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Do we need to pay more attention to ‘decluttering’ our innovation landscape?

Published and last updated by Michael Mbanunu

While the 10 Year Health Plan acknowledges the need to phase out outdated technologies and treatments, questions remain about how to achieve this in practice. In this blog, our Programme Director for Patient Safety, Catherine Dale, and current MSc student in Health and Social Care Policy at King’s College London, Ashleigh Goodall, explore healthcare innovation through the lens of de-implementation strategies.

Inspired by conversations with colleagues at NIHR ARC South London, the blog highlights how removing outdated practices can improve patient outcomes, support policy development, and drive sustainable change across health and social care systems.

The 10 Year Health Plan for England introduces dozens of fundamental shifts, mandates, and requirements across seven core areas, aimed at achieving three radical shifts: from hospital to community, from analogue to digital, and from sickness to prevention.

There is mention of the need to stop doing some things in the Plan; “NICE will also be given a new role to identify which outdated technologies and therapies can be removed from the NHS to free up resources for investment in more effective ones” (p17) and “NICE will re-evaluate priority clinical pathways on a rolling basis, identifying where existing innovation should be retired” (p126). However, it is rare for any consideration to be given to how these things might practically be removed from current activities. Is that why it can feel like we need to ‘declutter’ some of our ways of working?

At a recent meeting attended by some of this blog's authors, focused on UK healthcare research and innovation, participants discussed “de-implementation"; ending the use of certain innovations or treatments. While some questioned whether Health Innovation Networks or Applied Research Collaborations should lead this, a senior leader argued it should be the responsibility of the organisations delivering the services, framing it as an automatic part of improving efficiency. This has prompted further reflection.

The case for greater investment in support for the adoption and implementation of innovation has been quite well made12, but have we neglected to consider the efforts required to stop doing things? Surely efforts in de-implementation, guided by health economics, can support strategic decommissioning and better allocation of treatments and services to those who need them most?

What shapes implementation and de-implementation?

Implementation is fairly straightforward; its focus is on bringing in new treatments, tools, or approaches that promise to make care better. De-implementation is the opposite; it means stopping practices that don’t work, cost too much, or even cause harm.

Both processes are influenced by similar factors:

    • The treatment or intervention itself: Is it based on robust evidence? Does it carry risks?
    • Healthcare professionals: Do they believe in the treatment or approach? Do they feel confident using (or abandoning) it?
    • Patients or service users: How do they feel about the treatment or approach? Are they open to change?
    • The wider context: Culture within hospitals and clinics, plus the economic climate.

Take a radical mastectomy for breast cancer. It was the ‘gold standard’ treatment for decades, even after research showed that less extreme treatments worked just as well, if not better. Why didn’t the shift happen sooner? Known methodology, culture, and,  in some cases, the financial rewards attached to performing the more extensive surgery kept it in place.4

On the other hand, governments sometimes hesitate to implement new approaches because of cost. For instance, new cancer drugs often face delays in publicly funded systems like the NHS, not because they don’t work, but because the price tag is too high compared to the potential benefits.5

And then there are stakeholders, including patients themselves. Patients and carers have helped push positive changes forward. A good example is the My Medication Passport project in the UK, which spread quickly thanks to patients promoting it and encouraging pharmacists to stock it.6

But stakeholders can just as easily block change. Look at the COVID-19 vaccination. Many people were reluctant to take up the vaccine due to mistrust: “I don’t believe it’s safe”.7 This is despite clinical evidence that the vaccines are safe (with adverse side effects occurring very rarely) and effective at protecting patients from the risks posed by COVID-19.8

Now imagine trying to remove an existing practice people are used to; it’s often even harder. Take social care interventions to support homeless people: a study in Sweden found reluctance to abandon existing practices in favour of two new evidence-based interventions (‘Housing First’ and ‘Individual Placement and Support’). This was largely down to attitudes towards the effectiveness of the interventions, organisational culture and lack of collaboration between actors representing different parts of the system.9

Why de-implementation might feel harder than implementation

Part of the problem lies in human psychology:

      • Confirmation bias makes us hold onto old beliefs, even when evidence contradicts them.
      • Loss aversion means we feel the pain of losing an established practice more strongly than the benefit of adopting something new. 9

    These types of psychological barriers don’t exist when it comes to implementation. This means that some of the strategies that work to boost the implementation of a new treatment or approach simply won’t work when the time comes to remove or replace it. Take the example of prostate-specific antigen (PSA) testing for prostate cancer.

