Integrating healthcare and social care, interoperability

The challenge of making healthcare and socialcare information systems interoperable

It is important to remind ourselves of the context in which the changes in information management are taking place. First, the Transformational Government Programme is aiming to modernise public services, with services designed around the requirements of the citizen.(1)

The other major driver, particularly for healthcare and socialcare, is the challenge over the next half-century due to the ageing of the population boom of the late 1940s. It brings an increase in long-term illnesses, rising costs of care and a reduction in the ratio between the workforce and the non-working population.

The reports by Derek Wanless (2, 3) summarise these challenges, concluding that current healthcare and socialcare practices are unsustainable and that more flexible working, supported by information technology, is key to system reform.

In this article, I will focus on healthcare and socialcare information systems and will discuss the challenges of achieving interoperability between them.

To achieve seamless, people-centred services, it is important to ensure that information can follow the individual from childhood to adulthood and between healthcare and socialcare.

At present, responsibility for the development of healthcare and socialcare systems is split across government departments. England’s programme for the NHS is driven through the National Programme for IT (NPfIT), led by a Department of Health agency, NHS Connecting for Health (CfH). Lead responsibility for the socialcare personal record system is shared between the Department of Health (for adults) and Department for Education and Skills (DfES) (for children).

This split in lead responsibilities within the government departments is problematic. There is no over­arching governance arrangement to ensure consistency in vision, strategy or standards. Personal electronic healthcare records are not being developed to a consistent model.

The NHS’s national care-record system and the DfES-led Integrated Children’s System are both based on data-centric records. The Electronic Social Care Record (ESCR) is a document-centric record, reflecting guidance published in 2001 that predates the emphasis on interoperability and exchange of information.

There is no formal co-ordination of system governance or standards development across these different information systems. The NHS has a strong governance framework overseen by the Care Record Development Board.

Its Information Standards Board provides expertise and leadership in the development and implementation of consistent information standards across the NHS. DfES has recently established a Learner and Children’s Services Information Standards Board relating to children’s services. There is no adequate lead for adult socialcare information-standards development. Consequently, we have information-standards bodies ranging from very good to hardly visible. Collaboration between these bodies is informal with no recourse to any overall co-ordinating body should there be irreconcilable differences.

To allow this lack of co-ordination to continue risks the building of a technological Tower of Babel at enormous cost to the public purse, and the development of systems incapable of sharing information outside their technological towers.

Where do we want to get to?

The ESCR Implementation Board considered a paper commissioned through the National Programme for IT that outlined the strategic case for healthcare and socialcare integration. In this paper, four options were identified:

• Option 1: do nothing — ie, maintain the status quo;
• Option 2: develop separate care records for healthcare and socialcare;
• Option 3: implement integration of healthcare and socialcare services working to consistent, nationally defined standards. Within this option, two timescales were identified, the first being to aim to achieve the initial project scope by 2008 and the second to achieve the same by 2010; and
• Option 4: to implement a single healthcare and socialcare information system. The conclusion of this paper was that the most realistic and achievable option that had the best fit with strategic objectives was Option 3 — ie, to aim for the integration of healthcare and socialcare systems on an incremental basis within a national governance framework.

Such an approach would be consistent with that recommended by the Royal Society (4) and has similarities to the Canadian strategy. (5)

To achieve integration and interoperability of healthcare and socialcare information systems requires:

• clarity of purpose;
• identification of the benefits to the end user;
• demonstration of the efficiency and cost effectiveness of developing integrated information systems; and
• a consistently managed implemen­tation programme to ensure the objectives are delivered.

Need for stronger co-ordination

There are two weaknesses in the present arrangements for developing sharable personal-care records. First, the absence of a co-ordinating governing body and, secondly, a mandated formal structure to ensure consistency of information standards across healthcare, socialcare, children and adult information systems, where interoperability is a requirement.

In the absence of a co-ordinating body, we have separate work streams each focused on its own implementation requirements, albeit with an awareness of the need to work towards information exchange, but with insufficient attention to how that integration will be achieved.

Decisions being taken now — indeed some have already been taken — shape whether or not interoperability and information exchange is achievable in the future. The absence of a co-ordinating body puts at risk the goal of integrated personal-care records. Given the huge amount of public investment going into these initiatives, this is a high-risk omission.

If a Health and Welfare Care Record Programme Board were to be established, or responsibility for co-ordination vested in an existing body, its main remit would be to oversee the development of integrated systems across healthcare and socialcare, co-ordinating the personal-care record-development programmes in the DoH, NHS and DfES. It would:

• ensure that workforce issues are properly addressed. As The Royal Society report on digital healthcare states, “the single most important factor in realising the potential of healthcare ICTs is the people who use them. The end users of any new technology must be involved at all stages of the design, development and implementation, taking into account how people work together and how patients, carers and healthcare professionals interact”;
• ensure that there was a sound business case for all aspects of the implementation of integrated healthcare and socialcare records, with a fundamental premise that integration of information systems must benefit the patient and user of socialcare services.
• keep a focus on sustainability, which is particularly important if the implementation strategy is to be based on an iterative and evolutionary approach; and
• be responsible for co-ordinating the governance and standards framework that will deliver interoperability at local, regional, national and international levels.

Need for consistent information standards

There also needs to be a body charged with ensuring effective co-ordination of the governance infrastructure of integrated information systems.

A care-record guarantee covering both healthcare and socialcare (including adults and children) would establish consistent national standards for consent to data collection and its use, confidentiality and authorisation of access to data.

This body could also ensure a consistent national approach to standards development, including semantic interoperability (ie, human-to-human information exchange); functional interoperability (ie, machine-to-machine information exchange); terminology; security; messaging; and record structure.

Conclusion

Possibly the biggest threat to the successful implementation of sharable healthcare and socialcare records is the lack of overall co-ordination and the absence of a consistent national framework for the implementation of integrated personal-care records. Given the amount of public funds currently being invested and the tight timescales for delivery of objectives, the absence of overall co-ordination of these programmes presents a major risk not only to the strategy to develop integrated personal-care records but also to the Transformational Government Programme.

David Johnstone, Director of Adult and Community Services, Devon County Council; co-chair of the Electronic Social Care Record Implementation Board; and member of NPfIT National Programme Board.

Much of this article is based on papers, debates and discussions that have taken place within the Electronic Social Care Record (ESCR) Implementation Board and the Care Record Development Board (CRDB) over the past 18 months. The views are those of the author and do not represent either the formal position of the ESCR Implementation Board or of the Association of Directors of Social Services (ADSS).

References

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