the nottinghamshire forward view into action · 2020-01-29 · the nottinghamshire forward view...

The Nottinghamshire Forward View

into Action

An IGM&T Strategy for Nottinghamshire led by NHS Clinical Commissioning Groups

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Nottinghamshire CCGs IGM&T Strategy

2015-2020 Page i Version 3.1

Contents Contents ................................................................................................................................................... i

Version Control ....................................................................................................................................... 1

Executive Summary ................................................................................................................................. 3

1. Introduction .................................................................................................................................... 4

2. Where Are We Now? ...................................................................................................................... 5

3. Upgrading and modernising health and social care IT Systems ..................................................... 8

Overview ............................................................................................................................................. 9

4. Improving Communication and message flows between primary, community, secondary and social care providers ............................................................................................................................. 11

5. Improving Patients’ Access to Information ................................................................................... 14

6. Integration of health and care Systems ........................................................................................ 17

7. Technology Enabled Care Services – Remote and Assistive Care ................................................. 20

8. Use of data analysis to inform clinical behaviour and commissioning decisions ......................... 24

9. How will we deliver this strategy? ................................................................................................ 27

Appendix A: Nottinghamshire IM&T Road Map ................................................................................... 30

Appendix B: Glossary ............................................................................................................................ 31

Appendix C: The Information Governance Review Recommendations................................................ 34

Appendix D: Caldicott 2 Review - Table of Commitments .................................................................... 38


2015-2020 Page ii Version 3.1

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2014-17 Page 1 Version 3.4

Version Control

Reference

CCG IGMT Strategy v2.1.docx

Document Purpose This document lays out the strategic intent of Nottinghamshire CCGs in respect to developments in information governance, information management, and information technology and associated services.

Version 3.1

Status

APPROVED

Title IGM&T Strategy 2015 – 2020

Authors

Jason Mather, Nottingham City CCG Andy Evans, Connected Nottinghamshire Andy Hall, NHS Rushcliffe CCG

Contributors Dr Ei-Cheng Chui, NHS Newark & Sherwood CCG Carl Davis, NHS Rushcliffe CCG Di Butcher, NHS Newark & Sherwood CCG Gina Holmes, NHS Mansfield & Ashfield CCG Dr Mike O’Neil, NHS Nottingham West CCG Dr Sean Ottey, NHS Rushcliffe CCG Dr Ian Trimble, Nottingham City CCG

Approval Date

Approving Bodies CCG IGM&T/ICT Committees for all publishing CCGs

Review Date April 2016 (annually)

Target audience All Nottinghamshire Health and Care providers Public domain

Circulation list All Nottinghamshire Health and Care providers Public domain

Associated documents Clinical Commissioning Groups strategy documents; Operating Framework 2014/15; Caldicott 2: To Share or Not To Share; NHS Midlands and East Ambitions. CCG vision for 2020 NIB Personalised Health and Care 2020 Using Data and Technology to Transform Outcomes for Patients and Citizens: A Framework for Action The Forward view into action

Superseded documents CCG IGM&T Strategy version 2.1 CCG IGM&T Strategy version 2.0



CCG IGM&T Strategy version 1.0



Executive Summary This document describes how Information and Technology will support NHS Nottinghamshire Clinical Commissioning Group’s future vision for a digitally mature health care profile over the next five years. This document explains the importance of Information, Management and Technology (IM&T) within the health and social care community and how IM&T will best support the links between health and social care providers and commissioners which will be essential in delivering a comprehensive service. This document is an enabling strategy to support Health and care transformation and should be read alongside other key strategic documents identified later in this strategy. With the increasingly challenging financial environment, cost saving is affecting the NHS and Local Authorities across the whole health and care economy. The NHS has been tasked by NHS England to change the way that it delivers care in order to reduce cost while still improving the quality of care. Information and technology is a critical tool which health and social care communities will need to take advantage of in order to deliver the necessary improvements with limited resources available. Information and technology can bring enormous benefits by making the delivery of care more seamless and efficient. It is vital to health and wellbeing, and is pivotal to good quality care. It allows patients to understand how to improve their own health, to know what their care and treatment choices are and to assess for themselves the quality of services available. This IGM&T strategy is made up of seven sections that set out the six key deliverables and the Governance required to support the delivery of these:

1. Upgrading and modernising health and care IT systems 2. Improving Communication across the health and social care community 3. Improve patients’ access to information 4. Integrating primary care systems with other health and care systems 5. Supporting patients care through e-consultation, tele-care and tele-health 6. Use of data analysis to inform clinical behaviour and commissioning decisions 7. Governance and accountability

This document supersedes the CCG IGM&T Strategy version 2.1 for 2014/15 and sets the strategic direction for over the next five years. Driven by the National Information Boards paper in support of the NHS Five Year Forward View and clarity on the digital maturity framework, this strategy informs not just the local requirements but also takes into consideration the organisational attributes expected from external providers.



1. Introduction Rapidly advancing technologies have revolutionised the way we interact with each other in everyday life. Industry and the commercial sector have changed profoundly and the available technologies have the ability to enable a similar change in health and care services, shifting the relationships between patient and clinician towards one of shared decision-making. These changes are also influencing the behaviours between commissioner and provider towards one that is more focused on working in partnership or alliance and is more commercially effective. A critically important element of the National Information Board’s national vision is local design and delivery against the national objectives. CCGs from the 1st April 2016 will be accountable for the production of local digital roadmaps working with local authorities, local providers, and other local stakeholders to set the direction for fully interoperable digital records. This is the third version of Information, Governance, Management and Technology (IGM&T) Strategy for CCGs across Nottinghamshire, and sets the scene for the organisational attributes expected from providers. The interoperability and integration of systems within Nottinghamshire is critical to successful communication between clinical teams and the wider health and care economy including; primary, community, secondary, mental health, social and third sectors services. Information should be recorded once, at first contact and (with patients consent) shared securely with those professionals providing care. Information is a service in its own right, and local digital maturity will be closely monitored by the CCGs following national guidance, tools and standards set out within the NHS England Interoperability Handbook. The Five Year Forward View made a commitment that, by 2020, there would be “fully interoperable electronic health records so that patient’s records are paperless”. This was supported by a Government commitment in Personalised Health and Care 2020 that ‘all patient and care records will be digital, interoperable and real-time by 2020’. Radically new care delivery models supported by new payment arrangements which are value and outcome based are driving the need for change. This requires information to flow more effectively across health and care to support the delivery of direct care to the patients/citizens. This five-year strategy shows how Information Management and Technology will support the aims and ambitions of the Nottinghamshire Clinical Commissioning Groups and the health and social care community. The objectives within this document depend on all stakeholders having an up-to-date and robust IT infrastructure combined with modern optimised systems which provide good quality and relevant information. For this reason the Digital Maturity of all providers across Nottinghamshire will be monitored through the Digital Maturity Framework – a national requirement for providers to submit details of their digital readiness. Technology enables the use of information when and where required for best clinical, operational effect and delivery in care. The key elements to IM&T investment are:

Infrastructure (the physical hardware used to interconnect computers, users and services);

Systems (the clinical applications that provide staff, managers and clinicians with the tools and information to perform their tasks safely and efficiently);

Support (needed for all organisations involved including CCGs; Primary care; community care, acute and mental health secondary care; and Social Care);

Change Management (the management of change and development needed within Health and Care organisations);



Transitional Management (necessary in managing an institutional investment and enable the merging of funds and pooled resources).

2. Where Are We Now? The CCGs were given delegated responsibility for GP IT Systems and infrastructure, clinical systems, IT support and maintenance, networking, information governance, software licenses and hardware management. This allows direct influence of the Primary Care systems. The CCGs hold a Service Level Agreement (SLA) between their informatics service provider and the GP Practices. This SLA identifies and details all the elements necessary to maintain IT services. It provides a framework for the provision of specified services including operational support, desktop support, network support, application support, programme management and business change, training and telecommunications where locally agreed and funded. Nottinghamshire CCGs through connected Nottinghamshire have a vehicle to support and guide organisations in meeting the CCGs strategic aspirations. This vehicle will continue with the next phase scoping the opportunities to drive, support and influence all health and care providers to meet these strategic aims. The CCGs have formalised their transformation strategies for the next 5 years with a number of vanguard projects taking place across Nottinghamshire. These transformational programmes recognise there is a shift from secondary to primary and community care delivery and a need to keep more citizens, supported and healthy in their own home. IT is crucial in helping to provide effective health and care services to help deliver seamless, accessible care, improved outcomes, reduce inequalities and improve quality and capacity in the local health and care economy. In addition to transformation programmes the CCGs are also developing their 10 year Estates Strategies. Digital technological and estates planning will be essential to enable the improvement and expansion of joined-up out of hospital care for patients and accelerating investment for infrastructure to build stronger health and care services in Nottingham. The CCGs have a wide range of IT projects currently being underway across the county that will help to offer guidance and support to all providers across Nottinghamshire. Core and mandated services include:

GP Systems of Choice: (GPSoC) provides practices with a choice of systems from GPSoC Framework suppliers in line with the requirements of the GMS contractual agreement. As of 1st October 2015 Nottinghamshire has 117 Practices currently live on SystmOne and 29 live on EMIS Web with no practices using a non-compliant GPSoC system. Nottinghamshire CCGs wish to remain agile in their approach to integration and interoperability with a developing and emerging market place for these technologies. We recognise that it is important to make use of the best available technology whilst not becoming tied into anyone system long term. This approach should be drive value for money and ensure greatest return on investment.

