Digital Healthcare Strategy

Digital Healthcare Strategy 2015-2020

Croydon Clinical Commissioning Group Digital Healthcare Strategy 2015-20 Amendment history: Version Date Amendment V0.1 12/10/2015 Outline document created V0.2 17/11/2015 Document populated V0.3 18/11/2015 Internal HRC review and update Approvals: Name Lead Date of Review Date of signoff Version

Contents 1. Executive Summary... 3 2. Introduction... 5 2.1. Purpose of this document... 5 2.2. Process used for the development of this strategy... 5 3. Strategic Context... 6 3.1. National context... 6 3.1.1. The Five Year Forward View (FYFV) and the role of IM&T... 6 3.1.2. Implementing the Five Year Forward View Local Digital Roadmaps... 7 3.1.3. Local Digital Roadmaps... 7 3.1.4. Outcome Based Commissioning (OBC)... 8 3.1.5. Integrated care and population health... 9 3.2. Local context... 9 3.2.1. Croydon Clinical Commissioning Group... 9 3.2.2. Croydon s Population... 11 3.2.3. Commissioning... 11 3.2.4. General Practice... 12 3.3. Local and regional integrated care initiatives... 13 4. Stakeholder Analysis... 14 5. Current IM&T Environment... 16 5.1. Commissioning Support Service (CSU)... 16 5.1.1. CSU services... 16 5.1.2. Business Intelligence... 16 5.2. Primary Care... 17 5.2.1. Primary Care Systems... 17 5.2.2. Medicines Optimisation and Variation Teams... 18 5.2.3. Mobile and remote access... 19 5.2.4. Infrastructure and hardware... 19 5.3. CCG IM&T environment... 19 5.4. IM&T in the local healthcare economy... 20 5.5. Summary of current IM&T environment... 21 6. Vision and strategic objectives... 22 6.1. Vision and Mission... 22 1

6.2. IM&T strategic objectives... 22 6.2.1. Objective one - Utilising IM&T to improve integration and quality of care across the health economy... 23 6.2.2. Objective two - Sharing of patient information across provider organisations... 23 6.2.3. Objective three - Technology to promote wellness and engage and empower the people of Croydon... 26 6.2.4. Objective four Business Intelligence to understand population needs, and manage contracts 27 6.2.5. Objective five Provision of robust infrastructure and IM&T support... 28 6.2.6. Objective six Optimise, standardise and integrate GP software to support clinical knowledge and decision making... 29 6.2.7. Objective seven - Improving the satisfaction and productivity of the workforce through information and digital technology... 30 6.3. What will 2020 look like.... 31 7. Action and implementation plan... 34 8. Conclusion... 35 Appendix A Governance... 36 2

1. Executive Summary The Croydon Clinical Commissioning Group (CCG) was established in 2013 and provides services for a large and diverse population in south west London. The CCG represents 57 practices and six GP networks providing the clinical leadership which is instrumental in achieving the goals of the CCG, GPs, and their provider partners. NHS England s Five Year Forward View highlights the role digital and information technology will play in transforming the NHS to meet the challenges ahead. CCGs nationally have been handed the responsibility of coordinating and driving forward Local Digital Roadmaps. Croydon CCG has a significant task, and a strong opportunity in undertaking this role. This is the first Digital Healthcare Strategy produced by the CCG. The executive leadership and board members recognise the important role IM&T will play in ensuring success of the borough s integrated care, and outcomes based commissioning goals. This strategy sets out to deliver against these ambitious goals. This Digital Healthcare Strategy demonstrates the role information and digital technology will play in the delivery of improved population health outcomes for the people of Croydon for the next five years. The strategy explores both the national and local strategic context for IM&T and also engages with the needs and aspirations of partners and stakeholders. Croydon s strategic vision for IM&T is to: to achieve: use the power of intelligent information and digital technology Longer healthier lives for all the people in Croydon Through an ambitious programme of innovation and by working together with the diverse communities of Croydon and with our partners, we will use resources wisely to transform healthcare to help people look after themselves, and when people do need care they will be able to access high quality services The strategy outlines seven key strategic objectives to meet this vision. The first is an overarching goal for IM&T to support the CCG s integrated care, quality and health outcome goals. The remaining six provide core objectives to support and enable this objective to be achieved. The seven objectives are: Overarching goal: 1. Utilising IM&T to improve integration and quality of care across the health economy Core supporting objectives to achieve this goal are: Enabling objectives: 2. Sharing of patient information across provider organisations 3. Technology to promote wellness and engage and empower the people of Croydon 4. Business intelligence to understand population needs, and manage contracts 5. Provision of robust infrastructure and IM&T support 6. Optimise, standardise and integrate GP software to support clinical knowledge and decision making 3

