JOINT INFORMATION NETWORK – 4TH JUNE
DISCUSSION NOTES
1. Key issues for Health Boards:
· Management and responsibility for HEAT targets are, in general, not integrated on the ground. Associated teams mostly work in isolation and could be duplicating work, or carrying out work directly in conflict with another target. .
· In a similar vein, management of secondary and primary care are not integrated and can lead to silo thinking, with each sector not being fully aware of linkages across the whole system.
· In relation to A&E attendance, the older population (>65) often present with the most complex problems. Many of these problems would have been better served in the community or could have been prevented through anticipatory care planning.
· Care pathways and patient flows in primary and secondary care are often not properly aligned.
· Primary care services are not available on a 24 hour basis, thus people naturally divert to emergency and secondary care.
· HEAT targets are perceived by many to be a management incentive and not necessarily seen as the best choice clinically.
· Demand for healthcare is elastic, i.e. increased supply leads to increased demand. If public know that A&E services are available and easy to access they will attend A&E, whether it is clinically appropriate or not.
· There is much confusion among the public around what service to use. Too many services can lead to confusion. Services such as minor injury units and NHS24 are not as well known as A&E and the public may not be fully aware that they can be seen more appropriately by these services. The public are very aware, however, that they should be seen within four hours if they were to attend A&E. Better publicity and education about other services would be beneficial.
· Public view healthcare services as a commodity which should be available 24 hours/seven days a week.
· Consideration should be given to streamlining HEAT Targets and this should be addressed when re-looking at them.
· Coding:
– Accuracy and consistency of coding needs to be improved to ensure reliable data are available for decision making
– Coding on the diagnosis as it was thought this varies from one clinician to another. Clinicians need educated on coding.
– Fife is currently doing a pilot on Heart Coding to ascertain if the coding entered is correct – an analysis of this is due soon.
– Difficulties lie in the presentation problems being free text fields which reception staff are filling in for the primary diagnosis.
– ISD currently look at quarterly issues (by drilling down at board level) for coding and where issues are identified, they provide training. They feel that boards need to drill down at local level and feedback where they think there are coding issues.
– Bring coders to these events (like today) to give them a flavour of how important getting the correct codes are – or alternatively have a separate event just for coders.
· Data:
– It was suggested that ISD could provide each board with the Algorithm model to stratify and look at their own patient pathways; however, this would mean that boards would need to get access to GP data.
– Too many silo datasets around from locality to locality and even within same locality which don’t tie up – need a national dataset which links all data.
· It was felt that a lot of good work across all Heat Targets is happening but not always filtering through to other boards.
· Heat Targets are too big – ok for drive but not realistic. For boards to meet targets they need to be able to draw on insights from a range of sources eg SW, and general practice. Boards have limited influence to obtain data from these sources and the only guaranteed way to ensure the support of GPs currently is if QOF can be utilised [but even then, they still can’t obtain the data].
· Reliability of data needs to be improved so that it can be more accurately employed for reporting and as a basis for improvement
· Timeliness of data
· Cost constraints
· There is a lack of integration between Health Boards and IST re: data
· Sharing data with primary care and wider partners
· Continuity of improvements achieved from/through the work of the collaboratives.
· More detailed and relevant information at the front line.
2. What can ISD do?
· Health intelligence around emergency and secondary care data is really well known and shared. Primary care data, however, is not as widely available. Better intelligence sharing across the two sectors would enable greater understanding of how patient and care pathways operate and how to align and smooth transition.
Response: ISD also recognise this need and are providing input to the national GP extraction tool which providing it progresses will help to fill needs around GP primary care data. A project is underway to review the consistency of recording of data out of hours primary care emergency centres with a longer term view to getting national data. Pharmacy data are also being progressed.
· More information focusing on public’s attitude and behaviour once they have contacted NHS24. Would be beneficial to understand if once someone has contacted NHS24 whether they use the service again etc. Improved unscheduled care dataset across the system would assist.
Response: ISD are currently carrying out a ‘proof of concept’ project linking patient episode data from NHS24, SAS, A&E to ACaDMe (inpatients, deaths, cancer and mental health records). One of the aims of the project is to identify regular users of each health system and feed this information back. Other aims include identifying the pathways that patients take and clinical outcomes. It is envisioned that this work be valuable to the monitoring, planning of healthcare and may result in the development of an unscheduled care datamart (subject to need and resources).
· Map distances to A&E to understand whether or not attendance rates are affected by the distance travelled from home. (N.B. Are ISD planning to do this as part of the data mart?)
Response: ISD are currently awaiting GIS software being loaded to our network server (4 licenses) – once completed this work will then be carried out.
· Sharing intelligence focusing on Anticipatory Care Plans around secondary care would enhance understanding of preventative programmes already in place in primary and community settings which secondary care are often unaware of.
Response: ACPs are normally created by GPs and again there is difficulty in getting this information nationally. There are difficulties with national comparison with this as currently there are no existing standard criteria to determine individuals for care management, no agreed standard for ACPs and their use across the country. There are also the difficulties associated with joining up social and health care given there are no electronic solutions. Thoughts on how ISD could help with this would be welcomed.
· External parties to contribute more to ISD to pool data
Response: ISD would need more information from colleagues on this point.
· More detailed and relevant information at the front line.
Response: Examples would be useful here to help focus any resource on what information development would be useful.