Summary Care Records: provide healthcare staff treating patients in an emergency or out-of-hours with faster access to key clinical information about their medication and allergies.



All CCGs’ Practices are now live with SCR version 1 and opportunities for the deployment of version 2 will be closely monitored and explored throughout 2016/17 including options to expand this function to other providers such as community pharmacies.

The Electronic Prescription Service: (EPRS Release 2) enables prescribers, such as GPs and practice nurses, to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. Rollout of EPRS R2 is expected to be completed by July 2016.

Community Pharmacy: In June 2015, it was announced that the Health and Social Care Information Centre (HSCIC) had been commissioned by NHS England to lead on the implementation of SCR in to community pharmacies. Rollout has now commenced, and is expected to be complete by autumn 2017. The CCGs maintain good working relationships with all community providers and continue to support community pharmacies with further developments.

Patient access to GP records: will allow patients to view their own GP records online. In order to establish the true implication of providing patient access to GP records a pilot approach was adopted and was carried out Throughout 2014/15. This pilot established some interesting learning that will support various self-care projects across Nottinghamshire in 2015/16/17 and moving forward.

GP2GP: enables patients' electronic health records to be transferred directly and securely between GP practices. It improves patient care as GPs will usually have full and detailed medical records available to them for a new patient's first consultation. All practices across Nottinghamshire are now live with this functionality. The CCGs recognise the current issues with this functionality and will continue to work with suppliers to drive improvement of the service and delivery efficiencies through the electronic transfer of health records.

Consent management: eDSM is the enhanced data sharing model that has been introduced for TPP SystmOne sites which enables the safe sharing of patient information to support patient care on a consent basis. All practices live with TPP SystmOne have access to the data sharing function and a project started in 2015 to ensure practices follow the Nottinghamshire Consent Model policy guidance. This was developed by the Nottinghamshire Health and Social Care Records and Information Group. This included participation in this work from all health and care providers signed off by each organisation’s Caldicott Guardian and Senior Information Risk Owner.

Access to direct care information: with greater collaborative working across silos of care, shared access to all direct care information is essential. For this reason technology referred to as “Portal” technology is required. Nottinghamshire made a decision to support the provision of this service by Nottingham University Hospitals using the CareCentric set of technologies. From 2016-2020 this will form the main information exchange for sharing of direct care information across all Nottinghamshire health and care providers.

Sharing of GP Records: in 2015 the decision was made to roll out a system that allows access to direct care data from GP Practice records operating across both GP clinical systems in Nottinghamshire. This can then be viewed through a number of ways including full integration with the GPs clinical system, Out of Hours systems or through a simple web browser via an N3 connection. Progress has been made throughout 2015 and completion of



phase 1 provides urgent and emergency data sets to clinicians within those care settings. This work will continue throughout 2016/17 with a second phase of work, expanding the availability of the GP records for direct care and supporting the access to direct care information work.

Electronic results reporting and requesting: provides the ability to request tests electronically, receive results electronically including other results for that patient requested elsewhere. Full rollout was achieved in October 2014.

Electronic Correspondence: currently within South Nottinghamshire GP Access and NotIS are the systems used which allow GPs to view certain hospital information including discharge letters, summaries from certain NUH services, community physiotherapy, and Orion is used widely within Mid-Nottinghamshire. Recognising as part of the digital maturity framework CCGs will have oversight of IM&T developments, CCGs are aware that none of the current message flows conform to the strategic direction of travel and work will need to be done to ensure alignment to national ITK standards in anticipation for future contractual requirements. This work will also include message flows into social care providers and will rapidly improve processes such as discharge by moving these to digital workflow replacing Section 2 and Section 5 requests as a starting point.

Resource to support Data quality: is available in some but not all CCG areas for primary care. Providers have data quality and information teams which will need to reflect the shift towards a more digitally mature Health and Social care economy in Nottinghamshire. This will be essential as we move in the direction of standardisation of SNOMED codes by 2020 but have to deal with multiple systems during the transition. Good data quality is an essential element of digitalisation plans.

Social care: Nottingham City council and Nottinghamshire county council have made good progress with the matching of social and health care records using the NHS number as the key identifier with significant progress completed in 2015. This will support the integration of health and social care data with early access available in 2016. Nottingham City council are replacing their IT system with Liquid Logic and have plans to interoperate with health care systems and Nottinghamshire county council have additional interfaces added to their information system to allow messages and information to flow bi-directionally.

Nottinghamshire secondary care providers: have made good progress in replacing their key patient administration systems. Both acute secondary care providers have delivered systems to support electronic observations and have developed early plans to support the move to digitalisation. Both local providers are part of the EMRAD consortium and will be sharing the PACS solution offered as a service through Nottingham University Hospitals.

Mental health: has made significant progress in the re-provision of their key patient administration and clinical record systems. They have also made progress on the implementation of technology to support mobile access to records. With the implementation of a local portal product, key lessons have been learnt that will support further integration across the care community.

Community providers: continue to improve the use of mobile working with support from the nurse technology fund in 2015; this now means that most community clinicians have remote access to patient records when at the patient’s side regardless of the location. Through the use of TPP SystmOne further developments in the use of shared records with



primary care have been achieved. With the advent of care coordination team’s community providers have implemented a range of interim solutions in order to gain access to wider health and social care records.

Technology enabled care: several pieces of work are underway that use technology to support care delivered outside of traditional care settings and that support self-care by patient/citizens. The largest application of these is in supported living with home monitoring and alarm services. In health FLO is the largest deployment supporting self-management of a number of conditions but other work is also underway and gaining traction in Tele-health and Tele-dermatology. The use of video for remote consultations has also been trialled and produced excellent results in areas such as care homes.

Information Governance: the Nottinghamshire Health and Social Care Records and Information Group has developed since its setup in 2014 and now provides the central body of expertise in developing guidance across Nottinghamshire on Information Governance policy and best practice. This group is now well established and has been vital to the delivery of the Nottinghamshire Consent Model for direct care.

Third Sector Organisations: Work has already begun to incorporate SystmOne within care homes to increase information flows and intermediate care. Further pieces of work are underway with the Carers Federation and others in establishing what information needs to be shared to support wider care organisations.

3. Upgrading and modernising health and social care IT Systems

Technologies Key milestones

Patient administration systems (PAS) Online appointment booking / prescription ordering Community Of Interest Network (COIN) Electronic Prescribing Digital record systems (Clinical noting) Electronic transitions of care (Clinical correspondence) GPSoC Virtual Desktop Infrastructure (VDI) Remote Corresponding with GPs Records digitisation/Paper light working Digital maturity assessment Federated WiFi Mobile working for GPs Cross organisational authentication

July 2015 April 2015 April 2016 July 2016 2018 2018 July 2016 April 2017 April 2017 April 2018 (annually reviewed) October 2018 TBC in line with DMI October 2016

Key References and Publications

o General Practice Systems of Choice

Summary: Ensuring all of our providers are equipped with suitable compliant systems

that meet the standards and specifications set out by NHS England and the Health and Social Care Information Centre (HSCIC) e.g. ‘GP Systems of Choice’ (GPSoC), systems which meet the requirements of the strategic frameworks set out by HSCIC and achieve a suitable level of Digital Maturity as captured in the Digital Framework. This chapter covers the CCG responsibility to assess and monitor provider system suitability.



o Securing excellence in GP IT Services o NHS England interoperability handbook o HSCIC ISB/ISN o Forward view into action o Local Estates Strategies - A Framework for Commissioners

Key Ambitions

o Information sharing between all care organisations o All Nottinghamshire Practices to have access to GPSoC systems o All providers equipped with suitable compliant systems o Increasingly efficient ways of working o To ensure up to date IT platforms are available and meet levels of Digital Maturity o To enable the provision of IT Services to support the extended use of information systems in

the delivering of care o Explore flexible ways of working across traditional boundaries of care

Overview Fundamental changes to the way health care is delivered are necessary to ensure value for money and quality of care is achieved, including the linking together of Practices in a network or merged partnerships in order to increase a step change in the scale, scope and organisational capacity of General Practice, to deliver and demonstrate measured value. The exact nature of the organisational changes is likely to vary across Nottinghamshire but is likely to be dominated by new models of care driven by the five Nottinghamshire Vanguard programmes. The current pressures on the NHS are increasing, with staffing levels in short supply, costs on the rise and the increase in care being transferred from secondary care into the community, this makes transforming the current models of care imperative and even more challenging. Demand is increasing along with patient expectations of how they access health and care services. One way in coping with this demand is to free up the GP time to enable them to focus more on managing those patients with Long Term Conditions (LTC). General practice will utilise functions such as the Electronic Prescription Service which enables prescribers, such as GPs and practice nurses, to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. Alongside this GPs have full access to functions such as Sunquest ICE enabling them to request radiology reports and pathology tests electronically and to receive results electronically, including results for other tests requested by other clinicians for the same patient reducing duplication. The CCGs will support future developments of these systems, exploring options such as enabling acute trusts to send electronic letters and discharge reports electronically to GP Practices via currently utilised or new systems. Approach To enable primary care access to new innovative systems and programmes to aid the delivery of care, Nottinghamshire CCGs have invested in two GPSoC compliant clinical systems; TPP SystmOne and EMIS Web. The arrangements in the GPSoC framework are geared towards helping Practices get the best out of their GP clinical IT systems. User specified roadmaps and incentives for suppliers to improve the



utilisation of national services are aimed at developing an increased focus on good training and continuous improvement of delivered software. Through this arrangement CCGs will ensure that contractual arrangements are in place for support and training and ensure smooth transition for those utilising systems under the old LSP contractual arrangements to the newer GPSoC arrangements. Where there is a clear advantage to the health system, requests from GP practices for support to migrate to alternate GPSoC compliant systems will be considered. CCGs will commission health informatics services to provide support for business critical systems including 1st, 2nd and 3rd level support and extended hour’s service desk function. The CCGs will explore opportunities presented by new and emerging technologies that support improvements in care and efficiency in how it is delivered, e.g. Virtual Desktop Infrastructure (VDI) and Video conferencing. Using these technologies will ensure that Practices that consider working collaboratively to offer more choice or extended hours access can do so without limitations.