7. Improving the satisfaction and productivity of the workforce through information and digital technology An action plan is set out in section seven which outlines key developments over the next five years to deliver the structures and processes required to implement the strategy. The CCG will be required to rapidly put in place the foundations of this strategy in order to meet Digital Roadmap and Outcome Based Commissioning timelines. In conclusion, this strategy aims to ensure that CCG has the appropriate structures in place as they embark on a progressive integrated care and commissioning programme. The strategy aims to achieve the population health goals of Croydon while also aligning with the goals of local, regional and national initiatives. The importance of communication, intelligent data, and digital technology to support these collaborative goals cannot be understated. The strategy strongly recommends that the CCG invests in and drives forward additional structures and roles to support the successful delivery of this Digital Healthcare Strategy. It is also recommends that the strategy is refreshed on annual basis over the next five years to reflect the fast changing pace of technology and healthcare. 4

2. Introduction Croydon CCG is responsible for commissioning the health services for a diverse, growing and challenging population. It supports one of the largest number of GP practices of any CCG in London, while continuing to manage the significant shortfall it inherited at its inception in 2013. The CCG, along with its provider partners, has recently adopted new and forward thinking commissioning goals by moving to an Outcome Based Commissioning approach for people aged over 65. This is the first IM&T strategy produced by the CCG. Existing IM&T initiatives have focused on provision of technology and information to support GPs in their practices. This strategy aims to build on this base and create a solid environment for supporting the integration and quality improvement goals of the CCG. 2.1. Purpose of this document This documents sets out NHS Croydon CCG s high-level vision for the future of IT for health and social care across Croydon for the next five years. It identifies the strategic objectives to be achieved in order to fulfil that vision. The document will inform the CCG s Digital Roadmap for the local health economy which is required to be submitted to NHS England in April 2016. It will also inform the organisation s Strategic and Operational plans. The IM&T Strategic Vision illustrates how digital technology can help support the CCG in its commissioning goals, and as an enabler of transformational change in service delivery over the next five years. The target audience for the document includes the CCG s senior management, CGG governing board members, and senior primary and secondary care clinicians within Croydon. 2.2. Process used for the development of this strategy The strategy has been produced based on the following inputs: National policy and guidance in relation to healthcare IM&T Strategic documentation produced by the CCG and local healthcare economy Interviews conducted with over twenty local individual stakeholders A Strategic vision and objectives workshop with senior primary care and CCG personnel The process used for the development of this strategy is summarised in the diagram below: 5

3. Strategic Context This section describes the context in which the CCG operates and identifies the key strategic drivers at a national, regional and local level. 3.1. National context 3.1.1. The Five Year Forward View (FYFV) and the role of IM&T In October 2014, NHS England produced Five Year Forward View (FYFV). This sets out a clear view of the challenges ahead, why change is needed, and what change might look like. It outlines a vision to address the challenges facing the NHS, and to drive better patient outcomes. The estimated 30 billion gap in NHS funding predicted to appear by 2020-21 could be closed completely if the health service develops new, more efficient care models. Digital and information technology is a key enabler to deliver this transformed future for the benefit of every service user, carer, citizen and professional. The Five Year Forward View states that the biggest challenges the NHS is facing remains: 1. changes in patient health needs and personal preferences; 2. changes in treatments, technology and care delivery and the need to provide care that is genuinely co-ordinated around what people need and want; and 3. changes to funding continued decline in funding growth. Some key themes that need to be addressed to overcome these challenges are outlined below: Quality recent reports into quality of NHS care have all called for a truly patient focussed culture, greater transparency and more rigorous management of standards. The FYFV continues the focus on quality stating that NHS organisations must narrow the gap between the best and the worst whilst raising the bar for all. Prevention - As populations are living longer with more chronic health conditions, communities must work toward reducing causes of preventable illness such as obesity and lifestyle risks. Organisations must successfully incentivise and support healthier behaviours then we can prevent ill health and increasing demands on healthcare. The FYFV focusses on targeted prevention, supporting a healthier workforce and working across healthcare partners to enable local, democratic leadership. CCGs have been asked to work with local government partners to set goals to reduce local health and healthcare inequalities and improve outcomes for health and wellbeing. This includes specifying agreed actions, interventions and metrics, in line with NICE guidance, with respect to patient and staff lifestyle factors. Patients and communities- The FYFV builds on the Government s vision of an NHS that puts patients and the public first, where no decision about me, without me is the norm. It states that patients must have more access to their healthcare information, increased control over the care that is provided to them, and more support in managing their own health. The wider community, including carers, third sector and citizens, also play a vital role and must be engaged in new ways to support the challenges ahead. New models of care - Over the next 5 years and beyond the NHS will increasingly need to flex its traditional care boundaries to support truly integrated, patient centred care. The FYFV defines its own view of what healthcare should look like over the next 5 years and introduces new organisational types and care models including: 6

