Kate Warriner: The Liverpool Way - digital care in a joined-up health and care system

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  • Posted:Thursday 30 November 2017

Speaking at The King's Fund Annual Conference on 30 November 2017, Kate Warriner, Healthy Liverpool Digital Lead, Royal Liverpool Global Digital Exemplar Programme Director, NHS Liverpool Clinical Commissioning Group, shares lessons from Liverpool’s digital journey across the system.


Good afternoon everyone. I’m Kate Warriner I’m the digital lead at Liverpool CCG.  I’m also the digital lead for Cheshire and Merseyside STP and really proud that I’m also the programme director for the global digital exemplar programme at the Royal Liverpool, so several hats there.  

So just to start off, to give a little bit of a flavour as to our geography and our footprint.  From an STP perspective across Cheshire and Merseyside, so we’ve got a population of 2.6 million., 12 CCGs, 9 local authorities and 20 providers and I think it’s the second or third biggest STP nationally which gives us a set of challenges as you can imagine.  I guess more locally we’re split into local footprints and what we’re going to focus on today really is some of the work that’s been done closer into Liverpool at a North Mersey level and to the population there set just under a million.  Three CCGs but then quite a large number of provider organisations so we’ve got a number of big acute trusts but also quite a lot of specialist trusts in and around the city region, which again brings a level of challenge and a level of complexity to our work. 

So I guess just to start really, we’re quite reflective when we’re pulling the slides together around this, just around Liverpool’s journey on digital and I think this probably started over ten years ago and I found a document in our Chief Exec’s office only last week which was the legacy that the new Health Service for Liverpool left.  Interestingly, we saw kind of artists impressions of the new Royal, the new Alder Hey, two of our big trusts which one has now opened its doors, and another is opening its doors soon, all the kind of major investments that were made in the city, five or ten years ago, which we’re now starting to really see, so really paving the way for the future.  

From a digital perspective, we had our I links programme which was the start of our information sharing programme across Liverpool and North Mersey, and we set about with this to really start to change some of the culture of our local economy because we had this culture and again comments around information governance, people were saying can you not just sort out the IG and that’s kind of an absolute quo back pain to us and so we kind of said you know, we want to move towards a culture where we can share and we do share rather than why can’t we share.  So, set that up really through our I Links programme and that then went onto the Healthy Liverpool programme and what we did through Healthy Liverpool was really elevate the prominence of digital care and innovation.  So this became much more than what we’d historically terms around IT or IM&T and or informatics and it became around digital care and it became around how do we improve the health of our population through digital and really putting digital out there to not just previous language we would have used, IT as an enabler but actually  how do we use digital and technology to start a drive forward some of the changes in clinical pathways and really support delivery, but also kind of say this is what digital can do for you as well as what do you need digital to do for you.  So it’s kind of quite a two pronged approach there. 

I think across the city we’ve had real historic investment in all of those kinds of phrases and whichever the popular one is today, but across the key programme areas on the left there, we have historically invested across Liverpool, quite significantly in where we are now with digital and I think now we feel that that’s kind of led to a fortunate position for us in terms of the global digital exemplar programme, but I think also the recognition that the city’s got in innovation.  So, we’ve got a life sciences centre across the city, we’ve got a knowledge quarter and I think Liverpool’s really kind of up there as a beacon of innovation now.  

We are in the very unique situation that we’ve got four global digitalisation exemplar trusts in our city region and then across the STP we’ll have a number of fast followers in that programme as well and I think some of that is based on some of the historic investment and then the prominence and the elevation that we’ve given this really important topic.  

And then I think, kind of moving forward, you know, we’re doing lots of work more at STP level and looking ahead.  We spread some of that throughout all of that I think just to reflect that we’ve had great people and some people, like myself, being in from the very start of this selective few years since, but throughout our journey we’ve had some fabulous people involved.

So, just in terms of what some of our reflections and our core foundations are and I’ve just picked our four key areas and I’m going to start probably in the bottom right and I’ve called this boxes and wires, and this is the stuff that people can think, god that’s dead boring.  You know, you talk about infrastructure, you talk about networks but actually without that in place and without that being safe and secure, we can’t do any of them, the snazzy stuff or any of the clinical care.  So we invested heavily over the last five to ten years, in our infrastructure, across the city and then we got a local network that connects everything together.  

Moving up to the top right, so I think the second thing that we did, and we made some really brave decisions in Liverpool around systems consolidation and this started with primary and community services and we made a decision to consolidate all of our GP practices onto EMIS and then that grew across our broader health and social care economy.  From a social care perspective, again we had a consolidation so in terms of the previous footprint which I’ve shown, our social care organisations did consolidate onto a single platform and then from an acute perspective, some of our acute providers started to say, we need to kind of get together here and we’ve now got quite an ambitions EPR programme which is ongoing across our hospitals. 

Talking about the IG stuff earlier, I think one of our key foundations has been our information sharing programme and so we developed a single information sharing agreement across the whole of North Mersey and to date we’ve shared over 70 million records through that and some of that has been our EMIS work at the heart of that in terms of mobilising primary care and community information right the way across our city.  We’ve had a tactical set of things to do around interoperability and we’re then looking at what we need to do from a wider STP perspective in terms of our local record being bigger across our population that we’re serving. 