CCGs will be required to carry out a digital maturity assessment and will work with providers to identify areas of strength and weakness and work with them to develop robust plans for improvements. CCGs will exploit opportunities where funding exists to support provider requirements. CCGs expect all health and care providers systems to conform to national and local contractual requirements and standards e.g. GPSoC and HSCIC standards. Recognition that the local service provider contracts are coming to an end July 2016, health care providers with the exception of primary care are unable to migrate over to frameworks such as GPSoC. These providers will need to procure systems that best meet their requirements. CCGs will ensure providers use systems that are compatible and interoperable with existing systems e.g. GPSoC systems. Good quality network connections to all our providers underpin and enable the delivery of new IT systems and services for the NHS and Local Authorities. The N3 and PSN networks provide the essential technical infrastructure through which the benefits to patients and staff from the new systems and services will be fully realised and sustained in the future. The CCG will support improvements and innovations for developments moving towards a single Community of Interest Network (COIN) joining together multiple trusts and health communities with Local Authority partners.



4. Improving Communication and message flows between primary, community, secondary and social care providers

Technologies Key Milestones

Sunquest ICE Oct 2014

NHS Number (including PDS service) April 2015

Summary Care Record April 2015

GP2GP April 2015

Medical Interoperability Gateway Oct 2015

Clinical correspondence Oct 2016

ITK Messaging standards Oct 2017

Integration Engines (Highway, Ensemble, Rhapsody) Jan 2016

NHS mail 2 (secure email system compatibility) Dec 2016

SCR Viewer in community pharmacy Oct 2017


o General Practice Systems of Choice o Securing excellence in GP IT Services o Personalised Health and Care 2020 o Information standards, bulletins and notices o NHS England Interoperability handbook o The Forward View into Action

Key Ambitions

o Support electronic transfer of care across care interfaces to Increase efficient transitions of care

o To improve effective efficient clinical correspondence including migration to secure email systems

o To improve prescribing processes and support primary care transformation o Exploitation of the inherent clinical system capabilities between GP Practices and other care

sectors o Maximise the benefits of a duopoly of clinical system suppliers o Information sharing between all care organisations o Drive up productivity by reducing duplication and inefficient processes o Increase access to care plans for the purposes of direct care o Introduce flexible ways of working o Commission providers who use ITK accredited suppliers o The end of Fax use for any communication

Overview Relationships between health professionals have become more distant in recent years, perhaps due to increasing pressure of time, loss of shared educational forums. At the same time, the number of patient referrals is rising, which places a significant burden on waiting lists. At times of financial constraint, it is essential to ensure good communication between providers so that patients are only referred when necessary.

Summary: Faster communication to support the continuous improvement of the

services we commission by using information available to improve turn-around times across the health economy .



Strengthening communication and the sharing of information between organisations, to ensure patients are cared for seamlessly across organisations or speciality boundaries is vital. This will promote less duplication, improve patient transitions and improve quality and safer ways of working. Providing better information to points of advice and navigation in the care system will improve the citizen/patient experience and improve outcomes. A requirement of the 2015/16 standard NHS contract condition 11.6 requires acute and mental NHS trusts to send inpatient and day case discharge summaries subject to the 24 hour rule to GP practices electronically by October 2015. Trusts within Nottinghamshire have been providing electronic discharge information through existing systems for some time such as GP access and NoTiS. The CCGs are in direct support of the National Information Board (NIB): personalised health and social care 2020: Framework for action objectives to help clinicians ensure patients are safely transferred between episodes of care. This is the first step in a digital journey to move from paper to electronic, then to electronic structured messages sent directly into clinician’s workflow. Approach CCGs will encourage providers to ensure safer, quicker, more efficient care by transferring electronically all correspondence about patients and service users, including referrals, discharge summaries, medication details, assessments, outcomes and letters, between professionals and services. These data transfers should be coded and structured as far as possible, in particular in respect of discharge diagnoses. This will enable increasingly automated derivation of national data sets. It is expected that the HSCIC will continue to develop ITK standards and providers will need to conform to these. CCGs will support a duopoly of SystmOne and EMIS Web instances across their patches. Where this is the case the use of CareCentric, Medical Interoperability Gateway (MIG) and Clinical Record Viewer (CRV) can be implemented to support the sharing and viewing of records across care settings (choosing the most appropriate technology for the specific use). Depending on the level of collaboration between providers consideration will need to be given on the current limitations of CareCentric, MIG, CRV and similar technologies. The current strategy is to avoid writing back directly into clinical records but instead to use electronic correspondence sent as a structured message to report back to the originating system. Where required as an interim step clinicians and care professionals may need to be granted permission to access other clinical/care systems where Information Governance policies will allow this to take place. Nottinghamshire GP systems will be connected together using the Medical Interoperability Gateway (MIG) supplied by Healthcare Gateway during the development of a wider interoperability solution (CareCentric).The clinical data to feed the interoperability platform will be generated within provider systems. System developments underway at each of the secondary care providers will be managed from within the Trusts. The GP system developments will be managed from within the CCGs. Local Authorities will commission appropriate systems to connect into health systems. Connected Nottinghamshire will facilitate the development of an interoperability framework within which providers will need to work and share data. Other technologies will also be rolled out where there is a supporting business case to do so or where it is deemed to add value to patient experience and the quality of care they receive. An example would be the use of mobile technology to provide visiting clinicians access to patient records in a care home setting. This will provide more accurate access to patient information for the clinician and the ability to instantaneously updating the patient’s record with the necessary



observations and tasks, potentially eliminating unnecessary delays, referrals to other services and clinical errors.



5. Improving Patients’ Access to Information


eDSM April 2016

Summary Care Records (SCR) April 2015

Patient Online Access to records April 2016

Online appointment booking/prescription ordering April 2015

Web viewers / apps April 2017

Electronic correspondence April 2017

Information and advice websites April 2017

CCG websites April 2016


o The Department of Health’s National Mobile Health Worker Project – final report published January 2013

o The Five Year Forward view into Action

Key Ambitions

o Seek opportunities to help patients with long term health conditions in managing their own care and treatment

o Providing the information for staff to better help and support patients through the development of shared electronic care plans and records that link with key services such as NHS 111, 999 and Out of Hours

o To provide patients /citizens access to their record and to enable them to contribute information and preferences

Overview From March 2016 the GP contract will stipulate that GP Practices are required to provide patients with a view of their coded data from within the clinical system. Practices will need to ensure their information is up to date and accurate ensuring records of medication, allergies and adverse reactions from the patients GP records are recorded onto the national spine. This can then be accessed in the appropriate clinical settings with the appropriate access rights and with patient consent to support clinical care. All GP Practices within Nottinghamshire offer patients the option to book appointments and order repeat prescriptions online through SystmOnline or EMIS patient access. CCGs will encourage practices to promote this service to their patients. Results gained from the pilot run in 2015 suggest this can have an impact to support improvements in access and efficiency. The Department of Health’s National Mobile Health Worker Project - final report, published January

2013, revealed from information collected during the 15-month period of the project, that it is clear the adoption and long-term use of appropriate mobile solutions has the potential to significantly improve productivity, efficiency, safety and assist services to continue to provide good quality care and achieve good outcomes. The reported findings included significant saving in referrals can be achieved (up to 34%) as well as significant savings in admissions.

Summary: : This chapter covers the value of enabling patients to self-manage their

own health needs, as well as the utilisation of technology to improve health outcomes through access to information.



Clinicians should be able to access electronic information relating to their patients when they are treated in other parts of the health system. This particularly includes discharge and outpatient summaries, pathology, diagnostics and care delivered in community settings. The fast pace of evolving technology offers patients greater opportunities to engage with health and care services in ways that are convenient, cost effective and reliable. Furthermore patients themselves should be provided the capabilities to monitor and proactively manage their care more closely. As well as managing appointment and prescription renewal over the period of this strategy, it is anticipated patients will be able to:

Send secure messages to their care team;

Conduct e-consultations;

Submit requests to update medication and allergy lists;

View a summary of their consultations;

Access, review and update their personal care plan including management of long term conditions;

Undertake pre-visit reviews;

Access information from the record for their child up to age 12 (and beyond depending on their level of capacity as assessed by Gillick and Fraser competency;

View appropriate elements of their medical record including; test results, diagnoses, medications and immunisations.