Leadership and workforce - Radical change, can only be achieved with the leadership and people to make it happen. Greater support is needed to help mobilise leaders and workforces to work differently, develop the newly needed skills, values, behaviours and numbers to deliver the improvements needed. Efficiency and productivity - By 2015, the NHS needs to make savings of 20 billion with an additional 30 billion required by 2021. It has been estimated that funding growth will remain at 1.2% per annum, which will be half of what is needed to fund future services. With the Better Care Fund shifting a significant amount of NHS funding to Social Care in 2015/16, the financial future of the NHS is increasingly challenging. Greater efficiency and productivity is key to delivering the NHS vision for the future as demand increases and funding decreases. Health innovation - The FYFV highlights the need for health innovation in relation to research, personalised care, accelerated innovation in ways of delivering clinical care such as apps and telemedicine. Information and technology The FYFV focusses heavily on the importance of information and technology in achieving the required changes the NHS has to make. It talks of a national focus on key systems that will provide the electronic glue to enable different parts of the NHS to work better together. Key elements include: comprehensive transparency of performance data; expanding set of NHS accredited health apps to support digital inclusion; fully interoperable electronic health records continuing the move towards paperless; family Dr appointments and prescriptions online, everywhere; better audit data; increased focus on technology including smart phones; and support to help build capacity and help those unwilling or unable to use technology. 3.1.2. Implementing the Five Year Forward View Local Digital Roadmaps NHS England has subsequently released guidance and frameworks for organisations to achieve the goals outlined in the FYFV. The National Information Board (NIB) published a framework outlining proposals to transform outcomes for patients and the wider population. The Board plans to issue a set of road maps and standards which will provide a more detailed approach to transforming digital care. Key milestones include: from March 2015, all citizens will have online access to their GP records; by 2017, 100,000 individual genomes will have been sequenced; by 2018, clinicians in primary care, urgent and emergency care and other key transitions of care contexts will be operating without the use of paper records; by 2020, all care records will be digital real-time and interoperable. 3.1.3. Local Digital Roadmaps The NIB Framework for Action calls for CCGs to produce digital roadmaps outlining how their local health and care economies will achieve the ambition of being paper-free at the point of care by 2020. CCGs will be required to submit their plans in April 2016, as part of the annual Clinical Commissioning Group planning process. Commissioners have been asked to take a lead on coordinating and collaborating with their neighbouring providers to dissolve the artificial barriers between care settings, and between healthcare professionals. The local digital roadmaps will provide a means for the CCG to communicate plans to local stakeholders and inform local service transformation, commissioning and investment strategies. The most recently published timelines for digital roadmap activities are shown below but are regularly updated. 7

3.1.4. Outcome Based Commissioning (OBC) In answer to many of the challenges outlined above, commissioners are taking the opportunity to improve local health and care systems by developing new and innovative commissioning partnerships to support integrated care. Commissioners are moving away from traditional commissioning models towards an outcome based commissioning approach. Traditional commissioning tends to focus on processes such as payment for activity or organisational performance. With outcome based commissioning, health and care services are paid for based on achieving outcomes that are important to service users. OBC is interested in net productivity based on outcomes in relation to the resources used - an approach which aligns with the FYFV s focus on efficiency gains. The King s fund paper, Commissioning and Contracting for Integrated Care identifies some of the more common contractual outcomes including: patient experience and satisfaction with services early detection and intervention, to support people to recover and stay well supporting people to manage their condition, and increasing patient involvement in decisionmaking improved patient outcomes (including survival rates) reducing emergency admissions to hospital delivery of co-ordinated and patient-centred care, demonstrating joined-up working effective information-sharing, including use of technology It is clear from these examples that information management and technology will play a significant part in supporting organisations to achieve OBC. Identifying the supporting data elements, and technology platforms will need to play a key part in contract negotiations and redesign of services. The high level implications of OBC for IM&T are: pooling of population, patient, service and finance data to measure outcomes and report against contracts; health intelligence platforms to support the detection and early intervention of illness; 8

technology to support data collection across the continuum of care; data sharing to support co-ordination of patient centred care; business intelligence platforms to support benchmarking, data analysis, reporting and predictive modelling; and innovative technology to engage and empower patients. 3.1.5. Integrated care and population health Integrated care has become a central theme to health service reform in recent years due to the changing burden of disease and decreasing health and social care budgets outlined above. Integration of services through policy initiatives such as amendments to the Health and Social Care Bill, and the establishment of the Better Care Fund, have made some progress towards coordinating care of older people and those with complex needs. Integrated care has seen benefits such as allowing people to live independently in their own home, and reducing use of hospital services. However, these efforts have not yet extended to the broader health of local populations. Population health aims to achieve a wider co-ordination across a geographical population. It requires partnerships across many sectors to integrate investments and policies in order to improve the health of a total population. Access to traditional health and services plays an important part in the health of a population, however evidence indicates that it is not as important as lifestyle, the influence of the local environment and the wider determinants of health. With population health, accountability is spread across the community and not just within the boundaries of health and care services. The paper, Population Health Systems Going Beyond Integrated Care, (The Kings Fund, February 2015) sees integrated care as part of a broader shift to population health and cites evidence such as the large and avoidable differences in health outcomes between social groups, increase in co-morbidity increasing with deprivation, and the clear link between morbidities and lifestyle. A number of countries outside the UK have begun to make this shift from integrated care to population health and these all share similarities: At the macro level organisations work together across systems to improve health outcomes across a whole population. Specific interventions target the most deprived group. In contrast integrated care models tend to target frequent service users. At the meso level people with similar needs are grouped together and services and interventions are tailored accordingly. This requires population segmentation and risk stratification to identify the needs of different groups, and systems within systems to focus on the various groups. At the micro level, population health systems deliver a range of interventions aimed at improving the health of individuals and involve a range of varied services. This includes integrated health records to co-ordinate peoples care services, scaled up primary care services to co-ordinate effectively with other services. 3.2. Local context 3.2.1. Croydon Clinical Commissioning Group NHS Croydon Clinical Commissioning Group (Croydon CCG) was established in April 2013. The CCG inherited a significant financial shortfall of 33.9m which is evident in the historical underinvestment in certain services and infrastructure. 9

