towards collective working in digital health and care but it will only accelerate from here. There can be no going back.
Nick Hopkinson is a Chartered Healthcare CIO and Principal Associate with Ethical Healthcare Consulting.