Approach It is essential that our patients feel empowered to “self-manage” their own health needs and have the necessary information at hand to do this. We will ensure that all practices have information on how patients are able to direct themselves around the complexities within health and social care with support from the Practice clinical and administrative teams. CCGs want to encourage patients to take responsibility for their own health and become confident in managing their own health needs as much as possible. Each practice will have the technology to support patients on how to improve the “self-management” of their own care through the use of smart phone apps, and e-referral. Patients will be able to refer themselves into services that have been commissioned as suitable for self-referral. The CCGs will determine which services are appropriate to accept self-referrals from patients making them visible to patients and give the patient the choice to decide whether their GP is notified of the self-referral or not. The CCGs will support GPs in utilising their existing clinical system functionality to enable patients and carers to access online services. By 2016 patients will be able to access their coded GP record online including the ability to view test results, book appointments and order repeat prescriptions. All patients regardless of which Practice they are registered with will have access to booking appointments and repeat prescriptions online and building on the early full records access pilots we will work towards patients accessing their full health records where it is beneficial via the online clinical system used by the Practice. CCGs recognise there is a national agenda driven by the BMA and RCGP that will influence the Primary Care national digital road map and developments of other record access systems across Nottinghamshire also offer opportunities to learn and deliver functionality to meet the requirement of new models of self-care. The potential of CareCentric Care Portal linked to a Patient Portal, the “Wiki” application that supports children and younger people with Education, Health and Care Plans plus the emergence of a number of other applications such as MyRightCare and Patients Know Best all have the potential to deliver benefit. With such a fast developing area of technology the ambition is to continue with the agile approach, not limiting



individual pockets of innovation but not fully committing to a single direction of travel at this time. The technology should fit the patient requirement and it is hoped that through work with NHS England and the HSCIC that a set of standards can be reached which will allow the patient to choose the best solution for them irrespective of where the data is held. Working as an aggregator of the data these patient held care records can then access the information pertinent to the patient’s self-care plan. Practices will have the option to view Summary Care Records (SCR) for patients that are not fully registered as part the delivery of care, to do this Practices will ensure they have a privacy officer in place to ensure there is a mechanism for monitoring SCR accesses by that organisation and that those accesses are legitimate. SCR will continue to play a part in allowing access to records across Nottinghamshire where patients from outside the local care community present to our services. Building on the excellent progress made by all GP Practices and care providers the opportunities for the use of SCR Version 2 will be monitored and reviewed. The CCGs will explore options in relation to how patients access their GP and wider care team (including secondary care and care homes). This will include building on existing learning on the use of telephone consultations, online consultations, audio-visual consultations, face-to-face appointments, supported consultations (using subject experts in remote locations) and telephone triage. All these new ways of working will allow GP Practices to make informed decisions on what would work best for them and their patients. Care navigation, video conferencing and collaboration tools will offer health and social care providers a whole host of opportunities to provide their services in a more efficient and productive manner. By allowing real-time, two/three-way interaction, using technology to effectively simulate the experience traditionally obtained face-to-face or to obtain clinical input during multi-disciplinary team meetings as and when needed. Video will also provide GPs with the ability to diagnose certain symptoms such as skin disorders without the necessity for patients to attend the Practice with additional support of specialist involvement remotely. In order to gain the greatest benefit to the patients and the care providers the CCGs will continue to support and observe the innovative developments taking place locally and nationally, building into commissioning intentions those areas that deliver the greatest results.



6. Integration of health and care Systems


Medical Interoperability Gateway Oct 2015

eHealthscope Feb 2016

Interoperability April 2019

Use of NHS number as primary identifier April 2015

Integrated digital care record (CareCentric Portal) Oct 2016

Consent principles April 2016

PDS Spine compliance Oct 2017

GP Systems of Choice (GPSoC) July 2016


o Everyone Counts: Planning for Patients 2013/14 published December 2012 o Caldicott 2: To Share or Not To Share published April 2013 o Information: A report from the NHS Future Forum o National Information Board: Personalised Health and Care 2020 o NHS England: interoperability hand book o Five Year Forward View into Action o Health and Social Care (Quality & Safety) Act 2015 o Local Estates Strategies - A Framework for Commissioners

Key Ambitions

o To use the NHS number as primary identifier across all providers o Set the strategic roadmap for integration/interoperability o To enable integration of care records to support the changing models of care defined in the

Vanguard programmes

Overview Concerns over security and privacy issues have led to a culture that is sometimes risk averse and reluctant to share information, even where it would improve patient care. An output from the NHS Future Forum work has been the clear message that “not sharing information has the potential to do more harm than sharing it”. The new Caldicott principle states ‘*the+ duty to share information is as important as the ability to protect confidentiality’ particularly if sharing is in the patients best interest. Information sharing between organisations and across the health and care and support sector is fundamental to an integrated way of working. Information should be recorded once at first contact then shared securely between care providers. Nationally defined standards will allow information to move freely between services and organisations in the local health community with data sharing remaining confidential, safe and secure, promoting public confidence in local services and in the information itself. Nottinghamshire CCGs recognise that the GP clinical system is a strategic component within healthcare. The quality of clinical data held within GP systems has never been more important both

Summary: This chapter outlines plans for integrating health and care systems across

all organisations and providers as well as between individual GP Practices.



internally to support the clinical and business processes within GP practices, and externally to support the delivery of care in the wider context. The CCGs, where applicable will align Practices and community provision to utilise, co-locate and share resources for patients in line with their estates strategies. This will enable CCGs to move towards all teams becoming integrated and tailored to particular need, whilst working together to utilise and share a limited workforce. GP practices working collaboratively in these areas will have requirements for the sharing of patient clinical information, administrative functions, back office functions and workforce. With Primary Care and improved self-care at the heart of the emerging models of care provision Information Technology will drive seamless integrated digital care records that bring together information from all providers of care. The focus will become “patient/citizen centric records” that are no longer limited by the organisationally separated information systems. Approach Numerous organisations play key roles in the delivery of care and so effective communication between GP and provider is extremely important; as is the sharing of data and records so that we can support better and seamless delivery of care. CCGs will therefore expect all providers to contribute to the development of an integrated digital care record (shared/single care record). One of the Future Forum’s recommendations is that NHS organisations should strive for interoperability, to enable the provision of more joined-up care; Nottinghamshire CCGs will ensure this recommendation is extended to include wider care providers such as social care, third sector organisations and care homes. If a patient has a complex condition, or set of conditions, we will ensure they are appointed a care co-ordinator, to work with multi-disciplinary teams responsible for delivering care. These multi-disciplinary teams comprising of community services, primary care services and social care services will have appropriate access to patient information regardless of the clinical system used. The CCGs will adopt national standards to sharing information meaning that systems will be able to connect and join up, rather than every organisation using the same technology or product. GP systems will be connected through Interoperability Gateways and portals allowing patient medical records to be shared to clinicians and staff who have a ‘legitimate relationship’ with the patient for the purposes of direct care. A fundamental part of this support will be the comprehensive and consistent use of the NHS number across health and social care services, at the point of care with the aspiration of achieving “real time” NHS number matching as care is delivered. The NHS Number will be used to connect patient records across the whole system as patients move between services. This alongside professionals being able to access relevant records online, simply, securely and in one place will enable more joined-up care. The NHS number will become far more visible to patients themselves, for example on every letter and appointment. As users of health and care services, and as members of the public, patients should become increasingly aware of their own NHS number and its ability to ensure that they are always correctly identified and how it can help ensure that their care and their records are appropriately reconciled and coordinated.

Nottinghamshire CCGs will procure and use innovation and advances in technology that will integrate clinical systems data with the wider community in order to support our natural communities and the integrated work programme. We will encourage economy-wide joined up patient care through systems integration, interoperability and information sharing across all



providers and General Practices encompassing Primary, Community, Secondary, Out of Hours and Social Care service, ensuring information around the patients is available to those who provide care. Whilst new technologies will be needed to deliver the ultimate ambition of fully integrated digital care records the digital road map will be developed to ensure existing assets are used to the full. Existing products such as eHealthscope will continue to play a significant role in the management of patients care, singularly within organisations and in support of co-ordinating multi-disciplinary care team resources.

The CCG, in agreement with other organisations will support the commissioning of Interoperability Gateways and the CareCentric Portal which will allow data from GP Practices operating different clinical system to be viewed by appropriately authorised staff, (which have a legitimate relationship with the patient), in other agencies such as emergency departments, community and social care whilst also ensuring data can flow back to these care providers enabling them to make better, informed decisions about care.