The CCG s vision for longer healthier lives for all the people in Croydon is being delivered by transforming services that provide safe, effective, high quality, patient centred services through clinically-led, innovative redesign. In 2015 NHS Croydon CCG agreed the following aims: develop as a mature membership organisation; commission integrated safe, high quality services in the right place at the right time; have collaborative relationships to ensure an integrated approach; and achieve financial balance over five year. The CCG has responsibility for planning, buying and monitoring most local health services, including: outpatient appointments and planned operations (planned hospital care); urgent and emergency care (including out of hours services); rehabilitative care; maternity services; community health services (for example physiotherapy and district nursing); mental health services; services for people with disabilities; and prescribing by member practices. To ensure they make the best use of resources the CCG is embarking on a programme of transformational change through: prevention, self-care, shared decision making; outcomes based commissioning; transforming adult community services; improve integration of care; reducing unwarranted primary care variation; and whole system redesign. Some of the key local service providers are Croydon Health Services NHS Trust, St George s Healthcare NHS Trust, The Royal Marsden NHS Foundation Trust, South London and Maudsley NHS Foundation Trust, Care UK and Virgin Care. Priority outcomes The CCG has identified the following priority outcomes based local service challenges and on population needs identified through the Joint Strategic Needs Assessment: Reducing potential years of life lost through disease; Ensuring people are seen in the right place at the right time; Children and young people reach their full potential; Increased independence; and Positive patient experience. The CCG also focuses on the following long term needs of their population: Cardiology; Chronic Obstructive Pulmonary Disease (COPD); Diabetes; Cancer; Mental Health including Dementia; and Children and Young Adults. 10

3.2.2. Croydon s Population Health and care services in Croydon face the challenge of a growing and diverse population. In addition to the national trend of an aging population, Croydon also expects an increase in the number of young people due to the high birth rate and the effects of immigration. 395,000 people are registered with a GP in Croydon and based on current projections; the population of Croydon will increase by 9.2% over the next ten years, and by 16.8% over the next 20 years. The number of people aged over 65 is expected to increase by around two-thirds by 2030. Over half of the population of Croydon would identify themselves as being from an ethnic group other than White-British and this rate is expected to increase. Over 100 languages are spoken as a first language by patients registered with Croydon GPs. Croydon also has a high number of care homes. Croydon has 144 care homes that are registered with the Care Quality Commission (CQC), with a maximum capacity to care for 2,796 people. Health of the population The health of the population is complex and mixed when compared to the English average. For example: Life expectancy is higher than average, but significantly lower for people in the most deprived area of the borough. Deprivation is lower than average, but growing at a higher rate than surrounding boroughs. There is a higher need for mental health inpatient services than comparative boroughs and the number of people with mental health support needs is increasing. Lifestyle factors are a concern - an estimated 62% of adults are overweight or obese, and 17% of residents are smokers. The borough has a high number of looked after children including over 400 unaccompanied asylum-seeking children. The prevalence of diagnosed diabetes in Croydon is 6.5 % is significantly higher compared to the rest of London or England. Breast and cervical cancer screening rates are both significantly worse than the national average. The transformation of healthcare services provided by the CCG reflect this current and evolving demographic picture. 3.2.3. Commissioning The CCG have been transforming local healthcare services for two years through clinically-led, innovative redesign of services and are developing models of care planned and co-ordinated around the needs of patients and their families. Croydon s Outcomes Based Commissioning approach Croydon CCG and Croydon Council have jointly developed an Outcomes Based Commissioning approach to buying health and social care services for people of Croydon over the age of 65. The capitated payment mechanism allows both organisations to jointly buy services in a way that incentivises preventative and proactive care and keeps people, and improves outcomes for the population. The scope of the OBC includes people aged 65 and over registered with a Croydon GP. The contract will initially focus on planned and unplanned acute care, community, out of hospital services, continuing care, prescribing and older people mental health services, but to achieve the outcomes envisioned, the providers will need to work collaboratively across health and social care services. 11