    Even when evidence showed routine screening of older men did more harm than good, many patients and doctors in the United States resisted giving it up. Strategies that might normally work to encourage the implementation of a treatment, such as raising awareness and knowledge on its benefits, didn’t appear to work for the de-implementation of PSA tests. Perhaps because of these psychological barriers, patients worried they were losing protection, while doctors feared being put at risk of malpractice if they didn’t offer the test.11 12

    Strategies that work (and those that don’t)

    So how do we make change happen?

    Some strategies work for both implementation and de-implementation:

      • Engage stakeholders early and meaningfully, and get their buy-in. In Australia, when policymakers decided to restrict public funding for some fertility treatments that were less effective for older women, they didn’t just impose the change. They invited patients and clinicians into the decision-making process. This helped make the shift less controversial by giving stakeholders the opportunity to voice their concerns before the change was made and play a role in shaping the new funding arrangements and eligibility criteria.12
    • Education and training to explain the evidence behind changes and show stakeholders the new way of doing things. This works best when educational materials are tailored to specific audiences. In Ireland, the amount of unnecessary medicines prescribed was decreased by teaching professionals about the dangers of prescribing possibly unsuitable medications. Additionally, they were taught how to work with patients to examine medications and suggested substitute treatments using a web-based tool.13

    But - context matters. For example, audits and feedback have been effective in cutting unnecessary antibiotic prescriptions in hospitals. The same approach, however, failed to reduce the overuse of MRI scans to investigate back pain, because patients expected them and doctors didn’t want to appear as though they were withholding care.14

    Leadership of de-implementation seems broadly similar but not identical to that employed in implementation, although this topic merits further examination.

    That’s the challenge with de-implementation: it often requires more intense, multi-layered strategies, tackling not just knowledge gaps but also emotions, fears, organisational culture and long-held habits.

    Conclusion

    Implementation and de-implementation share common ground. Both are complex, shaped by culture, economics, and above all, people. Both rely on strategies like engagement and education.

    But de-implementation is often harder. Psychological biases, mistrust, and the fear of “taking away” care make it more complex. Strategies that work for implementation often need adapting, intensifying, or even rethinking when it comes to de-implementation.

    So, they are not really two sides of the same coin. They are connected but distinct. And if we treat them that way, healthcare systems stand a better chance of introducing the best new practices while letting go of the ones that no longer serve patients well.

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    The importance of evidence-based data in supporting services for wound care and the potential for Innovation.

    Published and last updated by Michael Mbanunu

    The DigitalHealth.London Accelerator and Health Innovation Network South London held a roundtable discussion on the current challenges facing wound care services. Our Senior Project Manager for Innovation Karla Richards shares her thoughts and reflections from this roundtable and how data and innovation can lead the way in transforming wound care services.

    In December 2023 a group of professionals including tissue viability nurses and clinical nurse specialists, consultants in vascular surgery and plastic surgery, podiatrists, representatives from the health tech industry, and other professionals came together to discuss the challenges they face in providing wound care.

    Participants highlighted multiple significant factors in the growing burden of wound management including unnecessary and unwarranted variation in the delivery of services, poor documentation, inconsistent information, lack of clear diagnosis, differences in evidence-based clinical practice and lack of continuity of care. People working within systems worry that the current ways of working are disjointed, and there is often a lack of communication across pathways, meaning clinicians may miss valuable information about their patients. In addition to the challenges and potential improvement opportunities in wound care, several key points were discussed, including using data to demonstrate demand and improve business cases for services and dressing budgets, improving communications about patient needs across services, and opportunities for new technology. A common thread across all these areas was data, or a lack thereof, and the ability to effectively demonstrate need.