7. Technology Enabled Care Services – Remote and Assistive Care


Tele-care TBC after review

Tele-health TBC after review

Tele-consultation TBC after review

Teledermatology March 2016

Telecoaching TBC after review

Self-Care Apps Ongoing developments


o Everyone Counts: Planning for Patients 2013/14 published December 2012

o Caldicott 2: To Share or Not To Share published April 2013

o Information: A report from the NHS Future Forum

o NHS England (2014): 5 Year Forward View

o National Information Board (2014) Personalised Health and Care 2020

o NHS Commissioning Assembly (2015) Technology Enabled Care Services (TECS) – Resource

for Commisioners

Key Ambitions

o Providing alternative methods for patients to access primary care

o Remote monitoring for patients in their own homes or care home setting to anticipate

exacerbations

o Promote and support patient empowerment to self-manage

o To increase capacity in teams and services

o Keep the population healthy

o Promote the benefits of tele-care and tele-health

Overview NHS England’s National Technology Enabled Care Services TECS implementation group meeting (September 2015) reported that the national TECS work plan is being reshaped to align with the National information Board work streams so that it is a more unified strategy which will have political support, funding and resources. The digital roadmap will provide a plan that includes how organisations are moving along the digital maturity of TECS. Support will be available from the East Midlands Academic Health Science Network (EMAHSN). Across Nottinghamshire there is variable uptake on the use of tele-care and tele-health services with services across Health and Social Care. The digital roadmap will support further spread and adoption of services deemed most appropriate and cost effective with evidence on patient outcomes required. The implementation of Florence Simple Telehealth (FLO STH) has been commissioned by the Nottinghamshire Clinical Congress (6 CCGs) since 2012. The Nottinghamshire Assistive Technology

Summary: This chapter sets out how Tele-care, Tele-health and Tele-consultation

currently support patients, as well as plans to grow Technology Enabled Care Services across the health and social care community.



Team (NATT) programme has contributed significantly to the Quality Innovation Productivity and Prevention (QIPP) agenda, including the integration of Health and Social Care Services across provider organisations. Over 2400 patients have now utilised FLO STH across Nottinghamshire and alongside publications, 2 evaluation reports have been commissioned and findings shared. The NATT service has been an operational service since April 2015, continuing on the growth and success of the number of patients utilising FLO STH since the inception as a project in 2012. The FLO STH service is currently being utilised across care settings and pathways such as:

Hypertension Management

Heart Failure

COPD

Diabetes

Asthma

Ascites Management

Medication optimisation and compliance

There are over 140 different local protocols in use across primary, acute, community, mental health and social services. The AHSN are currently funding the evaluation of FLO STH use in acute settings and findings will be share in 2016. Across Nottinghamshire Healthcare Foundation Trust FLO STH is utilised within community and mental health teams alongside Buddyapp and Silvercloud, with evaluations of the latter two currently not yet completed. CCGs will assess the suitability of Flo and similar technologies in order to develop a better quality, more cost-effective service to vulnerable people across health and social care. This will be an integral part of Nottinghamshire’s integrated health and social care programme. Alongside the traditional use of tele-medicine applications the CCGs will provide patients with the ability to consult with their GPs using e-consultation capabilities (either video- or tele-consultation). Typically this will be through the use of Skype® or other similar technologies. Whilst the CCGs and other organisations in the health and social care community have elected to implement proprietary products, the success of e-consultation facilities will hinge on the flexibility for patients to use their system of choice. It is, therefore, imperative that the infrastructure deployed into GP Practices and other points of access is sufficiently flexible to communicate seamlessly with a range of products in common use. The NATT service vision is to join up solutions such as FLO STH with the use of for example Skype and has already successfully piloted the use of a virtual ward round between GP surgeries and learning disability and care homes. The team have also tested the AliveCor ECG app (highlighted as an NHS Innovation Accelerator) within a Heart Failure setting. The service and knowledge within the NATT team to create and design clinically effective protocols has been transferable to other solutions as technology changes. FLO STH also has interoperability with another Telehealth solution called Whzan which using biometric devices send readings and has been highlighted as a potential solution to be used by East Midlands Ambulance Service (EMAS) in order to avoid unnecessary transfer to hospital and allow remote monitoring of observations for say a 24 hour period. Where new innovations are implemented these should be integral to existing clinical systems where required but should not overwhelm clinicians and care professionals with inappropriate volumes of data. The NATT team are leading nationally on the drive to integrate FLO STH with TPP SystmOne and EMIS and this work is currently underway with the HSCIC. The focus of the NATT service and on how FLO has been deployed is on whole pathways transactions and utilisation of cost effective TECS and is



embedded into a number of the Vanguards programmes as well as across all Nottinghamshire providers with the Better Together programme in Mid Nottinghamshire having already made great progress in this area. The NATT service will work alongside other services such as Self Help UK and the voluntary sector to further roll out TECS and raise awareness amongst patients. Nottingham City CCG and City Council have an Assistive Technology Strategy which will see the successful integration of the Telecare and Telehealth services currently operated separately through the City Council and CCG, in partnership with Nottingham City Homes. The integrated Assistive Technology (AT) Service, effective from mid-2016, will provide a range of equipment and service to support citizens and patients with a variety of conditions, needs and risks, promoting a step up step down model for having the right equipment at the right time. An AT vision has been adopted which promotes the provision of AT to support key priority groups. These being:-

Preventing or delaying a move into residential care;

Hospital admission avoidance and supporting safe and timely discharges;

Patients with long term conditions – particularly those with respiratory conditions, heart

failure and diabetes;

Adults with learning disability, including autism;

Adults with dementia;

Disabled young people.

The AT vision sets out a target of supporting 10,000 people with Telecare and Telehealth by 2018.

Nottingham CCG is a Vanguard site for providing new care models into care homes. Promotion of Assistive Technology is a key element within the proposals which will see care home residents supported by Telecare, Telehealth and Telemedicine with a view to reduce hospital admissions from and support timely discharges back to the care home. There is a wealth of knowledge being collated across Nottinghamshire and this will be further utilised and required as Remote and Assistive care will be embedded into the 16/17 Operating Framework and will be mandated through the GP contract. Approach Nottinghamshire CCGs will continue to build on their existing work and will commission a strategic review into the most appropriate technologies by which their ambitions can be delivered going forward. Initially this will focus on the implementation of e-consultations in order to rapidly support the introduction of these options for patients and to introduce a mechanism by which demand on primary care can be managed more effectively. It is likely that the introduction of e-consultation capabilities will require hardware enhancements to consultation room IT equipment, since the availability of web cams is not covered under the existing GMS / PMS blue book minimum standards. The added financial pressure of reduced GP IT revenue allocations will mean that consideration may be given to a phased introduction for this capability over a period of up to 3 years. The CCGs will also consider the evidenced benefits of existing and emerging tele-care and tele-health technologies. Where there is clear evidence of positive impacts to quality and patient experience the CCGs will implement such technologies for those patients and / or conditions best suited to realise the projected benefits. It is envisaged this will extend beyond the traditional services



designed to support patients with chronic illnesses and could apply to patients with a wide range of conditions and complexities, supported by a wide range of devices used for the gathering of patient information. To help improve the patient’s ability to self-manage their own health needs the use of this technology may allow patients to text or email their self-taken readings through to the devices taking the readings and asking the patient to answer condition specific questions informing the appropriate clinicians as appropriate. These devices will also support patient education providing the correct advice to allow patients to make informed decisions in order to better self-manage their care reducing continuous unnecessary visits to their GP. The CCGs will also ensure clinicians understand their role in identifying suitable patients. The CCGs along with their member Practices will look at ways we can utilise these technologies to the benefit of General Practice across the primary care landscape. Exploring innovations in technology that will allow secure remote visual consultations to work alongside, for example, tele-dermatology to help patients gain access to health care that might be otherwise out of reach, lack the means of transportation or have mobility challenges, enabling patient’s access to specialists and clinicians without them leaving their home.



8. Use of data analysis to inform clinical behaviour and commissioning decisions


Risk Stratification tools (eHealthScope) Feb 2016

Data warehousing Maintained annually

Referral and decision support tools TBC in line with DMI

GP repository for clinical care (GPRCC) October 2016

Telecare apps linked to clinical systems On going development


o Everyone Counts: Planning for Patients 2013/14 published December 2012 o Caldicott 2: To Share or Not To Share published April 2013 o Information: A report from the NHS Future Forum o Five Year Forward View into Action

Key Ambitions

o Develop a Clinical Audit and Secondary Use data sharing and acceptable use model o Encourage the safe sharing of clinical audit and performance information o Create an environment in which clinicians are encouraged and empowered to evaluate their

decisions against the latest evidence and peer behaviour o Reduction in unwarranted clinical variation o Validation of the performance of new models of care o Allow benchmarking of organisational and care model performance

Overview Information is not always valued as a key tool to support decision-making and this has a knock-on effect in terms of cultures and behaviour. Information is often seen as the preserve of IT specialists and systems analysts, rather than as an enabler to providing better, more efficient care. Better use of information will enable better care and allow clinicians to compare their own performance and use richer sources of evidence for research, developing new services and innovations which will improve the range and quality of services available to patients. GPs need access to clear information that helps them understand and make informed decisions about the type of care and support that is best suited to individual patients, patient groups and the health economy as a whole. This includes the ability to compare the relative quality and benefits of different pathway options for patients and clinical audit of processes to understand which are the most effective. There is enormous potential from joining up information at the population level. Information on individual patients, when combined securely at a population level, gives the opportunity to have greater confidence in the accuracy and outcome of changes and provision of care models. This is essential if pathways changes are to be brought into effect quickly and efficiently to improve health and care outcomes. Nottinghamshire like other communities is undertaking a significant period of changes that will mean the introduction of new treatments, technologies and care delivery models. Technology is