Providers have together formed a legal entity called the Accountable Provider Alliance (APA) to meet this need. The APA consists of: Age UK (Croydon); Croydon Council (Social Care); Croydon Health Services NHS Trust; GP Federation; and South London and Maudsley NHS Foundation Trust. 3.2.4. General Practice The Croydon CCG consists of 57 GP practices across Croydon. There are six geographically based networks of practices are each led by a GP Clinical Lead and supported by network co-ordinators. These networks are: East Croydon Network Mayday Network New Addington/Selsdon Network Purley Network Thornton Heath Network Woodside/Shirley Network In addition to this the Clinical Leadership Group (CLG) provides clinical and corporate support to the CCG s Governing Body, by driving key development and implementation of plans. The Croydon GP Collaborative GPs in Croydon have recently converged under a new organisation to provide services at a greater scale than is often possible at individual GP practice level. This move has been driven by the strategic need for to 12

ensure that GPs have the capacity to meet current and future demand and deliver a comprehensive, high quality service for the whole Croydon population. In addition, GPs need to ensure they are in position to meet commissioning requirements, GPSoC Standards and LMA obligations. 3.3. Local and regional integrated care initiatives Better Health for London Better Health for London aims to work toward London becoming the world s healthiest major city. It consists of the joint partnership of The Mayor of London, NHS England, Public Health England, London Councils and the 32 GP-led clinical commissioning groups. Partners will align the objectives and aims of health and wellbeing strategies to achieve a common goal. South West London Collaborative Commissioning The six south west London CCGs (Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth) and NHS England, came together in April 2014 to work under the umbrella name of South West London Collaborative Commissioning (SWLCC). The CCGs are working together as SWLCC on a long-term plan to improve the quality of care in South West London for the benefit of patients and people of the area, and jointly developed commissioning intentions for 2015/16. This focusses on the priority work areas outlined in the five year strategy. Developing an IM&T Strategy to support this shared goal has been a key aim of the collaborative. Integrated commissioning unit (ICU) The CCG launched the ICU in partnership with Croydon Council in April 2014. The ICU has brought together commissioning support functions in relation to services for children, mental health, learning disabilities and vulnerable older people. The joint approach aims to improve the quality of local services, and to achieve results more efficiently whilst combining commissioning resources. The Better Care Fund will build on this joint working to achieve its goals and aims, and will provide Croydon will total 21.5m for 2015-16. 13

4. Stakeholder Analysis Stakeholder engagement interviews were held with local stakeholder groups to ensure all perspectives were considered during development of the strategy and to understand key strategic themes. CCG management and board members; General Practitioners and practice staff; CCG staff; Patient advocacy group, Healthwatch; Accountable Care Provider (APA) representatives including NHS Croydon Health Services; Local Health Authority; Commissioning Support Unit (CSU); Croydon GP Collaboration; and South West London Commissioning Collaboration. Findings of the interviews are summarised in the table below (not listed in any order): 14

Croydon Clinical Commissioning Group 2015-2020 Digital Healthcare Strategy 15

5. Current IM&T Environment This section describes the current status of the CCGs IM&T environment, capacity and capabilities. This information has primarily been sourced from stakeholder interviews. 5.1. Commissioning Support Service (CSU) Currently all IM&T services for Croydon CCG and Primary Care IM&T are outsourced to the South East Commissioning Support Unit (CSU). There are no IM&T services or functions provided in-house apart from an oversight role through the CCG s Director of Quality and Governance. This review also found that prior to development of this strategy there has been no IM&T strategy or strategy function in place for either the GPs or the CCG. 5.1.1. CSU services The CSU provides a wide range of IM&T services including: service desk support (hardware and software); infrastructure; software and hardware licencing; information governance (IG) guidance and support; telephony; procurement and supplier management; business intelligence (BI); and transformation and redesign. The CCG relies on the CSU for a range of services. The CCG most recent large project provided by the CSU was to upgrade GP practices to Microsoft Windows 7. Satisfaction with help desk services from the CSU is variable but most stakeholders felt that there were opportunities for improvement. The CCG is committed to outsourcing their IM&T and there is a desire to create a successful technology partnership with the CSU. 5.1.2. Business Intelligence Business Intelligence is a critical service for the CCG. They are dependent on analytics to understand the health needs of their population, and to manage and monitor contracts both core functions of their business. The CCG has a contract in place to receive additional services from the CSU s BI team. A dedicated team of data analysts provide data and analytics based on CCG requests for data. CCG staff also have access to data cubes to analyse data themselves. Feedback from the stakeholder interviews raised a number of gaps in relation to provision of Business Intelligence. These included: misalignment between CCG and BI team understanding of priorities and output of BI requests; underutilisation of the Data Cube query tool by CCG staff; lack of standardised and centralised primary care data; breadth of data data is primary and secondary care focused with very little mental health or community data and these cannot currently be linked (for example, for purpose of tracking outcomes); GP and secondary data is activity based (for example, QOF and CDS), not meaningful or outcomes based 16

