Tracey Grainger: lessons from primary care – how digital health can enable new ways of working

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  • Posted:Monday 28 September 2015

Tracey Grainger, Head of Digital Primary Care Development at NHS England, shares lessons learnt from implementing digital strategies in primary care.

This presentation was recorded on 16 September 2015 at our Multi-specialty community providers: implementing new models of care conference.


My two primary focus really this afternoon is to share with you our successes and challenges and our lessons learnt around the digital team what we’ve been supporting primary care innovation in particular around the Prime Minister’s challenge fund. Secondly it’s thinking about what’s the next steps and how do we create new models of care in primary care at scale?  So what do we need to do beyond what we’ve learnt so far?  So that’s what I want to touch upon.

So just an introduction, our scope after wave one of the Prime Minister’s challenge fund we were commissioned to support wave two because of the challenges around technology and introducing digital into primary care and in particular around the intra-operability agenda, the innovation around information governance. It was really testing new ways of working and coming across things what they’ve never been challenged before.  So we were commissioned to support that.  So our objective really was to make sure the schemes of providing technology solutions which weren’t just fit for purposes for that local area but could be rolled out at scale and learn from it really.  So in terms of our national policy what do we need to do to help new models of care for primary care?

So we had a number of objectives, the Prime Minister’s challenge fund was about access, creating more access for general practice, how we provide strengthening primary care for seven day services, increase patient satisfaction and also how are we assuring that we’re meeting the harness of information revolution which are the five key areas which I’ll touch upon.

So in that we were commissioned to support wave one because they still had challenges from the experience and also to really enable wave two. We had additional associate networks which we commissioned so they had new innovations which would provide a technology support for that.  Helping really around the intra-operability agenda and understand the requirements for primary care especially around federation and also really supporting primary care in that informed customer capability because generally in general practice we have a national contract for GP systems of choice and actually that’s done for them, requirements are set for them, systems are provided to them.  So how do we on the ground help them become good intelligent commissioners of technology?

So these are our five high impact changes for NHS England. So what we did for each of the schemes is we mapped all of their ambitions against these five impact changes to understand really is our digital commitments championing digital enablement for digital primary care?  Are we putting in a modern customer intelligence going forward and what’s our professional enablement?  So again what have we got?  Are we reusing?  Are we learning from that?  Are we optimising what we’ve already got?

So as part of the schemes and as part of the national information board framework for action in the Prime Minister’s challenge fund we’ve tested seven digital capabilities as well around digital services. So we’ve got online repeat prescriptions which we now offer online access for repeat prescriptions, pre-referral diagnosis these are kind of technologies where we triage patients prior to booking an appointment, online booking appointments, practice infrastructure again Wi-Fi for practices.  If you’re going to use apps or you’re going to use games for children who have got a long term condition they obviously need to get on to Wi-Fi to enable that in practice.  So some of the infrastructure we tested around patient records and what we found around the patient records, if we get patients access to their record when we transfer or they transfer general practice from GP to GP if they’re not enabled to transfer that record if they go to a new practice we’ve got to think about optimisation because they’re not going to get the same level of service.  So we were kind of testing some of those care pathways and there's many others.

So these are our schemes. Across wave one and wave two we have 57, 18 million patients, 2,500 practices.  So this is quite large, it’s not just a small pilot, this is a third of the country which we’ve covered in terms of testing some of these digital capabilities.

So the scheme types which has been quite challenging is … well some of the behaviour is that for intra-operability they want a single solutions so they took practices off that existing clinical system, done all the business change and implemented a new system to create intra-operability which that may be a short term fix but it’s not going to fix the longer term especially when we’re looking at new models of care and you’ve got to integrate wider across all care settings. So that was only a short term.  So we had 23 schemes on a single solution.  Now when we come to multiple technology, so that’s a number of GP clinical systems or integrating with urgent care around 111 or Out of Hours, that was a little bit more technical.  So there are technical options and solutions which we’re trying to advise the schemes of what they could do right now as well as understanding some of the requirements what they’re going to need for future proof to enable some of that development for the future.

