Integrating healthcare and social care, interoperability

Making it personal: the challenge of multi-agency care

The recent white paper Our health, our care, our say identifies concerns over people’s perception of poor co-ordination between care agencies.(1) The current interface between healthcare and socialcare, it says, appears confusing and lacking in co-ordination, and it can feel fragmented to the individual.

These concerns echo others that have been raised in recent years. Inquiries into the tragic deaths of both children and vulnerable adults have highlighted problems with the interfaces between agencies not just concerning failures to share information, but also in the ability of those agencies to work together effectively to support and protect the people in their care. Our health, our care, our say expresses an ambition to rectify those shortcomings. First, by placing the public at the centre of the services they receive, and secondly, where services come from different providers, to amalgamate those services as effectively as possible. Delivery of services, it says, will be integrated and built round the needs of individuals and not service providers.
The Department of Health is not alone in promoting closer working between care agencies. Under the banner headline of Every child matters,(2) the Department for Education and Skills is leading on a programme of work that includes the common-assessment framework (CAF) for children, the concept of the lead professional and much closer integration between all agencies providing support for a child. The development of childrens trust arrangements is intended to provide a framework for the local integration of childrens' services, including healthcare services.

The expectations that lie behind these ambitions are those of integration at a fundamental level: moving the focus of service delivery from individual agencies to a shared, person-focused perspective. This shift in perspective implies a similar shift in approaches to information management. The delivery of person-centred care will require access to person-centred records.

The person-centred approach

Our health, our care, our say spells it out: an integrated healthcare and socialcare information system, it says, will enable a shared healthcare and socialcare plan to follow a person as they move through the care system. By 2008 we would expect everyone with both long-term health and socialcare needs to have an integrated care plan if they want one. By 2010 we would expect everyone with a long-term condition to be offered a care plan.

The challenge doesn't stop there. The intention is to develop joint health and socialcare teams, with dedicated case management through a single expert case manager, 24 × 7 service contact and an information system that supports a shared health and socialcare record.

It seems reasonable to assume that sharing an individuals records, with, of course, the individuals consent, will make it easier for different services to provide co-ordinated care to the individual user. The development of England's NHS Electronic Care Records Service will provide the first steps towards supporting this approach, enabling access to information across a range of healthcare services. But the next steps developing systems that provide effective, managed integration between a range of disparate agencies are only part of the challenge these services face.

Cultural change is also implied. Increasingly, staff will be expected to have the skills to operate confidently in a multi-agency environment, using common tools and processes. And it will be through the closer integration of the NHS and socialcare workforces supported by common education frameworks, as well as career structures and rewards that agencies will be expected to deliver more personalised care, more effectively.

The message is clear: multi-agency care will be person-centred care. Service users and their carers become participative partners rather than passive consumers. They should be as empowered to influence and direct outcomes as any other provider or commissioner. It is the exercise of choice, enabled by informed consent, that gives them that power.

Which means that access to information, and the service users ability to manage that access becomes key.

Redefining boundaries

Traditionally, information is shared in an exchange between agencies. There should be obvious points of interface where it happens, and clear boundaries that help define ownership and responsibility. Where joint teams have been established, information needs to be managed and shared within the team, and boundaries need to be defined to manage the interface between the team and its contributing partner agencies.

But in fully integrated services information will be shared across services. Boundaries that define and protect that information will have to be established and managed independently of the agencies involved. Interoperable technology will help, but agencies will also need to have consistent standards for recording and coding, to establish clear processes for managing and protecting records and to have compatible approaches to providing subject access, record retention, archiving and other information-governance concerns.
Our health, our care, our say states that organisational boundaries should not be barriers; but it will be important to recognise and manage those boundaries rather than trying to get rid of them altogether. Some of them are enshrined in law.

Agencies can be daunted by the labyrinth of legislation that appears to wind its way around the management of personal information. It is complex, but it provides a framework that respects personal privacy and individual choice while protecting the vulnerable from risk of harm. The law says what we need to have in place to allow sharing to take place. It defines when we can and cannot share. But it is professional judgement the knowledge and experience of skilled practitioners that identifies what we need to share and why.

Another set of boundaries that needs to be recognised and managed concerns the practitioners themselves. Professional boundaries are challenged by multi-agency, multiprofessional working. Work that has traditionally lain with a specific profession (that of the qualified nurse, or the qualified social worker, for instance) may now be influenced by the work of another; in particular, information collected by members of one agency is likely to become the basis on which another is asked to deliver services.

Person-centred care is dependent on trust not just the trust of the individual for the practitioners delivering their service, but trust between those practitioners that expectations and standards are being met. When establishing multi-agency services, common language and understanding between practitioner groups needs to be developed and agreed, not just assumed. The contribution of expertise needs to be acknowledged and recognised. Differences in practice need to be identified and accounted for, and professional codes of practice may need to be aligned.

Enabling practice across agencies

Policy and practice are converging through the introduction of more holistic approaches to the assessment of needs and planning for care. This was first seen in the introduction of the single-assessment process for older people (SAP). A common assessment framework is now being developed for children, and work is being undertaken to extend the SAP into a similar common assessment framework for all adult-client groups. The next step will be to introduce frameworks for joint care planning, based on a common understanding of a clients needs and circumstances.

These approaches are intended to enable multi-agency assessments and reviews that consider the whole person rather than focusing on a specific need or service.

In practice, it will be developments in technology that support and deliver these changes. The integration of systems and the exchange of data will facilitate the collected once, shared among many expectations that underpin these new approaches. But effective implementation of multi-agency technology will need to deliver more than data exchange; it should enable management of workflow within and between agencies and provide mechanisms for service users to manage access to their records.

Improvements in data collection/quality should streamline performance measurement and mitigate concerns over client/patient safety: essential information will no longer lie buried in paper files.

The challenge

There are, of course, risks inherent in implementing change: rushing to achieve integration may result in cumbersome or unsustainable solutions. Specialisms may become eroded and the value of multiprofessional perspectives lost. Focus could fall on a single model of care, rather than a holistic understanding of need. Lack of trust across professional boundaries could result in duplication of work and uncertainty for clients/patients, while high reliance on tickbox data collection might encourage overly mechanistic assessment/diagnosis. Tensions between budgets hold the potential to overload reliance on one agency, or allow service users with complex needs to fall between the cracks. And, perhaps of most concern, access to integrated-record systems may encourage unethical and inappropriate use of data.

The challenge, therefore, is to deliver flexible, person-centred information services that support multi-agency working without compromising confidentiality, the information needs of the contributing agencies or the requirements of the practitioners who deliver care.

It makes sense to build on what already exists, rather than tearing everything down to start again, but that will mean finding ways to interface and integrate a range of disparate systems, developing common standards for information as well as technology and implementing information-governance mechanisms systems, process and behaviours that enable as well as protect the service user at the heart of each record.

Penelope Hill, Information Strategy Manager for Social Care, Warwickshire County Council. Member of the Care Record Development Board. Member of the Electronic Social Care Record Implementation Board.

References

1. Department of Health. Our care, our health, our say: a new direction for community services. London: Department of Health, 2006. Command Paper, Cm 6737.

2. Department for Education and Skills. Every child matters: change for children. Nottingham: DfES Publications. 2004. DfES/1081/2004.