Published: 03/11/2005 Volume 115 No. 5980 Page 4 5 7
The joint-working ethos is sweeping through the health service, and it is vital that the spirit of co-operation is extended to IT systems. Steve Mathieson reports
Joint working between health service organisations and other parts of the public sector, particularly local authorities, has gone from being a good idea to something the government wants everyone to do.
The notion is backed up through legislation such as the Children's Act, the concept of single assessment processes and even the Gershon efficiency agenda. But in terms of IT, it remains a difficult goal.
Eric Woods, government practice director at consultancy Ovum, says there are three types of barrier to joint working. 'You have got the organisational differences: where people belong, where they report, what governance they are under. Then There is the data privacy issues on what can be shared and the technical integration.' The technical problems are significant, even when the organisational and legal ones can be overcome.
Mr Woods says the health service has something of a head start in NHS Connecting for Health: 'At least it has a framework in which systems can be developed. There is no equivalent, of course, for social care, either with a common directorate or the£6.5bn.' With social care systems, he explains, 'the situation at the moment is a mix of new systems and extreme legacy systems.' The new ones are likely to support universal data interchange standards such as XML, which should make it easier to link health and social care IT as older systems are replaced.
'People are trying to solve it through joint teams and pragmatic solutions, sharing information where they can, ' says Mr Woods.
'Increasingly, with single assessment systems and child safety issues they are obliged to address this.
It is all about critical points: knowing they are talking about the same person, making sure people are not lost in the system, making sure elderly people are not interviewed six times.' However, such work could be threatened in some areas by the merging of primary care trusts.
'It is much easier to do this when you have coterminosity, ' says Stockport PCT chief executive Richard Popplewell. For organisations like his, which share boundaries with the local authority, joint working is 'just about the mechanics and the processes, which are not trivial'. However, 'you then get into the detail of how you do these things, not whether you should'.
The current plan for Greater Manchester is to reduce 14 PCTs to 10, making all of them coterminous with the area's 10 unitary metropolitan borough councils. 'The challenge is, of course, in whether that will deliver sufficient management savings to hit Greater Manchester's share of the£250m, ' said Mr Popplewell, referring to the targeted national savings from ongoing PCT reorganisation.
The same situation, a unitary borough council sharing boundaries with a PCT, has benefited Telford and Wrekin, which has pioneered work on sharing data on children. 'We are coterminous, and that brings real benefits, ' said Sara Tough, senior manager of the Change for Children programme at Telford and Wrekin borough council.
'We are not in that difficulty of having a vast number of PCTs to work with.
We have redefined boundaries so We are all coterminous. If that were to change in the future, it would be problematic.' A February 2004 informationsharing protocol between the council, PCT and other agencies including schools, Connexions and police, established a shared electronic index of children. 'We have devised an IT system that holds very basic information, to point practitioners towards each other, ' says Ms Tough.
Since then, the agencies have been working on a common assessment process, although the data it collects would continue to be held by individual organisations. 'The assessment belongs to the agency and the individual who produces it, ' explains Ms Tough, and sharing requires consent to be obtained. 'It is not your automatic right to have access to that information.' Telford and Wrekin had considered markers of concern on children's records, showing that a professional had reason for concern, although not explaining why. However, it decided against this. 'We only put [a marker] there when an assessment has been made and action has been taken to meet that need, ' says Ms Tough.
'Our concern was, you would create flags of concern, but what would you do about it?' The council has also changed its approach to security. Initially, it used biometric thumbprint readers, but has moved to creating a virtual private network with the partner agencies, meaning that those agencies' network security protocols, such as logins and passwords, also allow access to the shared index (although only for children that a practitioner deals with - they cannot browse through the list). 'It was technology moving on, and reliability, ' says Ms Tough of the decision to move away from thumbprint reader technology.
'It wasn't that it wasn't secure, it just didn't always work.' Regarding health, the council is working on extending the amount of data shared. 'We are focused on sharing universal data with health, ' she adds. 'Once We are satisfied That is working well, We are looking at more sensitive data, how It is shared and held.'