And then our fourth foundation really is some of the work that we’ve done on assistive technology and it’s the only area we’ve led Europe on recently but we’ve seen the biggest cohort of patients in Europe using assistive technology and this is a range of technology in people’s homes supported by a care team in terms of tele-health and tele-care and with that we saw 32% reduction in emergency admissions for the patients on that cohort, so really some brilliant outcomes from that and we’re now scaling that up to more patients. 

So, one of the things that we did, and I think recognising that it can be challenging to engage the public on this topic and public think we do this stuff anyway, so we tried to bring things to life a bit and so one of our clinical leads, Dr Simon Bowers, who some colleagues in the room may be familiar with, we let him loose with some comms people and this is what we ended up with.  I’m hoping the sound works. 

[Soundtrack of the video being shown]
-    Patient is 43 years old, found lying unconscious in a pool of blood.  No visible signs of injury.  She’s breathing but has low blood pressure, tachycardia 110 and fever of 38.5.  

-    This certainly sounds like a bleed or a head trauma, let’s get a CT scan set up so we can do a head check.

-    Whoa hang on a minute and you are?

-    Dr Bowers Health for Liverpool programme.  I think we can save you some valuable time. 

-    Yes of course, that could be helpful.  

-    If you had this patient’s entire medical record available to you right now, you’d see she has epilepsy and she attends review at the Walton Centre.

-    So it could actually be a seizure.  Thanks.   It’s probably secondary to infection so let’s get an FBC, U&E, bloods, gases and a chest x-ray.  Nurse Richards if you could administer a dose of penicillin to be going on with. 

-    Whoa hold your horses.  

-    Yes Dr Bowers?

-    Little bit more Healthy Liverpool advice for you because I think you could probably use it. 

-    We’re all ears. 

-    If you had access to the patient’s entire medical record immediately you’d be able to see she has a fairly serious allergic reaction to penicillin.

-    Whoa.  Close shave.  We would have lost valuable time. Thank you.  Okay, let’s go with a different antibiotic.  Now let’s find out where this bleed is coming from.  Nurse Richards if you could bleep the on call surgeon for an urgent gastroscopy. 

-    Easy tiger.  

-    Dr Bowers, I’m afraid a gastroscopy is essential given Mrs Green’s condition.

-    I agree completely.  However, if you had access to her medical record immediately you would see she takes Warfarin tablets which thin the blood. 

-    Extremely helpful Dr Bowers thank you.   We could have been in for a nasty surprise otherwise.  Nurse if you could check an INR to see if she needs vitamin K.  

-    So as you can see, when health teams have access to the right information, in the right place at the right time, there is always safe and effective care 24/7.  Unfortunately as it stands that isn’t always the case and the information that’s shared from your GP to hospital services or to community services is very often shared on paper or fax machine and that takes precious time.  Time that could and must be reduced if we’re to improve every aspect of your care.  

Now the Healthy Liverpool programme has a new approach to this.  A joined up system where your doctor, your hospital services and community staff will work collaboratively around you.  What that means is your doctor, your nurse, your therapist, your mental health practitioner, your support worker will have access to all the information they need to make quicker, safer decisions with you about your care and they’ll ask you permission before they look at any shared information about you and you don’t have to say yes.  You can either opt out of the whole thing if you prefer, we’d rather you didn’t opt out because the benefits are really clear and your information will only be used for your care in our region.  

To find out more about how sharing your record will improve your care, go to www.healthyliverpool.nhs.uk 

Our comms team absolutely loved him for that when he didn’t tell them in advance that he was doing it and then tweeted about it when we had the link, but I guess that’s been how we’ve tried to engage with our public and that is on YouTube so if anyone wants to use it in your local organisations please feel free. 

Talked a little bit about some of the foundations and some of our history and some of our early achievements but I wanted to just spend the next bit of the presentation on was some of where we are now and then some of the how we’ve achieved some of this from a GD perspective we’re one year in, in terms of the Royal Liverpool so it would be remiss of me not to reflect on some of the work that’s been done there.  

So I think one of the key things that’s been delivered from a digital Liverpool point of view, so there’s a lot of that going across the economy which is our foundations, but we’ve had a significant piece of work across the Royal Liverpool in terms of paper free, so the Royal has gone paper free in advance of moving into a new build without any storage for paper records and it kind of focus the minds of people to say, you know we’ve got nowhere to put it so we need to do something about it and our staff kind of just really got on board with this brilliantly and I think a lot of staff across the trust with any of their clinical interactions they record their information using a variety of devices digitally so they type into systems in a hospital environment, in real time the clinical work that they’re doing.  So that includes all of our observations, all of our kind of continuation sheets so there is kind of no paper across the trust.  