    The need for data sharing across systems is vital to transforming wound care. Data provides clinicians with information about the patient’s journey. This can be previous medical history, referrals, types of wounds and treatments, clinical concerns, and patient progress. Decisions driven by this data can be used as a guide for clinicians to provide accurate, solution-based care focussed on the needs of each patient. However, with clinicians operating on separate systems it can be challenging to collect and share information as a patient moves across care settings.

    One key point made in the discussion is that there are no metrics for counting the actual number of patients receiving wound care in a particular geographical area or ICS. Anecdotally, there is huge unmet need for high quality wound care, but without standardised reporting, it is difficult to gather data for business cases or to justify increased spending on care.  One clinician explained that when looking at amputations, it is impossible to identify how many patients were also diabetic as this information is not captured on admission as standard. Coding is erratic and does not always translate from primary to community and secondary care. There is also no standardised way of capturing physical information about a wound. Some teams still use a tape measure to document wound size, with others taking photographs and often it is impossible to track the full history of a wound from first origins to current status, even in cases leading to amputation.

    “It is clear from this discussion that there are passionate, talented and committed people working in wound care but they have to fight against the system to deliver high quality care to their patients. I hope this discussion can be a mini catalyst to bringing services and people together to improve wound care for everyone.”Mr. Saahil Mehta MD FRCS (Plast), Founder, Plexaa

    Clinicians are missing crucial data on dressings too. There is a wide range of dressing types available, with a wide range of costs, from simple bandages to specialist materials which are indicated for particular types of wounds. Some teams are reluctant to use the most expensive dressings, whilst others may use them more frequently than is clinically required. Without a standard way to track dressing selection and use in relation to healing progress, there is no evidence to justify spending on these consumables and to support business cases.  Currently some providers of dressings can provide platforms that show quantity and type of dressing at a team level, but this data is rarely recorded and linked to outcomes for individual patients. The gold standard would include tracking patient progress from first engagement with health care services thorough treatments, dressings used, and outcomes all with standard coding in order to demonstrate how many people are getting evidence-based care.

    One participant in the discussion, from an independent social enterprise running a wound care clinic, shared how they collect data on their own system. As a social enterprise, they are a smaller organisation and able to control their own record keeping very closely, and they are also held to a very high standard by their commissioners. They take pride in their systems creating a “story” about each patient which ultimately shapes the care they receive, and whilst being cared for by them this works well. However, this data remains in their system if the patient changes to another provider, as the digital record doesn’t follow patients from independent providers to the NHS. Conversely, the clinic doesn’t have access to the full NHS record on their patients and may not be able to see their full referral history. This highlights the need for patients to own their own data, whatever provider they use.

    The Roundtable participants also expressed concerns around relationships and staffing. Changes to immigration rules have seen a drop in the number of EU professionals working in the NHS, and one team mentioned that they have listed jobs and had no one apply. Covid-19 has also affected staffing and it has affected patients, who seem to be presenting much later than previously or calling about their concerns rather than going for face-to-face appointments. The specialist teams report that when they are finally seeing patients in clinic, many of them have a much higher level of wound acuity than would have been seen in initial appointments in the past.

    So what are the solutions to these issues? The overarching priority for the professionals was improved data sharing and consistency in recording care and outcomes. New technology was also discussed – but as a tool to facilitate the gold standard of care and not just a “shiny new thing” to distract.

    Two health tech innovators were in the room - Healthy.io with their wound care product Minuteful for Wound and a consultant in plastic surgery from Plexaa. These two innovations address wound care from opposite ends of the problem; Plexaa is a smart wearable which preconditions the skin pre-operatively to improve blood supply to the skin. This has been shown to prevent wound healing complications following surgery in clinical trials. Minuteful for Wound allows for better, more accurate decision making and wound care management with consistent documentation through 3D scanning and colour imaging. This medical device uses a smartphone to track wounds over time, identify tissue types, and to provide recommendations on dressings and treatment. The data for each patient can sit within the app and be transferred across providers and along the patient care pathway.