Summary: This chapter identifies how information from clinical systems can be used

to improve outcomes and address inequalities in primary care.



transforming our ability to predict, diagnose and treat disease. New treatments are coming on stream each year. We can now demonstrate, both from examples within the NHS and internationally, that there are better ways of organising care by breaking out of the artificial boundaries between Primary and Secondary care, health and social care, between generalists and specialists—all of which get in the way of care that is genuinely coordinated around what citizens and patients that need and want it. Approach The use of risk stratification and decision support tools will be encouraged to help improve the quality of care whilst increasing efficiency and productivity. The CCGs recognise the enormous potential that these tools can offer but also understands their dependency on high quality data and the importance of enhancing that information through appropriate sharing. Risk stratification tools will continue to be used to identify those patients who are at greatest risk, enabling appropriate care plans to be in place. It is therefore important that we work with GPs and our IT providers when determining what technologies are best placed to ensure that data is captured both safely and appropriately. To this end eHealthscope will be re-launched to ensure it is fit for purpose moving forward. This tool will become more powerful, combining disparate data sources and providing the identification of those most at risk according to the most appropriate identification algorithm. This will not be limited to the current use of the Devon Tool. The development and implementation of the Nottinghamshire Clinical Audit and Secondary Use model will enhance our abilities to provide front-line primary care clinicians with this information whilst remaining compliant with the legislative changes withdrawing the ability for NHS commissioners to process patient identifiable data. Within Nottinghamshire considerable progress has been made over many years in the development of information provision. Within the CCGs the existence of a single, common data warehouse accessible through eHealthScope has made good inroads into the provision of an online resource bringing together the best of the relevant information allowing practices to access data around their patient population. In some instances CCGs will consider the use of national products to support the referencing of national or locally-defined clinical pathways. Map of Medicine will be considered as a product to deliver this functionality alongside its ability to record details of individual referrals. EHealthScope also provides this functionality but CCGs will consider the use of other functionality and the cost when implementing these as their preferred option. It is anticipated that there will be variations in some of the tools used to deliver improvements in particular aspects of care e.g. referral rates and clinical variation. CCGs and local authorities will make better use of the information they have, and move towards collecting and using information based on outcomes and quality, rather than simply the traditional activity and finance. Over time the CCGs will develop capabilities to share information for a wider variety of uses as the source data derives from patient’s care records. For GPs and their wider clinical teams this includes making information available on the performance and quality of services, in particular on individual clinical and other care outcomes at a more detailed level. This can include clinical audits down to individual clinician or clinical team, staff feedback and views, and patients’ and service users’ opinions, feedback and complaints. As the orchestrator of care the GP remains the most qualified to assess all data sources joined up around a citizen/patients care. For this reason they will be given the tools to enable the Clinical Audit and Performance Management that they require. Whilst others may assist in the processing of data on behalf of the



GPs, it is they who will decide in turn what anonymous information is made available for commissioning purposes. To strengthen these data processing capabilities CCGs will continue work with IT providers to commission data warehouses, creating a central repository of integrated data from disparate clinical sources allowing the data to be analysed helping to identify priorities for investment to improve outcomes and address inequalities. To ensure patients are being managed in the most effective manner, the CCGs will continually work towards enhancing existing systems to:

Provide multi-disciplinary teams the ability to assess and stratify the level or risk for patients being readmitted to hospital;

The provision of more granular information to support clinicians in examining variations in clinical behaviour through clinical audits;

The ability for GP Practices to normalise reported clinical variations by considering differences in working patterns and expertise of individual clinicians and early provision of data sharing across organisations to support Long Term Conditions and End of Life care.



9. How will we deliver this strategy? Digital Maturity From April 2016 CCGs are accountable for the development of Digital Roadmaps for their communities as part of their Authorisation Framework. This means that they need to set IM&T vision and strategy, agree plans to ensure digital maturity, drive integration, establish standards and maintain over all budgetary oversight. Primary care providers will continue to have a choice of high quality solutions, tailored to local need, underpinned by a commitment from the NHS Commissioning Board to support the development of a world-class information and technology infrastructure across health and care. This will be measured through the Primary Care Infrastructure Assessment Framework. Other sectors do not work in the same way and information systems and infrastructure are provided by the organisation’s themselves. This will also be assessed through the Digital Maturity Assessment Framework annually. To support the development of systems national funding is likely to become available as stimulus or capital funds. The CCG will ensure these opportunities are fully embraced in order to support a suitable level of Digital Maturity that meets the intentions of this and other strategies in line with local transformation and vanguard plans. User Support Successful organisations are underpinned by successful, resilient and well-supported IT systems. For the Nottinghamshire CCGs to continue their success they must be supported by high quality, resilient, responsive and cost-effective IT services. The increased reliance on IT and the probable extension to the hours within which primary care services are accessible to patients means that the CCGs’ IT service providers must respond to cover the broader scope and time required and meet the rising customer expectations. The CCG will review the arrangements for IT support in 2016/17 and ensure fit for purpose, appropriate and cost effective user support is in place to underpin the ambitions of this strategy. Training Through the revised GPSoC contracts, the Primary Care Development Centre and local provider arrangements, the CCGs will ensure training is provided to all Nottinghamshire Practices. CCGs recognise the importance of training and its vital contribution towards best and efficient use of clinical systems and IT and supported by Connected Nottinghamshire will also review plans as part of the Digital Roadmaps to ensure suitable change management and training is built into plans for all users across all providers. Information Governance The strategic aims will be delivered in line with Information Governance requirements including the legislative and regulatory obligations relating to the handling of information. All new system changes and developments will be done so within a framework which ensures necessary safeguards are in place for the appropriate use of personal and sensitive information. The Records and Information Group (RIG) will act as the lead for system wide development of Information Governance principles to support the sharing of information for direct care and secondary use. Through the development of Guidance Notices, the principles by which Nottinghamshire Health and Social Care providers will be directed. This will be supported by recognition of the importance of engagement and alignment of the group members by the CCGs in commissioning services. Oversight



and assurance will be provided to the CCGs’ IGM&T/Risk and Performance Committees to manage any risks to confidentiality and/or information security. The CCGs will support the review of the Nottinghamshire Consent model for information sharing on an annual basis (as well as ad-hoc where necessary). The RIG will develop guidance around the Nottinghamshire Clinical Audit and Secondary Use model to ensure data used for purposes other than direct care also conforms to legislation and best practice. Production and review of Privacy Impact Assessments (PIA) has now become an essential and useful part of an information related project. The CCGs will ensure the use of these and maintain an oversight of the content and quality of these through the IGM&T/risk and performance Committees. Furthermore, in line with the requirements of DSCNs 14/2009 and 18/2009, the CCGs’ IM&T Clinical Safety Officer will continue to undertake formal assessments for any local changes to existing software applications or new ones being implemented as part of local developments. Key areas to provide assurance of Information Governance and overall compliance will include assurance that the following are in place:

Robust polices, systems and processes are embedded in any project or new development;

The rights of patients and service users are respected at all times;

Privacy impact assessments will be built into all new processes to ensure any privacy concerns are highlighted at project initiation stage (and where there is a significant change to an existing information system or process) and must be approved by one or more Caldicott Guardians;

Risk assessments are carried out for all projects which will balance identified IG risks against the introduction of any new risks associated with the cessation of existing processes;

The confidentiality, integrity and accessibility of data is not compromised;

Developments and projects are delivered in accordance with the Information Governance framework and standards as set out in the Information Governance Toolkit (including but not limited to risk assessment processes, access controls and business continuity);

Equality Impact Assessments and Quality Impact Assessments will be completed for all new pieces of work;

The vision is delivered in line with the joint health and social agenda and involvement with wider stakeholder and partners;

Compliance with national, regulatory and local best practice and guidance;

There is close working with the nominated informatics provider. Governance Delivery of the strategic aims will be overseen by the IGM&T/risk and performance Committees of the CCG Boards. Regular updates will be presented to these groups from the Connected Nottinghamshire Board which will direct the implementation of the strategy and ensure delivery. Through the CCG Chief Officers the Health and Well Being Boards will sign off plans on an annual basis and ensure co-operation across organisational boundaries and sectors of care. Resources



In order to deliver these strategic aims significant resources will be required. Much of this is in place within organisations already but some will be new. It is vital that clinical leadership is in place to support each IGM&T initiative (with representation from all CCGs). These will be transitional resources and will vary over time. These will be identified within the Digital Roadmaps on an annual basis and will indicate where funding is available and where there is a shortfall. Where there are shortfalls the CCG will co-ordinate efforts to access funds to support these requirements. Finance To support delivery of this strategy there will be a requirement for new funding and innovative use of existing funding for both Capital and Revenue investment. As part of the controls for each project, identification of finance and controls on expenditure will be managed by the Project lead and reported to the appropriate programme board or IGMT/Risk and Performance meeting. In addition to this each project will have a benefits evaluation, including return on investment and value for money calculation (where appropriate). These controls will provide assurance to each project board attributed to individual CCG area. It is anticipated that applications for funding will be submitted against a number of national, regional and local finance schemes. These include but are not limited to; GP Information Technology fund, Primary Care Transformation Fund, Digital Roadmap/National Technology Fund, Vanguard support, Better Care Fund Pioneer scheme, Care Act Trailblazer scheme, Prime Ministers Access fund, Academic Health Science Network funding and other opportunities as they arise. Annually a finance plan will be produced to demonstrate affordability of the IGTM initiatives. Conclusion

Opportunities to utilise these current and new technologies are vast. From providing fast and efficient consultations with difficult to reach services, such as Prison Health Care environments or seeking a remote second opinion from a specialist physician in other areas of the country the options for new ways to deliver care are wide ranging.