Connecting for Cambridge
But allowing deeper integration can be difficult. Cambridgeshire county council ran two pilots on joint working between health and social services as part of Project Nomad, a national scheme funded by the Office of the Deputy Prime Minister to research mobile working within local authorities.
The first, which ran from July to December last year, aimed to provide a mobile technology system able to support the single assessment process of older people for health and social services professionals. This required data to be retrieved from, and returned to, the county's Swift social care information system, supplied by Anite.
Professionals would connect using Vodafone's fast 3G or slower GPRS network, depending on coverage, and fill in electronic forms on tablet PCs supplied by Fujitsu Siemens, with the process managed by Microsoft's BizTalk software. The data, which was encrypted, would be collected using the county's common assessment tool.
The intention was to pilot the system with health systems, including two GP surgeries running Emis software, as well as a hospital patient administration system. However, it never got that far. The tablet PCs and the mobile networking, which were used to avoid relying on power supplies and telephone lines in clients' homes, worked fine. But retrieving data from the Swift system caused severe problems.
'The products from the supplier allowed information to come out, but it was painfully slow, ' recalls Cambridgeshire county council information and communications technology development manager Alan Shields. 'The rest of the system was working perfectly adequately in prototype. We just didn't get an end-to-end solution that we could put out to real users. We fell at the last hurdle.' As a trial, particularly one funded by central government to see how a concept would work, this nevertheless represents useful experience. 'In hindsight, we should have had a plan B, a backup database outside the application, ' says Mr Shields. This would have provided a buffer for data entering and leaving the Swift system, allowing users to make progress even if that central database could not keep up.
Mr Shields suggests this could be a useful technique for other councils looking to introduce such systems.
'If we had had more time, that was the way we were going to go, ' he says, although time and money constraints meant the trial had to end without resolving the problem.
'These are not trivial things to do in technical terms, ' argues Anite Public Services business development director Tony Barron of the project.
'The ability to work across agencies on things like project governance arrangements are crucial, as are what protocols are in place and what the expectations of each agency are.' In a second project, the county provided -7 access to the same social services database for ambulances based at Addenbrooke's Hospital near Cambridge. This worked in a simpler fashion, taking the data the Swift database would display on a monitor (a technique known as screen scraping) and relaying it to ambulances, again in encrypted form, through mobile Blackberry devices, best known for providing remote access to e-mail. Vodafone was again used as the network.
'If you see the single assessment project as being the Rolls-Royce of integration, this was the Morris Minor, ' says Mr Shields. In the pilot, no data on the central social services database was changed, although the set-up was technically able to allow this.
The aim of the four-week test was to keep the system simple. 'Ambulance paramedics do not want to worry about technology, ' said Mr Shields. 'It was web-based, so it was very simple, and it worked like a dream.' Such data transfers were covered by an existing agreement between the council and East Anglian Ambulance trust, although this had previously been used for telephone requests, and was of limited use outside office hours. 'It is something We are possibly going to reintroduce, maybe next year, ' he adds.
Although the simpler project succeeded and the problems with the more complex one could not be resolved by its deadline, Mr Shields believes both types will be needed in future. 'The simpler things are easier to do, but they are less scalable and expandable. They have their restrictions, and you would come across them eventually.' Mr Barron of Anite, which supplies the majority of the UK's social services departments, reckons his firm has created a standard way for its systems to link to others. But there are severe problems in dealing with health IT at the moment: 'There is a plethora of legacy systems, some using meaningful technology that can be integrated easily, some being legacy crap. The national IT programme is attempting to bulldoze those, but that has caused planning blight, ' he says, with trusts unwilling to spend before the programme comes in with new systems.
Furthermore, CfH has not worked hard enough on allowing its incoming systems to link with other agencies: 'The Department of Health has got a responsibility to make sure social services are taken into account in the national programme. They are not, ' says Mr Barron. .
This week HSJ has launched a new online Good Management service for readers. If you would like more specific information about IT in joint working, please visit www. goodmanagement-hsj. co. uk/ jointworking
JOINT WORKING IN PRACTICE
Share for care West Lothian council and the West Lothian Division of Lothian Health is piloting a single virtual organisation, the West Lothian Community Health and Care Partnership. The two-year trial started in April, although work has been ongoing for several years.