ability to derive cohorts or registers of data is limited; benchmarking data is available but not utilised fully; more agile development of real-time dashboards is needed for clinicians and managers; and data analytics requirements are lacking for OBC. 5.2. Primary Care Croydon GPs have been moving towards use of a single primary care system, EMIS, across the borough as a result of individual practice choice. However, even across practices using EMIS, there are non-standardised workflows and utilisation producing variation in outputs (for example, data and coding). This variation is greater between EMIS and non-emis practices. Non-standardisation in the use of systems has contributed to some of the variations found in benchmarking and performance data. Historical underinvestment in IM&T strategy has meant that there is not a single strategic approach to the selection and purchasing of IM&T solutions. This has led to issues with the deployment and adoption of some GP software solutions. They are not perceived to be fully meeting the needs of the GPs, or value for money. 5.2.1. Primary Care Systems The following clinical systems are currently in use: GP Clinical Systems Through the national General Practice Systems of Choice (GPSoC) scheme Croydon s GPs can choose which clinical system the wish to use. An increasing number of practices (approximately 90%) are using EMIS Web and the remaining practices using InPractice Systems (InPS). It is believed that more practices will move to an EMIS as the practices organise themselves to deliver services seven days a week and look for other opportunities to exploit economies of scale. Docman - Docman is a document management system, which integrates with the GP clinical systems. It is used for receiving, editing, sharing, storing and viewing documents, including electronic letters and discharge summaries from secondary care. The workflow also encompasses automatic patient identification, filing and a coding tool. Docman is regarded positively by GPs and practice staff but is not used consistently across Croydon practices. GPs and practice staff have indicated dissatisfaction with quality of discharge summaries as one reason for disengagement with Docman. However, feedback also indicated that discharge summaries are improving, and there are opportunities for this to improve further now that Croydon Health Services are released from the National Program for IT (NPfIT). Sunquest ICE ICE is used for pathology requesting and has recently been extended to requesting 2 week wait cancer referrals. This has not been well received by GPs due to lack of consultation, duplication of data entry and deviation from existing workflows and data flows. National Systems - The National e-referral and Electronic Prescription Services are in use at most practices. Clinical Decision Support The CCG has recently implemented DXS, a point of care Clinical Decision Support System (CDSS) which allows CCGs to manage and distribute decision support information to primary care users. The software is designed to equip with GPs with support information aligned to local pathways and CCG clinical, policy and business objectives. Context is shared between DXS 17

and GP system, so that patient information pre-populates the form avoiding duplication of data entry and transcription error. However, decision support information is only available to GPs when they access a patient record and cannot be used as a resource to access ad-hoc information. There are no other on-line knowledge content systems available to GPs apart from prescribing protocols stored on the intranet and maintained by the CCG Medicines Optimisation team. The deployment of DXS has had some issues which are still being resolved. Rollout of the pathways has been slow and adoption has been low. However, this functionality will be an important means to ensuring locally agreed pathways are met in an integrated care environment. The status of the deployment is currently: Total Forms = 127 Number sent to DXS = 105 (83%) Number available on DXS = 77 (61%) Dashboards The only dashboard currently available to Croydon GPs is an Urgent Care Dashboard provided by the CSU providing a static view of recent urgent care data within an excel format. Urgent Care Dashboards support proactive care planning and case management as part of the Avoiding Unplanned Admissions Directed Enhanced Service (AUPA ES). There is a strong demand from the GPs for real-time data and this is being addressed. The CCG has recently submitted a business case to provide a web based Clinical Dashboard with a daily refresh of data. It will provide one location for practices and other assigned healthcare professionals to quickly access patient level information about patient s A&E attendances, emergency admissions, and other patient contacts across local community, urgent care, mental health and social service providers. The Clinical Dashboard will leverage the Sollis platform to link data to GP records. Sollis Sollis is a patient based data warehouse which captures NHS data sets for the delivery of commissioning intelligence. It has the potential to support secondary care, primary care, community, mental health and prescribing but currently focuses on primary care data. Sollis allows the CCG, practices, and networks of practices to analyse practice data for the purpose of risk stratification and analytics. Data is anonymised but records can be re-identified at the practice by authorised users for person level case management. Since dissolution of the PCT Sollis has been managed by the CSU. Stakeholders felt that the Sollis is currently not being utilised to its full extent for a number of reasons including Information Governance (IG) policies, CSU ownership, and due to the process involved in re-identifying patients at the practice level. 5.2.2. Medicines Optimisation and Variation Teams The CCG s Medicines Optimisation team work with GPs and provider organisations optimising use of medicines to improve patient outcomes and reduce costs. The team provides guidance and information to GPs to prescribe cost-effectively and optimise the use of drugs. The hospital also identifies patients who require additional help with the drug compliance and management. This is currently a manual process which has opportunity to be automated. The Medicines Optimisation team use ScriptSwitch, a prescribing decision support solution for primary care. ScriptSwitch integrates with GP systems to automatically display a recommendation, at the point at which a drug is prescribed. They are currently planning to move to a web based tool, Eclipse Live, for risk stratification in prescribing & screening. They use Primis software and audit tools to extract, analyse and review data from patient records but are currently looking to replace this function with Eclipse. 18