    “Innovation is the idea, clinicians, patients, carers, and the voluntary sector coming together to think creatively about how wound services can be improved and sustainable. Our aim as industry partners is for our technology to provide the platform to underpin this change."Thariea Whisker, Director of Minuteful for Wound Services U.K., Healthy.io

    The use of technology across multiple settings would mean that professionals have access to the full history of a wound, can see previous treatment plans, and get AI-generated decision support for care. Supporting the use of these types of technology to become part of the existing pathways of care would not only help clinicians, but patients could also see their own progress and begin to understand their own journey better. By empowering patients to participate in their own care, compliance to medication and treatments is improved. Engaged patients may also be interested in participating in peer support, which some of the clinicians agreed could be a valuable tool for patients on similar treatment journeys.

    The key conclusions from this event were around the importance of the whole story of the patient’s wound moving with them across different care settings, and finding a clear, unified method to share data, coding and decision making. Technology does have a place in supporting care for patients in both the preparation of skin for surgery and with digital measurement standardising the tracking of wounds and their improvement, or the flagging of decline.  More work is needed to address the perception of innovation and how it can reinforce the sharing of good data-driven decision making and support the workforce to understand existing care pathways. However, effective change also requires personal connections, strong networks, standardisation, and enthusiasm for meaningful transformation.

    Thank you to all those who took part in this roundtable, for your honest thoughts and experiences and to Sara Nelson, Programme Director, DigitalHealth.London, for chairing this discussion.

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    Deep dive into digital advance care planning

    Published and last updated by Simon Ellery

    What are the benefits of advance care planning using digital tools and how challenging is it to implement an effective system?  In this Q&A discussion, NHS South West London CCGs Digital Urgent Care Planning Project Officer Lucy Colleer and NHS England Assistant Director for Enhanced Health and Care Homes and Care Sector Support Fay Sibley answer key questions in the aftermath of Covid-19 and its impact in care homes. The conversation centres on the advance digital care record, Coordinate My Care (CMC).

    Photo of Fay Sibley

    Photo above: Fay Sibley

    Why is advance care planning and having a digital urgent care record important for care home residents?

    Fay:

    I think it's incredibly important that care home residents have a digital urgent care record. We know that care home residents are often in the end phases of life. Even those that aren’t, are living with often extremely complex health and social care needs. So to have a single place where information is recorded about their wishes and preferences as well as their medical needs, including their medication, diagnosis and CPR status means that we are able to look after care home residents in a more holistic way.

    "I think that's particularly important when we start to think about people who, for various reasons, aren’t able to necessarily advocate for themselves."Fay Sibley

    It means that all of the health care professionals who are involved in that person’s care, and look after that person have access to information about that person. I think that's particularly important when we start to think about people who, for various reasons, aren’t able to necessarily advocate for themselves. Or may not be well enough at the point in which they're accessing care to be able to advocate for themselves, or to put forward their needs and preferences.

    Putting in place a system 

    To have that in a systematic way that's consistent and that everybody is familiar with, really does help them with transfer of care. This means we can make sure that we do meet those wishes and preferences and just means we can deliver the right care. Whether that's keeping somebody comfortable at home, or whether that's escalating and transferring them to hospital. If you can access that information, it allows you to consider that on a very individual basis.

    Photo of Lucy Colleer

    Bitesize info

    A series of short case study videos have been produced to demonstrate the value of individual patients having advance/urgent care plans brings to the wider health and care system.

    Photo above: Lucy Colleer

    Lucy:

    We conducted a case study recently with a care home in Kingston, to look at how they were using CMC. How they got on with setting up CMC in the care home as well as getting their staff trained and using it. I think the biggest benefit, is that [CMC] puts the resident’s wishes first.