· Links and patterns should be looked at by ISD more in the future and shared with Scottish Government and Health Boards.
Response: Again specific examples would be useful to ensure that ISD are developing useful and relevant intelligence for NHS boards.
· Sharing understanding of trends and what is going on.
Response: We are planning to consult with a wide variety of customers and stakeholders for an A&E publication. Information on trends for emergency inpatients can be found on the acute activity webpageshttp://www.isdscotland.org/isd/4150.html. Again other examples would be useful as if not already produced they could be incorporated into our publications.
· The data should be regularly put out to the field.
Response: ISD require more information on this point.
· There should be more feed back systems put in place to be able to advise Health Boards on good practice re: coding, systems, changes, trends etc.
Response: Some work is already done with this e.g. clinical coding tutors, trend information on the website etc. however, we do appreciate that ISD can add more value to this area and will take this forward.
· A&E datamart and SMR1 (inpatient data) should be more amalgamated.
Response: Agree and the linkage project mentioned above is the first step with this. ISD are planning to include A&E data in SHIS rollout towards the end of 2010. this will mean that as well as access to ACaDMe and SMR00 (outpatients) NHS Boards will also be able to access the A&E datamart.
· Coding: ISD currently look at quarterly issues (by drilling down at board level) for coding and where issues are identified, they provide training. They feel that boards need to drill down at local level and feedback where they think there are coding issues.
Response: Unfortunately I can’t find in ISD who produces this information on a quarterly basis, therefore more information would be useful. However, there are a variety of work streams that help to improve the quality of data e.g. clinical coding guidelines (produced roughly twice per year), team of clinical coding tutors who provide training on request or if there is large national change required, validation errors/queries are reviewed on an ongoing basis, bi-annual data monitoring meetings. Navigator provides useful high level comparative information for NHS Boards.
· Data:
– ISD have a lot of data which goes back years but is always with a time lag and if things are to improve then we need the data now – ‘at the right time in the right place’.
Response: NHS boards have access to the linked dataset (ACaDMe, SMR00 and soon A&E) this will mean that boards can produce their own analysis. Due to the number of requests that ISD handles on a daily basis, we do have to plan and prioritise these. The aim to deliver information/interpretation requests within 20 working days. Again examples of what information is required would be useful. There is also the issue of the time delay in getting the data from boards e.g. with SMR01 delays can occur when the record is not clinically coded. A completed SMR record should be with ISD within 6 weeks of discharge. ISD monitor this on a monthly basis.
– It was mentioned that ISD don’t have the resources to cover T12 although they have the data. It would be good to look at the differences between age groups, by conditions etc.
Response: some additional analyses have already been produced, would be interested to know what other information could be provided that Boards would find useful.
– ISD are beginning to look at primary care data – prescribing etc – they have 3 to 4 pilots going on at moment. They will be looking at what is available and what can be shared.
– It was suggested that ISD could provide each board with the Algorithm model to stratify and look at their own patient pathways; however, this would mean that boards would need to get access to GP data
Response: ISD would need further information for clarification on this point
– Too many silo datasets around from locality to locality and even within same locality which don’t tie up – need a national dataset which links all data.
Response: Agree, again the linkage work will hopefully prove that this is something that needs to be taken forward i.e. an unscheduled care datamart.
3. What can SG do?
· Useful for T10 to know more about the activity of T8 and T12. Effective communication early on.
Response: Noted: In the last few months there has been discussion across each of these targets within SG as part of the process for refreshing the HEAT framework.
· More detailed national information is required around attitudes to general practice. Evidence from some Health Boards suggests that inappropriate A&E attendances may be the result of patients not being able to make an appointment with their GP, or not accepting the advice of their GP and seeking advice from a hospital consultant.
Response: GP Patient Experience Survey Access results for Practices 2010: http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/Access2010pdf
Recent report from the Scottish Primary Care Collaborative http://www.scotland.gov.uk/Publications/2010/08/09162114/13
Delivering Quality in Primary Care National Action plan http://www.scotland.gov.uk/Publications/2010/08/16120707/5 – as an output from regional events held earlier in the year at which there was wide engagement with colleagues from NHS, local authority, voluntary sector and patient representatives.
RCGP has been commissioned to develop GP Access Toolkit – this will be available shortly.
· Drop targets, should be a direction of travel rather than a target.
Response: The HEAT framework is being revised at present. This will be aligned to the 3 Quality Ambitions.
· Targets are too focused on secondary care. Introducing targets for primary care may focus attention on providing more care in the community rather than chasing targets within an acute hospital.
Response: It is challenging to identify targets for primary care which are measurable and able to be evaluated. If the group, or individuals have suggestions, these would be considered.
· Could reform the four hour waiting target. Please note that during discussion it was noted that has moved beyond merely being a target and has now become to be seen as a standard. Therefore, to try and reform this target would be seen as radical and would more than likely be opposed.
Response: The previous 4 hour wait target has now become a standard. Waiting times in A&E are seen as a barometer of how the hospital – and the wider system is coping. Focus will therefore continue to be given to this measure. Information on achievement is received from ISD on a monthly basis to monitor performance at individual sites and Board level.
· A new GP contract should be looked at urgently.
Response: Work is currently taking place internally looking at the implications in relation to community hospitals. For further details please contact Max Brown ()