The Variation Team work directly with GPs and practices to standardise the quality of care and remove significant variations across the borough. They use local risk stratification tools as well as the nationally published data. They rely on local and national benchmarking and prescribing data which can be outdated when published. The teams can only access patient data when they are located at the GP practice. IG policy dictates that data cannot be accessed centrally unless the user has a legitimate relationship with the patient, so data is analysed practice by practice. They feel they have access to a lot of benchmarking and data but do not have the tools to make best use of it. 5.2.3. Mobile and remote access GPs and practice staff currently do not have a defined mobile device policy. Remote access to clinical systems on mobile devices is variable depending on the practice, mobile device platform, and clinical solution. For example, some GPs are able to access EMIS web from their ipad but cannot access Docman. Mobile and remote access is seen as a critical tool for flexible working, and providing care in the community. EMIS offer a product called EMIS Anywhere that runs across the N3 network on a dedicated Dell tablet with an inbuilt Smartcard reader. This is marketed as being capable of supporting the remote viewing of patient notes, appointments and medications, and when used with EMIS Mobile it can be used offline i.e. when here is no network coverage. The GPs within Croydon are awaiting a demonstration of the EMIS Anywhere, so that they can assess its suitable. However, there are concerns that remote access to Docman will still be an issue. 5.2.4. Infrastructure and hardware Feedback from stakeholders indicates that aspects of infrastructure and hardware are inadequate to fully meet GP needs and support the planned goals of improved integration with local care providers. The perception amongst some GP is that the centrally provided hardware conforms to the minimum specification or is second hand and this contributes to the reliability and speed issues they experience. Printer faults were also cited as being particularly disruptive, because a consulting room cannot be used if the GP is unable to print out prescriptions. User satisfaction has also been affected since the Windows 7 upgrade. For example, Practice Manager s administration rights were revoked adding additional barriers to the resolving of printer issues. The national NHS secure N3 network, is regarded to be slow and creates a barrier to integration with social care as Local Authorities are currently unauthorised to access the network. A national outline business case has recently been approved to replace N3 in 2017 when the current contract expires. 5.3. CCG IM&T environment The CCG staff work within a hot-desking environment. Roaming profiles allow staff to log on at any workstation within the office. Many staff have found this unsatisfactory due to the lack of true hot desks, and the time it takes to load a roaming profile onto a local PC. The result is that the majority of staff sit at the same desk each day. This has some advantages i.e. teams are co-located and in an open planned space teams which deal with sensitive data can be shielded from the rest of the CCG. However, there are some disadvantages with this approach. For example visitors are increasingly finding it difficult to find a desk to 19

work at. As there is currently no flexible working policy in place the staff do not have an option of working remotely to free up desk space. At times staff find an open plan workplace disruptive and need a productive place to work for intensive assignments. Staff also feel that they do not have access to modern business tools to optimise workplace efficiency and productivity. For example, intranet and content management tools, on-line collaboration tools, mobile and remote working. Staff who do have access to flexible or remote working are required to use security fobs to access the CCG s network which are currently purchased at a high cost to the CCG. 5.4. IM&T in the local healthcare economy Sharing of data within the local healthcare economy is limited to: referrals; electronic prescribing; hospital discharge summaries and letters; and laboratory requesting and results. An instance of Orion Portal is currently deployed for purposes of pathology messaging only. Some local systems (for example, community) collect very limited data electronically, or have systems which lack interoperability. Local health providers will be required to undertake a self-assessment of the readiness, capabilities and infrastructure of their systems as part of NHS England s Local Digital Roadmap initiative. The systems currently in place within Croydon s local health healthcare economy are listed in the table below. Organisation System Croydon GP Practices EMIS (51) and Inpractice Systems Vision (6) Croydon University Hospital Acute Croydon University Hospital Community South London & Maudsley NHS Trust (Mental Health) Croydon LA adults (Social Care) Croydon LA children (Social Care) GPOOH: Virgin Healthcare Cerner Millennium Ascribe EPEX RiO Integrated System (AIS) Liquidlogic Children s Social Care System (LCS) Adastra NHS 111 St Christophers Palliative Care Co-ordinate My Care 20

5.5. Summary of current IM&T environment The primary strengths, weaknesses, opportunities and threats of the current IM&T environment have been identified and will provide key points to address in the strategies to follow. 21

6. Vision and strategic objectives This section aims to describe the vision for IM&T across the healthcare economy of Croydon, and to identify the key strategic objectives for the CCG to achieve their vision. 6.1. Vision and Mission Croydon CCG s Vision is: Longer healthier lives for all the people in Croydon Through an ambitious programme of innovation and by working together with the diverse communities of Croydon and with our partners, we will use resources wisely to transform healthcare to help people look after themselves, and when people do need care they will be able to access high quality services IM&T is one of the key enablers to realising this vision and strategy The CCG s IM&T vision is therefore to use the power of intelligent information and digital technology The CCG s IM&T mission or aim is: To provide clinicians, patients and staff with accessible, insightful information and efficient technologies to facilitate the sharing of knowledge, of health information across the care continuum, and to improve the efficiencies of the organisation. 6.2. IM&T strategic objectives The following set of objectives for IM&T focuses on building the foundations and capability which will enable the CCG to succeed in achieving health outcome, care quality and integration goals over the next five years. The strategy consists of seven key themes. The first is an overarching goal to reflect the organisation s IM&T vision, the remaining are core supporting, and enabling goals. 22