'What's been good is that the staff from both perspectives have been very focused on the best way of working better together to meet the needs of service users, ' says partnership director David Kelly.
On the IT side, there was a fairly basic initial problem on access to systems. 'In the council, we all had our own PCs. In health, they had shared PCs, ' says Moira MacKenzie, one of the practitioner managers involved in the initiative. 'That is been overcome now.' Persuading clients to allow data to be shared is often one of the thorniest issues in joint working. In this case, West Lothian's GPs, on behalf of the partnership, sought their patients' permission to share a basic set of data.
'The GPs were as committed to sharing as the others, ' says Mary Wintershausen, an associate of state sector IT analyst Socitm Insight and author of a report on West Lothian's work. 'I feel That is the refreshing thing - the turf wars you see elsewhere do not seem to happen in West Lothian. It is not, 'how can we sneak past the public? We'll use the GP, ' but 'who is the most appropriate person to write to the public?' GPs are trusted.
'What stands out is how much sharing is a standard part of the way they do things across health and local government. While there are still privacy issues, they have asked if there is a good reason not to do this.' Where there is not, data has been shared.
The basic shared data, known as Base Camp, contains little more about someone than might be contained in a close friend's address book: name, contact details, date of birth, next of kin, whether they are known by any other name, marital status and warning flags, along with the contact details of the professionals involved.
It has the benefit that, for example, GPs know that if they contact the council's housing or social services staff to discuss a patient, both parties are talking about the same person.
The shared information system currently involves health, social services and housing, but West Lothian is already looking at the potential of expanding this further. As part of another initiative, West Lothian council already shares office space with staff from the benefits agency and the employment service. The council thinks this presents potential for linking up further.
Ms MacKenzie explains that separate consent is sought to share data gathered from the partnership's needs assessments. 'You could have consent to share your Base Camp data, but not your assessment data, ' she says. If so, the IT systems do not allow that assessment information to go beyond the organisation that collects it, even when the Base Camp data is shared.
With NHS professionals using a different network to the council, the shared data is kept on a specific system. 'It is not a matter of council staff changing NHS data, ' insists Ms MacKenzie.
Any changes to records are tracked and managed by staff in that service - one of the uses for the shared messaging and workflow system MyMessages. 'That allows us to transfer, in a clearly auditable way, responsibility between assessors and organisations, ' she adds.
The council has a shared Careline call centre which, like others across the country, is accustomed to contacting GPs or other services. In West Lothian, it was run by a housing association before being transferred to the council.
'They were working out our systems, ' says Ms MacKenzie. 'It wasn't that we had any problem with the housing association at all, but it limited us in integrating.' For example, if someone asks repeatedly for help with their wheelie-bin, this may be a reason for action beyond contacting environmental services.
Careline also deals with alerts from the assistive technology in some housing, such as devices to detect flooding and fires, allowing the elderly to make quicker moves from hospitals and care homes to individual accommodation. In one case, a triggered flood detector alerted Careline staff who, on getting no response to a telephone call, sent other staff to investigate. The elderly resident in question had slipped while defrosting his fridge, fractured his hip, and was unable to reach the phone to get help.
Ms Wintershausen says that getting health and social workers to collaborate on such alarms produces good results. 'The medical people say it must function, it must be reliable; the social services people say yes it must, but it must fit into people's lives.
You are likely to get more than the sum of the parts.' For example, a young mother with diabetes was prone to collapsing from low blood sugar. Her husband lost his job because of the amount of time he took off to care for her and their child.
A fall detector was the solution, but it was made smaller so she would be happy to wear it. She is, and her husband found a new job.
Overall, Mr Kelly believes the main IT lesson was to decide how joint processes would work before thinking about which IT system to buy. 'You have to invest a lot of time in the business process mapping, appoint a project manager, develop a common language, and that all has to be done before the IT specification, ' he says.
Joint working in IT between health and social services and local authorities remains difficult, with technical and organisational barriers.
A number of areas have tried information-sharing, but so far they are only able to deal with very basic data. Two Cambridegshire pilots of deeper integration had mixed results.
Persuading the public to allow their information to be shared presents another hurdle to trusts and local authorities.