    From a technical point of view, having a digital urgent care plan allows everyone to have access to the same information. It’s updated automatically, which means that you don't have to worry about bits of paper going out of date or going missing.

    Saving time in an urgent situation

    One of the things that the care manager we interviewed spoke about, was that it saved them so much time in an urgent care situation. In one instance, they had a resident who had a fall, and they called the ambulance service. Normally they would get phone calls from A&E saying, ‘What are the patient’s medical details?’, ‘What medication are they taking?’ But having it in that digital care record just meant that they didn't have to spend time printing documents, or taking those phone calls. And also for the staff in A&E as well, it was really helpful to have that information. Having an End of Life care plan really saves time and can strengthen decision-making.

    It's just about putting the resident and the patient first. It also helps make life easier for clinicians who don't have an awful lot of time on their hands, and the care home staff as well.

    "(A CMC care plan) really means that we are able to look after care home residents in a more holistic way."Lucy Colleer

    Bitesize info

    In July 2020, the HIN was commissioned to deliver a programme to increase use and quality of shared electronic advance and urgent care plans using Co-ordinate my Care (CMC). The programme concentrated on clinical engagement. Read about the Advance and Urgent Care Plans – London Accelerator

    Fay:

    I used to work for the ambulance service and one of the most difficult things was going to a care home in the early hours of the morning after being called to a resident. In one instance where this happened to me, the resident was acutely unwell, had a complex medical history and wasn't able to communicate. I was faced with trying to make an informed clinical decision with no access to information. Often at night in a care home they're operating with skeleton staff and, quite often, agency staff or bank staff because there are challenges in the care sector workforce. So they might not even be able to access patients records because they would be locked in the manager's office.

    The problem with limited information

    What we would know about that resident would be so limited that often as a paramedic, you end up taking people to A&E despite having concerns about whether the distress that course of action entails would justify the benefits. At that point it comes down to questions around what is “right” or “fair”, which are very difficult to answer as a clinician.

    You are so limited to be able to make any other choice, because you didn't know their medical history. You didn't know what their wishes were. Nor which family member to call or who might have some more information about that person.

    Seeing the info on an iPad

    When paramedics first started to be able to access urgent care records we used to have to do that by phoning up the control centre. Amazingly, now paramedics can actually see it in real time on an iPad. But even when I left the service, you could call up the control centre and ask for that information. It just meant that you could make a different decision and you could justify that decision.

    It was an informed clinical decision that was backed up and supported by the input of that person's GP. The input of that person's family, the input, hopefully, of that person themselves, as it allows you to make different decisions. And as Lucy said, a decision that really puts the person at the centre.

    "There was real recognition that care needed to change quite quickly [because of Covid], and that those effects would probably be lasting."Fay Sibley

    Bitesize info

    The HIN, in partnership with the End of Life Care Strategic Clinical Network, secured funding from the NHS England (NHSE) personalisation team to work with Marie Curie nurses to create CMC records for care home residents in three nursing homes in south east London over a five week period. Read Increasing the number of care home residents in Lambeth supported by a Co-ordinate My Care plan

    How is the HIN doing in terms of speeding up the spread and adoption of digital urgent care records in south London?

    Fay:

    The HIN has been working in this space for a long time, probably since the HIN started (in 2016) and more formally with CMC for the last two and a half years. Through a small pot of funding, through The Health Foundation, we were able to do a pilot project with about 10 care homes looking at different methods of getting care homes access to CMC. We also looked at the things that care homes would need to do in order to be able to access CMC. Either to view it or to put information into the record.

    The challenges for care homes

    From that project we learnt an awful lot about some of the process aspects of this that are challenging for care homes. Things like Information Governance (IG) requirements, the hardware requirements, having a laptop or a device to use and the Wi-Fi requirements.  I think that learning has then helped us to try to move this conversation on.