I think that’s led to some really just stunning outcomes and we’ve been quite cautious through the GD programme of some of the outcomes that we’ve been mapping and so the first one I’ll just pick out, a couple on this slide is around sepsis.  So we had a range of challenges around sepsis a number of years ago as I’m sure other organisations have and we’re now we have 100% sepsis screening, our antibiotic administration has improved significantly and we have reduced mortality quite significantly in terms of the technologies that we’ve put in place.  So all of our nurses and HCAs record their obs digitally and we’ve got an e-sepsis system that makes the staff think sepsis as they then take every set of obs for patients and so in in the reporting period between April and September, there were fifty cases of reduced harm from having our team in place and the technology to support that. 

Just a couple of other outcomes I’ve picked out, so the cardiac arrest one in the middle there, so we’ve had a 46% reduction in cardiac arrests and again that’s been through digitising our records, digitising our obs and our team and our staff being able to see, at a glance, right the way across the trust who’s getting sic and when they’re getting sick and intervene much earlier, and then just the third one which isn’t on there, but we’ve had a significant decrease in the number of falls through digitising the falls assessments as well, and I think where we currently are is we’re seeing a 37% reduction in falls through people just capturing the falls assessment.  So we’ve seen some brilliant outcomes there across the trust.  

So, just the final bit of the presentation, and this is the quirky bit now, so this is how we’ve done some of this and I think one of the things we want to be remember for post GDE, particularly, but I think this is our whole digital Liverpool journey, is how we’ve got to where we’ve got and I guess just some reflections over how we’ve done some of this.  

So, my colleague who was due to present with me today, introduced a little while ago to the concept of Badges on Speedos and so the story goes, as a kid it’s great to have your 5 metre badge and your 10 metre badge and you kind of parade round with them and how brilliant this is.  I think in terms of our digital leadership across Liverpool, we’ve taken quite a different approach.  So we’ve tried to get the right people together, the right skills together and the right team together; some technical people, some non-technical people, people with leadership experience and Simon who you saw on the video, he was asked by a technical person, well what language is that written in?  And he said, English.  And they said, we mean what technical language and so putting that team of people together has really helped us.  

But in terms of the Badges on Speedos, this is then how we introduce ourselves and how we work with our stakeholders, how we work with our staff and it’s not introducing myself as I’m a, with my how every many Badges on my Speedos I have, but you know introducing ourselves in such a way and working with our team in such a way that we can have disruptive conversations that isn’t about your stature or it isn’t about your hierarchy and really trying to focus on innovation and I think in our digital world pre-kind of some of this way of working, we had a culture of well my servers’ bigger than your server, well my servers are really big, and we’ve really tried to stop some of that culture and to work more effectively across all of the organisations that you saw on my first slide as a virtual leadership team.  And please feel free to Tweet with the hashtag Badges on Speedos because Chris who’s in seeing patients in intensive care will be delighted to see that on screen. 

The second key thing in terms of how we’ve done some stuff and colleagues may be familiar with the Harvey’s gang story, and I think the message in this is around walking in each other’s shoes, so I regularly go and do a ward round with our staff.  I go over to primary care, just to see how it feels in some of the stuff that we’re doing.  Does this help?  Does it hinder?  Could we do things differently?  But equally then, other staff will come and spend time with our team, so maybe on the service desk to really understand then the pressures and challenges of individual’s jobs in terms then how we lead and what do to deliver change.  

This is one of my favourites this, so the tenacity bit and it’s like really keep going and I think the paper free journey in the Royal was a great learning thing and the quote that was our favourite quote of all time which was at Medical Board through A&E, so A&E were the last service area to go live, the quote of the week the other week was “we were a little bit resistant and this is what they actually said, its was marching not walking”.  

So I think our message for that really is you know sometimes you’ve just got to keep going at something and you will get resistance in change along the way but kind of keep at it and have a bit of tenacity and the team in question now, they wouldn’t go back and we’ve asked, well what would you do if we give you the paper back?  And they go, but you can’t do that because that would slow us down, so brill. 

We’ve had a motto around keeping things simple. So in the NHS, how often do we just make things more complicated because we can.  And so every time we’ll redesign a pathway, every time we’re looking at a new initiative, we just kind of sit and say, is that simple enough?  And if it’s not we use our Badges on Speedos ethos to challenge each other and say, let’s just keep this simple.  

We saw something recently from one of our colleagues at The King’s Fund and this resonated with us a bit really, and I think the whole topic was around compassionate leadership and listening to people with fascination.  So in true Scouse style, we kind of called that being nice and just being nice to each other and being nice to our colleagues, being nice to our staff, because if you’re nice to people and you’re kind, you kind of get that back then don’t you? And then you get kind of points in the bank and if you then trying to do some stuff just be nice and you’ll get nice back.  Even with the valley of death.

So when we started off on this, it would be wrong not to have something from the Beatles in here wouldn’t it?  I think we thought were heading for like a revolution, this is going to revolutionise the world. Actually what we found, is a bit more evolution and what we’ve done is bring our whole system together kind with a shared vision, a shared direction of where we’re heading and we’re really, really proud of that. 

Simply, where we’re going next, and it’s more of the same. It’s continuing to support our population with digital and improve their health and care experiences and I’ll just leave you with this from the wonderful Steve Job. 

Thank you.