We will improve communication across health and care providers by integrating services to reduce duplication and errors and make care more holistic. We will promote the right culture that places the patient at the heart of everything we do, and which will encourage innovation and transformation. Implementation of change must be performed at pace if clinical benefits are to be realised and the improvement in quality and patient experience felt by members of the public. To operate at this pace the CCGs will need to act decisively and in support of their IT service providers alongside those in other parts of the Nottinghamshire health and care community. It is essential that the CCGs engage with all primary care users of information and technology in order to commission the right solutions for the problems faced in Nottinghamshire’s wider health and care community. It is also essential that the CCG fulfils its new role in ensuring that all care providers across all sectors engage with their users to ensure the key deliverables and milestones identified within this strategy can be met. Great progress has been made to date in utilising technology to improve care. In order to meet the technological needs of the new models of care it is essential that this pace of change continues.



Appendix A: Nottinghamshire IM&T Road Map

01/01/2015

31/12/2015

01/01/2016

31/12/2016

Nottinghamshire IGM&T Strategy -

Key Milestones

01/10/2015

National requirement for all major providers to share discharge summaries electronically. All GP practices able to receive discharge summaries electronically

30/11/2015

Medical Interoperability Gateway (MIG) - Phase one complete Patient read code summaries viewed In all emergency care settings GP Repository for Clinical Care (GPRCC) – Pilot phase complete (NW CCG) Information sharing principles adopted across all health care providers SystmOne in care homes Pilot complete (in 5 care homes)

31/03/2016

Sharing of child protection information SYS CP-15 Patient online access to read code information Anticipated 25% increase in online booking and prescription transactions First digital Maturity framework results published First submission of CCG led Digital Roadmap April. Clinical Audit & secondary use data sharing model agreed across Nottinghamshire – April 16' First submission of new primary care digital Maturity framework -May 16' NHS Mail 2 Deployment

01/04/2015

Patient access to SCR becomes national requirement Use of NHS number as primary identifier in clinical correspondence and for identifying all patient activity in health and social care EPaCCS Deployment complete GP2GP Rolled out to all practices

01/01/2018

31/12/201801/01/2019

31/12/2019

01/01/2020

31/12/2020

01/04/2019

Full Interoperability across health in Nottinghamshire Full record digitalisation achieved across Nottinghamshire

Paper light working across Nottinghamshire Health economy

01/04/2020 NIB milestone: By 2020, all care records will be digital real-time and interoperable between health and social care. By April 2020, the entire health system will Adopt SNOMED clinical terminology Patients will have access to their full patient record

01/01/2017

31/12/2017

31/10/2016

GP server replacement project completion MIG phase 2 complete NUH rollout of care centric complete, exploit portal technologies to allow viewing of information across organisations Electronic discharge and transfer of care to use ITK Structured clinical messaging Primary care and community view into NUH via MIG Text messaging review on the use of SMS in primary care Secure email systems adopted by all health care community

31/07/2016

N3/COIN Network Upgrade complete Electronic Prescription service rolled out to all practices GP LSP contracts moved over to GPSoC contracts Summary Care Records version 2 review complete EHealthScope 2 deployment complete Full roll out of GPRCC complete

12/04/2017

All major health organisations to be PDS compliant Full adoption of ITK messaging standards for purpose of clinical correspondence

14/03/2018

Successor to GPSoC Implemented

19/10/2018 01/10/2017 SCR rolled out to community Pharmacy Exploit portal technologies in year 2 indicating incremental

interoperability across health and social care



Appendix B: Glossary

Community of Interest Network (CoIN) connects together multiple Trusts to network their services more efficiently.

Comprehensive Geriatric Assessment (CGA) is a multidimensional and usually interdisciplinary diagnostic process designed to determine a frail older person’s medical conditions, mental health, functional capacity and social circumstances

Connected Nottinghamshire Care Portal is a proposed tool that will give a detailed view of care provided to individuals from multiple care settings in Nottinghamshire to assist in the specific, direct delivery of clinical and social care.

Desktop on Demand provides a user with access to their desktop interface from any device and from any network.

East Midlands Radiology (EMRAD) is a consortium of seven NHS trusts within the East Midlands working together, hosted by Nottingham University Hospitals NHS Trust. Together they aim to create a clinical network, providing timely and expert radiology care for patients across the East Midlands regardless of their location, which will be seen as a national benchmark for new models of clinical collaboration within NHS radiology services.

E-consultations are consultations between patient and Clinician other than face to face via the use of technology, email, audio visual, or telephone.

eDSM is the enhanced data sharing model that has been introduced for TPP SystmOne sites which enables the safe sharing of patient information to support patient care on a consent basis.

Electronic Prescription Service (EPS Release 2) enables prescribers, such as GPs and practice nurses, to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient's choice.

Fair Warning provides an interface for Compliance Officers, Privacy Analysts, Auditors, and others which includes graphical dashboards for tracking privacy monitoring trends and reporting for "Audit Controls and Systems Activity Review".

GP2GP enables patients' electronic health records to be transferred directly and securely between GP practices that use different clinical systems.

GP Access is the system which allows GPs to view certain hospital information including discharge letters from certain NUH services, and allows booking of x-rays

GP Systems of Choice (GPSoC) provides practices with a choice of systems from GPSoC Framework suppliers in line with the requirements of the GMS contractual agreement.

Interoperability is the capacity for different computer systems to 'talk to each other'. It is a key theme in published policy documents, including the NHS Future Forum report 'The Power of Information’.



Medical Interoperability Gateway (MIG) allows access to care data from GP practices operating either clinical system. This can then be viewed through a number of ways including full integration with the GP system and through a web browser.

Missed appointment management system Tools or functions in place to better manage missed appointments such as text appointment reminders and email reminders.

Mobile working is the ability to work anywhere and at any time to access and update information from a supported mobile device.

NotIS is an internal NUH system which has been developed into a clinical portal which allows GPs to view certain hospital information including discharge summaries.

Online appointment booking/repeat prescriptions remote online access to a GPs appointment system enabling patients to book appointments and/or order repeat prescriptions.

Patient access to GP records will allow patients to view their own GP records online.

Portal brings a range of health indicators together in one place. Providing quick and easy access to hundreds of indicators, it's a valuable information resource for all health and social care professionals.

Primary and acute care systems (PACS) a whole system integration of primary, community, secondary, mental health, social and third party sector services provision new models of care.

Privacy Officer (Summary Care Records) When GP practices are able to view SCRs for patients that are not fully registered as part of delivering care; a local privacy officer will need to be in place to ensure there is a mechanism for monitoring SCR accesses by that organisation and that those accesses are legitimate.

SNOMED CT is a standardised, multilingual vocabulary of terms relating to the care of the individual and enables the representation of care information consistently, reliably and comprehensively as an integral part of the electronic care record. The use of SNOMED coding will support the recording of information to enable decision support such as care pathway management and drug alerts to support care of individuals and of populations.

Summary Care Records (SCR) provide healthcare staff treating patients in an emergency or out-of-hours with faster access to key clinical information about their medication and allergies.

Sunquest ICE provides the ability to request tests electronically, receive results electronically including other results for that patient requested elsewhere.

Tele-care is support and assistance provided at a distance using information and communication technology.

Tele-health is the remote monitoring of patients’ vital signs, usually as part of a treatment plan for a long term condition.



Appendix C: The Information Governance Review Recommendations The Information Governance Review was made public on the 26th April 2013. The report, some 139 pages long included key definitions, an additional Caldicott Principle as well as twenty six recommendations for organisations to adopt.

Document Reference Recommendation

1 (section 2.4)

People must have the fullest possible access to all the electronic care records about them, across the whole health and social care system, without charge. An audit trail that details anyone and everyone who has accessed a patient’s record should be made available in a suitable form to patients via their personal health and social care records. The Department of Health and NHS Commissioning Board should drive a clear plan for implementation to ensure this happens as soon as possible.

2 (sections 3.3 and 3.4)

For the purposes of direct care, relevant personal confidential data should be shared among the registered and regulated health and social care professionals who have a legitimate relationship with the individual. Health and social care providers should audit their services against NICE Clinical Guideline 138, specifically against those quality statements concerned with sharing information for direct care.

3 (section 3.5)

The health and social care professional regulators must agree upon and publish the conditions under which regulated and registered professionals can rely on implied consent to share personal confidential data for direct care. Where appropriate, this should be done in consultation with the relevant Royal College. This process should be commissioned from the Professional Standards Authority.

