Transformation Directorate

Delivering excellent, joined up care for older patients

Dr David Attwood is GP partner with a special interest in older people at Pathfields Medical Group, Plymouth, is Honorary Secretary of the British Geriatrics Society (BGS) and member of BGS GeriGP Group, and is Clinical Lead for the Integrated Care of Older People in Devon. David explains the importance of shared IT and information governance (IG) in coordinating care across different health and care organisations.

I’m a GP in Plymouth and in my day-to-day job, I see many older people living with frailty, dementia, and multiple health conditions. This complex group of patients benefit from the skills of multiple professionals such as GPs, district nurses, pharmacists and physiotherapists. To make sure that this multidisciplinary team of professionals is able to work together effectively, we need clear rules around sharing data, capable IT systems and a professional culture that allows them to share information and communicate across organisational boundaries.

Every day, lives are saved because we have the information we need to make decisions and are confident in sharing data to support care. My patient Mary, an 87 year old who lives at home, is one such example. In February I received an email from the district nurses asking for more pain relief for her leg ulcers and I telephoned Mary. It was clear on the phone that there was more to the issue than initially met the eye, so I accessed her shared care record. At this point the unfolding tragedy was laid bare; her leg ulcers were rapidly deteriorating, she had recurrent falls and was losing weight due to malnourishment. She was potentially weeks away from death.

An urgent comprehensive geriatric assessment (CGA) was started. Mary’s goals were to be in less pain and spend as much of her remaining time with her partner, Bill, as possible. The hospital was contacted and within days, the vascular surgeons had improved the blood supply to her legs. This reduced the pain and meant the district nurses could start to heal Mary’s ulcers, liaising closely with the primary care pharmacists who supported her to gradually reduce her pain medications.

Mary was malnourished and struggling to walk and manage things like her personal care. She was seen by a physiotherapist after she was discharged who offered her some equipment and a rehabilitation plan. A package of care was put in to support her in her own home with personal care and nutrition.

At the end of this period of assessment Mary was a normal weight, walking independently with a frame, was off most of her pain relief, and her ulcers were healing. The team produced a personalised care plan, which was shared with Mary and all health and care organisations in the locality.

Mary’s story illustrates how the different areas of the CGA are inextricably intertwined. If one area fails, the whole CGA unravels. Coordinating this across the hospital, community services, and primary care requires healthcare professionals to work together as one, where they produce, share, and update a shared CGA on a shared record.

There are two key enablers for this:

  • A robust IG framework, known and understood by all parties, to enable information sharing.
  • IT systems that enable healthcare professionals in different organisations to read, write and update a shared CGA in shared care record.

The pandemic has accelerated developments in information sharing for direct patient care. Also, NHSX’s IG portal provides clear guidance and advice, in lay person’s language, outlining when and how information can be shared. We are making great progress towards changing information sharing behaviour across health and care organisations.

Another critical barrier lies in IT systems’ capabilities to enable shared working across providers. When contemplating IT systems in a locality, certain minimum standards are needed to ensure healthcare professionals have the functionality they need to do their jobs well. I’d suggest that these include, as a minimum, read and write access across organisations, so that all the right professionals are viewing and inputting into the same information; scheduled appointment reminders so that professionals are regularly checking in on patients who may not make contact proactively, and a secure way of communicating across organisational boundaries.

In summary there are 10,000 people like Mary in my locality alone, all needing healthcare professionals to work together across organisations in the way outlined above. Sensible and proportionate information sharing is an essential enabler to this method of care. IT systems’ capabilities are similarly critical. I’ve outlined my own thoughts on some minimum standards above, which are desperately needed to ensure excellent, joined up care.

I believe that the next steps start with a thorough appraisal of both IG frameworks and IT systems against standards, so that healthcare professionals can work together as one big team, delivering the service specifications (particularly the Ageing Well workstreams) outlined in the NHS Long Term Plan.