Then we had various digital schemes like patient online services, we’ve already touched upon the digital services, video consultation where does that work, what kind of patient group does that support, e.consultation very much been quite a success in care homes and mobile access. So there’s various types of schemes what we’ve been testing for digital technology and this is really useful for us because for optimising, learning from other schemes we could say it’s happened over in this area so we can share them lessons learnt etc.

So what did the scheme say to us? So these are our major challenges what we’ve had.  So digital innovation in primary care although … well almost 100% digitised.  When we’re looking at federation or taking digital across care settings innovation is limited because of intra-operability in primary care.  So again we’re thinking about what does that strategic intra-operability standards look like to support primary care across federation as well as care settings?  Something as simple as appointment sharing so this is something every scheme found that sharing appointments and work flow would be so much simpler and why couldn’t we do that?  So we’ve got behaviours where our administrators are sitting with two clinical systems on their desk and they’re re-keying information.  We’re talking about innovation and then we’re going back really two steps because we haven’t got that at pace change in terms of system intra-operability.  So this is something what really our key challenge is, is getting appointment sharing and back office work flow integrated.

So integration across products, which I’ve already touched upon that, again this is not just about clinical systems it’s how do we work with that wider supplier market and how do we create that intra-operability where we’ve got plug and play technology where we can have IT systems of not choice and not just general practice IT systems of choice?

IG, I’m sure you are all feeling the pressures of IG. One of the big things in primary care was around the consent to share policy and that is still rumbling on.  So we need a consistent approach around consent and we’ve got a number of work streams going on to provide that guidance and national policy around consent.  Then use of business intelligence.  So again access to  the intelligence to see the impact of what we’ve done in terms of these schemes and innovations and access to that data to be able to understand return on investment, what’s working, how it’s working, what should we scale up, where should we invest and that’s really challenging in terms of getting that business intelligence.

So from that wave one what we did for wave two was put in an end to end digital team to really help the schemes get off the ground, take the learning from wave one, support it for wave two so we could then really look at how we’re going to provide primary care at scale.

So these are a number of functions what we put in place which has been quite successful. So we have a commercial and procurement function and that has allowed us to have the schemes access to commercial expertise, we’ve created frameworks, we’ve driven down cost, we’ve created economies of scale in terms of purchasing, we’ve tried to drive behaviours in the supplier market as well around open APIs where we can.  So we’ve got that really flexible marketplace and intra-operable technology.  From wave one it was a massive challenge in terms of information governance and it really stopped the schemes progressing.

So what we have done is provided consistent advice and guidance, lifted some of that guidance so schemes could adopt to implement again that’s sharable to the wider vanguard areas and we’ve provided IG surgeries where we’ve looked at fair processing and got patients to look at the communication mechanisms. So we’ve really helped in terms of understanding, demystifying information governance.

Another key area is where we’ve had solution design, technical experts. So this is just not coming up with an idea and ambition we’ve really looked at the patterns and the technical solutions.  So what we found from wave one although that was fine for that locality in terms of what they implemented it wasn’t scalable.  So what we’ve been trying to do is provide that technical advice to look at what other technical options it’s about enablement, it’s not about being prescriptive and how do we help that enablement and these are your technical options to achieve that.  So there’s a number of things we’ve put in place to improve for wave two and I’m hoping that can be all shared and scaled and you can learn from us in terms of primary care for your innovations and challenges.

Another key area of what we found is due diligence. So again what we’ve tried to do is create that community interest network where we’re bringing learning together, bringing communities together, not being fatigued by the same issue and you think it’s getting escalated and nothing has happened.  We’ve really brought people together and looked at the solutions for that and as a barometer for all of the schemes right the way through we’ve provided some due diligence.  So we can tailor our support wherever that scheme is needed right the way through from initiation to implementation and if there’s anybody now still in procurement that are not going to hit their twelve month funding because that’s what we’re dealing with in terms of the program so we will help them target and actually put easier mechanisms in for procurement and implementation.