Overarching goal: 1. Utilising IM&T to improve integration and quality of care across the health economy Core supporting objectives to achieve this goal are: Enabling objectives: 2. Sharing of patient information across provider organisations 3. Technology to promote wellness and engage and empower the people of Croydon 4. Business intelligence to understand population needs, and manage contracts 5. Provision of robust infrastructure and IM&T support 6. Optimise, standardise and integrate GP software to support clinical knowledge and decision making 7. Improving the satisfaction and productivity of the workforce through information and digital technology 6.2.1. Objective one - Utilising IM&T to improve integration and quality of care across the health economy Fundamental to this Digital Healthcare Strategy is the need to provide the infrastructure, information and technology to underpin Croydon s ambitious integration and commissioning plans. It is crucial that the fundamental foundation blocks are in place before deploying the necessary digital technology and architecture. Under NHS England s Local Digital Roadmap, the CCG are expected to co-ordinate and drive forward the digital integration plans for their local healthcare economy. In order to achieve this the CCG must address the following over the next three to six months: Ensure healthcare vision, timelines and goals are understood and agreed across all stakeholder organisations. Establish an intra-borough structure to support digital integration, data sharing and implementation of joint commissioning goals. The structure must represent all commissioning and provider stakeholders and drive the development and implementation of the Local Digital Roadmap. The CCG may consider proposing an independent Project Management Office (PMO) to manage the delivery of the digital roadmap. Establish a cross-organisation Board to oversee this structure and the delivery of Croydon s Digital Roadmap. A forum must be in place for key managers and clinicians across both commissioners and providers to agree outcomes, indicators and data to be shared for purposes of improved quality of care, and outcome measurement. The CCG will provide representation on the inter-borough digital roadmap lead by the South West London Commissioning Collaborative. 6.2.2. Objective two - Sharing of patient information across provider organisations A patient centred approach to sharing information is crucial to delivering safe, efficient, co-ordinated care. The SW London Commissioning Collaborative IM&T Strategy aims to achieve information sharing across SW London Health and Social Care in in two phases: 23

Tactical Solution: within 1-2 years focuses on building on the existing systems Strategic Solution: within 2-5 years including self management and prevention Croydon is one of the few boroughs in SW London which currently is not sharing patient records across care settings within the borough (for example, via a Clinical Portal, or Health Information Exchange). This is a step which Croydon commissioners and providers should address prior to addressing the wider goals of population health, or inter-borough record sharing is addressed. However, it is recommended the CCG and providers explore record sharing options which can be deployed quickly and cost effectively, and that energy is focused on the strategic vision of population management and preventative healthcare. Given that the community and social care solutions are currently not capable of sharing data, short term emphasis should be placed on access records between GPs and Acute. Sharing of records will also alleviate some of the current issues in handover of care such as quality of discharge summaries. The following goals need to be achieved to ensure this objective is met. Over the next 3-6 months: Assessment of current capabilities of provider systems and barriers to sharing information (undertaken through the Local Digital Roadmap Initiative). Agree data sets for sharing information which align with health outcome and CCG care quality goals Identify and evaluate short-term options for sharing patient records across General Practice and acute settings, learning from the experiences of neighbouring CCGs. Over the next 6-12 moths: Identify and evaluate medium to longer-term options for sharing records including community, mental health and social care settings. These options may take into consideration population health and preventative care goals. Some of the differences between a Portal or Health Information Exchange (HIE) solution and a Population Health Management solutions are explained in the table below. 24

The impact on a typical patient journey of improving the sharing of patient information across provider organisations is shown below: 25

6.2.3. Objective three - Technology to promote wellness and engage and empower the people of Croydon Self-management and prevention of illness is crucial to improvements in population based health outcomes. Patients require access to information, their care records, decision support tools to self manage their health. Intelligent data is required to understand and profile who is ill, or at risk of ill health, and target with appropriate interventions. The relationship between population health management and patient engagement is highlighted in the diagram below. SW London Commissioning Collaborative aim to procure a holistic population health solution, and develop patient engagement and telehealth/telecare strategies. These timeframes may not align with the CCG s commissioning goals as Croydon move to supporting Outcome Based Commissioning by the next financial year. It is recommended that the CCG remain engaged with the plans and activity of SW London to ensure alignment and to avoid duplication, but take a lead on investigating a population health and patient engagement solution in a timeframe that meets their needs. The approach to achieving this objective over the next 6 to 24 months should include: Optimising use of the CCGs existing risk stratification tools (for example, Sollis) to understand population health needs. Review and evaluate Population Health Management, Patient Engagement and telehealth/telecare solutions and strategies solutions available to the UK market in collaboration with the SW London Collaboration. Utilise and build upon the CCGs Prevention, Self-care And Shared Decision Making Strategy. Collaborating with Healthwatch to understand the wants and needs of the people of Croydon taking into consideration the unique characteristics of the diverse Croydon population. 26