4 (sections 3.6 and 3.7)

Direct care is provided by health and social care staff working in multi-disciplinary ‘care teams’. The Review recommends that registered and regulated social workers be considered a part of the care team. Relevant information should be shared with members of the care team, when they have a legitimate relationship with the patient or service user. Providers must ensure that sharing is effective and safe. Commissioners must assure themselves on providers’ performance. Care teams may also contain staff that are not registered with a regulatory authority and yet undertake direct care. Health and social care provider organisations must ensure that robust combinations of safeguards are put in place for these staff with regard to the processing of personal confidential data.

5 (section 3.10)

In cases when there is a breach of personal confidential data, the data controller, the individual or organisation legally responsible for the data, must give a full explanation of the cause of the breach with the remedial action being undertaken and an apology to the person whose confidentiality has been breached.

6 (section 4.6)

The processing of data without a legal basis, where one is required, must be reported to the board, or equivalent body of the health or social care organisation involved and dealt with as a data breach. There should be a standard severity scale for breaches agreed across the whole of the health and social care system. The board or equivalent body of each organisation in the health and social care system must publish all




such data breaches. This should be in the quality report of NHS organisations, or as part of the annual report or performance report for non-NHS organisations.

7 (section 5.5)

All organisations in the health and social care system should clearly explain to patients and the public how the personal information they collect could be used in de-identified form for research, audit, public health and other purposes. All organisations must also make clear what rights the individual has open to them, including any ability to actively dissent (i.e. withhold their consent).

8 (section 5.5)

Consent is one way in which personal confidential data can be legally shared. In such situations people are entitled to have their consent decisions reliably recorded and available to be shared whenever appropriate, so their wishes can be respected. In this context, the Informatics Services Commissioning Group must develop or commission: guidance for the reliable recording in the care record of any consent decision an individual makes in relation to sharing their personal confidential data; and a strategy to ensure these consent decisions can be shared and provide assurance that the individual’s wishes are respected.

9 (section 5.9)

The rights, pledges and duties relating to patient information set out in the NHS Constitution should be extended to cover the whole health and social care system.

10 (section 6.5)

The linkage of personal confidential data, which requires a legal basis, or data that has been de-identified, but still carries a high risk that it could be re-identified with reasonable effort, from more than one organisation for any purpose other than direct care should only be done in specialist, well-governed, independently scrutinised and accredited environments called ‘accredited safe havens’. The Health and Social Care Information Centre must detail the attributes of an accredited safe haven in their code for processing confidential information, to which all public bodies must have regard. The Informatics Services Commissioning Group should advise the Secretary of State on granting accredited status, based on the data stewardship requirements in the Information Centre code, and subject to the publication of an independent external audit.

11 (section 7.4)

The Information Centre’s code of practice should establish that an individual’s existing right to object to their personal confidential data being shared, and to have that objection considered, applies to both current and future disclosures irrespective of whether they are mandated or permitted by statute. Both the criteria used to assess reasonable objections and the consistent application of those criteria should be reviewed on an ongoing basis.

12 (section 7.6)

The boards or equivalent bodies in the NHS Commissioning Board, clinical commissioning groups, Public Health England and local authorities must ensure that their organisation has due regard for information governance and adherence to its legal and statutory framework. An executive director at board level should be formally responsible for the organisation’s standards of practice in information governance, and its performance should be described in the annual report or equivalent document. Boards should ensure that the organisation is competent in information




governance practice, and assured of that through its risk management. This mirrors the arrangements required of provider trusts for some years.

13 (section 8.6)

The Secretary of State for Health should commission a task and finish group including but not limited to the Department of Health, Public Health England, Healthwatch England, providers and the Information Centre to determine whether the information governance issues in registries and public health functions outside health protection and cancer should be covered by specific health service regulations.

14 (section 9.2)

Regulatory, professional and educational bodies should ensure that:

information governance, and especially best practice on appropriate sharing, is a core competency of undergraduate training; and

information governance, appropriate sharing, sound record keeping and the importance of data quality are part of continuous professional development and are assessed as part of any professional revalidation process.

15 (section 9.4.2)

The Department of Health should recommend that all organisations within the health and social care system which process personal confidential data, including but not limited to local authorities and social care providers as well as telephony and other virtual service providers, appoint a Caldicott Guardian and any information governance leaders required, and assure themselves of their continuous professional development.

16 (section 10.3)

Given the number of social welfare initiatives involving the creation or use of family records, the Review Panel recommends that such initiatives should be examined in detail from the perspective of Article 8 of the Human Rights Act. The Law Commission should consider including this in its forthcoming review of the data sharing between public bodies.

17 (section 11.2)

The NHS Commissioning Board, clinical commissioning groups and local authorities must ensure that health and social care services that offer virtual consultations and/or are dependent on medical devices for biometric monitoring are conforming to best practice with regard to information governance and will do so in the future.

18 (section 12.8)

The Department of Health and the Department for Education should jointly commission a task and finish group to develop and implement a single approach to recording information about ‘the unborn’ to enable integrated, safe and effective care through the optimum appropriate data sharing between health and social care professionals.

19 (section 12.9)

All health and social care organisations must publish in a prominent and accessible form: • a description of the personal confidential data they disclose; • a description of the de-identified data they disclose on a limited basis; • who the disclosure is to; and • the purpose of the disclosure.

20 (section 12.10)

The Department of Health should lead the development and implementation of a standard template that all health and social care organisations can use when creating data controller to data controller data sharing agreements. The template should ensure that agreements meet legal requirements and require minimum resources to implement.

21 (section 13.2)

The Health and Social Care Information Centre’s Code of Practice for processing personal confidential data should adopt the standards and good




practice guidance contained within this report.

22 (section 13.3)

The information governance advisory board to the Informatics Services Commissioning Group should ensure that the health and social care system adopts a single set of terms and definitions relating to information governance that both staff and the public can understand. These terms and definitions should begin with those set out in this document. All education, guidance and documents should use this terminology.

23 (section 13.3)

The health and social care system requires effective regulation to ensure the safe, effective, appropriate and legal sharing of personal confidential data. This process should be balanced and proportionate and utilise the existing and proposed duties within the health and social care system in England. The three minimum components of such a system would include:

a Memorandum of Understanding between the CQC and the ICO;

an annual data sharing report by the CQC and the ICO; and

an action plan agreed through the Informatics Services Commissioning Group on any remedial actions necessary to improve the situation shown to be deteriorating in the CQC-led annual ‘data sharing’ report.

24 (section 14.1)

The Review Panel recommends that the Secretary of State publicly supports the redress activities proposed by this review and promulgates actions to ensure that they are delivered.

25 (section 14.2)

The Review Panel recommends that the revised Caldicott principles should be adopted and promulgated throughout the health and social care system.

26 (section 14.3)

The Secretary of State for Health should maintain oversight of the recommendations from the Information Governance Review and should publish an assessment of the implementation of those recommendations within 12 months of the publication of the review’s final report.



Appendix D: Caldicott 2 Review - Table of Commitments This table summarises the expectations and commitments that are within the body of this government response with a reference to the section or recommendation where the commitments or expectations can be found.

Organisational Group Commitment

All staff and workers within the health and care system expectation

Be aware that the duty to safeguard children or vulnerable adults may mean that information should be shared, if it is in the public interest to do so, even without consent (introduction)

All health and care organisations expectations

Look at information governance best practice and how it affects their work (introduction)

Examine their existing arrangements, and lead by example with their local partners to make it easier to share information (introduction)

Expect that relevant personal confidential data is shared among the registered and regulated health and social care professionals who have a legitimate relationship with the individual (2)

Seek advice from the ICO and refer to the HSCIC’s Confidentiality Code of Practice for further advice on managing and reporting data breaches (5)

Explain and apologise for every personal data breach, with appropriate action agreed to prevent recurrence (5)

Clearly explain to patients and the public how the personal information they collect could be used in de-identified form for research, audit, public health and other purposes (7)

Make clear what rights the individual has open to them, including any ability to actively dissent (7)

Use the best practice contained in the HSCIC’s Confidentiality Code of Practice when reviewing their information governance practices to ensure that they adhere to the required standards (12)

That social care providers use the Information Governance Toolkit (12)

Appoint a Caldicott Guardian or Caldicott lead with access to appropriate training and support (15)

Local authorities consider extending Caldicott Guardian arrangements to children’s services (15)

Strengthen their leadership on information governance (15)

Ensure that the information provided to inform citizens about how their information is used does not exclude disadvantaged groups (19)

Use the revised Caldicott principles in all relevant information governance material and communications (25)

Local NHS providers expectation

Audit their information sharing practices in adult NHS services against NICE Clinical Guideline 138 (2)

Local commissioners expectations

Use the NICE Quality Standard 15 in commissioning and monitoring adult NHS services (in relation to information sharing) (2)



Organisational Group Commitment

Investigate, manage, report and publish personal data breaches and ensure that commissioned bodies are investigated, managed, reported and published appropriately (6)

Implement appropriate arrangements in relation to information governance including the demonstration of strong leadership on information governance and adopt information governance procedures that are equivalent to those already established by healthcare providers (12)

Documents ends