So the next steps for us, so the common themes which is a challenge still in primary care, are these areas: inter-operability although we have mapped all the requirements what we need for primary care we understand what that intra-operability strategy is, we are developing an open source solution where we can try and share APIs and test that so we’ve got a test integrator where we can try and get intra-operability, citizens identity especially around digital services we’re looking at the strategy for that now, if we’re going to look at scale we’ve got to really think about what does that look like for the future especially as we’re getting more online and public facing services, consent to share policy we’ve touched upon that again a consistent approach this has been escalated and we really need a national consistent policy around how we’re going to share information and again this is IT systems of choice. So for general practice we provide GP IT to general practice is that still the right approach, should it be that we provide co-functions that would have the intra-operable modules?  So we’re really looking at the strategy what IT systems of choice looks like for general practice.  Then there’s a whole supplier market development.  So again in primary care although we aren’t 100% digitised we’ve got starting really now where we’ve really connected with the wider supplier market to look at new innovation and how we do things.  So through our procurement tool we’ve actually connected schemes to suppliers which before they didn’t really test the market or they checked their neighbour etc and just adopted technology in terms of what their neighbour was doing.  So really we need to create that open flexible vibrant market.

Then the least is the adoption strategy. So although we’ve helped them, tactically helped their schemes it’s how they’re now … the next steps of making that at scale, adopt, roll out, share learning, how do we connect all those digital services?  It’s not just about the technology.  So for us, you will all be familiar with securing excellence in GP IT services, and we’re completely reviewing that financial accountability operating model responsibilities and we delegated three years ago to CCGs the commissioning of IT for general practice.  Again is that the right approach when we’re looking at new models of care?  So we’re doing a refresh of that operating model and at the moment technology is commissioned separately to service and what we’re trying to do is not put technology on the edge it should be absolutely embedded fundamentally into commissioning.

So again when we’re commissioning services it’s not about commission a service and then what’s the technology look like? It’s all embedded as part of that so again we are really looking at the holistic view of where IT plays in terms of service delivery.

So where we are right now is although we’ve learnt from the schemes, we’ve provided tactical approaches to them, we understand what we need to take next in terms of national policy and where do we fulfil a role in terms of a national role, but the whole entire operating model is under review. So for GP IT we need to think about what does our digital primary care service of the future look like?  There’s a changing landscape.  Is what we’ve got now futureproof?  That’s what we’re going through the strategic review about.  Again technology does it really matter what we say and being prescriptive around what you should be using or should it be outcome focused?  So our digital assurance and maturity model is about specifying the outcomes for patient services rather than the types of technology used which is actually GP IT at the moment.

Then what we do in terms of digital informed customers, so what does that commissioning function look like? We haven’t got technology now on the side-lines it will be embedded as a service.  I don’t know how familiar you are with GP IT, but capital every year is absolutely problematic for us to deal with because actually IT now is a service it’s not about commodity.  So we are looking at all these various levers and incentives and the entire but also what’s our enablers and disrupters?  So what infrastructure do we need?  What IT systems of choice?  What’s our market development strategy look like?  The biggest area what we haven’t even touched upon is what is the digitally enabled patient of the future?  What technologies do they bring?  How do they interact with us?  So we’ve got a number of reviews and working with patient groups at the moment to think about actually what does the future look like?  Are we set up in terms of structure, commissioning, technology to meet that?  So from learning from the Prime Minister’s challenge fund scheme it’s really questioned some of our operating models.

What we’ve also done is to try and be transparent which is really difficult in your innovations of who’s doing what, where etc and so we’ve set up a collaboration tool. So you can join us on that if you want to it’s and there’s online discussions going on there, if you’ve got a common problem there’s people on there to answer it, you can connect with the schemes etc, you can get access to guidance material.  So please come and join us on that and if you have any questions around what we’re doing or further information about the schemes just email us at the england.digitalprimarycare.


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