    Obviously in terms of the [Covid-19] pandemic, it changed lots of things. Particularly the work that care homes are doing and the focus being put on care homes by the Government.  So at the beginning of the pandemic the HIN was really instrumental in trying to pull together various stakeholders who were looking at the key questions ‘How do we create records for care home residents?’ There was real recognition that care needed to change quite quickly, and that those effects would probably be lasting.

    Collaborative working

    The other thing we did was we worked with the End of Life Care Strategic Clinical Network to secure some funding and ran a small-scale pilot with Marie Curie. That was really interesting because Marie Curie had a number of frontline clinical staff who were shielding themselves because of the pandemic. Those staff were at risk of being furloughed and not able to work because they weren't able to do their frontline job. So what Marie Curie did was give them some additional training and upskilling. This meant they could support care homes to create CMC records for residents.

    Working with care homes

    We worked with three care homes in Lambeth, one GP practice and Marie Curie to deliver a small kind of, ‘proof of concept’ project around the use of CMC in a care home.  We learnt lots. We realised that to create quality records remotely with another organisation that doesn't perhaps know that person or have access to all of their clinical information has its challenges. They were able to do a fantastic job in starting the record off, but they still required a fair amount of input from the GP. It was not a perfect model, but we learnt a lot from the project. It was really interesting to use voluntary sector organisations to support this work.  In particular, organisations like Marie Curie that really have a lot of knowledge around end of life and advance care planning. And to use a staff group that otherwise, perhaps, wouldn't have been working during the pandemic and certainly couldn't do their main role.

    Bitesize info

    The HIN Healthy Ageing and Informatics Teams were commissioned to create a user friendly and useful digital maturity dashboard for care homes across London. This project was led by the Health Innovation Network and funded by the Digital First London region team.

    Since then we've been doing a lot of work with Lucy and trying to support the coordinated pan-London effort around care homes and CMC. So it's absolutely brilliant to see this is on the commissioners’ radar and the work that Lucy’s doing. Lucy's pulled together a steering group that now meets monthly, and the HIN is also trying to help with some of the analysis of the data.

    A dashboard for care home digital maturity

    We've developed a Care Homes Digital Maturity Dashboard. This is a tool to be able to  monitor each care homes maturity status, in terms of their digital abilities. A key part of that for London care homes is CMC. 'Do they have access to CMC?' 'Do they have the right IG requirements that allow access to CMC?  'How many residents in their home have CMC?' We’re pulling all of those data sources together and presenting that information in a way that's useful to Lucy and other colleagues across London working in this space.

    I think the HIN’s moved more into a supportive role, trying to share the lessons that we've learned from some of the early work. And then really letting the commissioner drive it forward in a way that we don’t have the reach to do.

    "(A CMC care plan) really means that we are able to look after care home residents in a more holistic way."Lucy Colleer

    Bitesize info

    View the collection of resources. Coordinate My Care has provided a wealth of info to support the patient-led portal to create an end of life care plan. MyCMC: your plan, in your own time, in your own home

    How many digital urgent care records have been created through CMC?

    Lucy:

    It’s in the region of thousands (see chart below). There are lots and lots of residents who do have care records, so the focus of our pan London work at the moment is actually getting care home staff themselves to look at those records. At the moment the majority of those records are created by the GPs and sometimes in the acute trust. So we're trying to encourage care home staff to start looking at those resident plans and keep them up to date.

    The power of data

    We have been working really closely with Fay and the HIN and I would say that the HIN has been more than just support. We're trying to lead the way from where you paved the way and the Care Homes Digital Maturity Dashboard is really, really helpful especially from a commissioning perspective because we can look at how it's affecting the ambulance call-outs and the conveyance rates and use the information to make commissioning and transformation decisions. From a commissioning point of view, obviously patient-centred care is the most important thing, but financial return on investment is important too. It’s been really great to be working with it with the HIN and supporting work that Fay and the team have been doing.

    Fay:

    I think the other thing that's really helpful is about data, and CMC actually produce a fair bit of data.  Again we could debate the data set of course we could, but they do produce a commissioners’ workbook, again on a monthly basis. One of the useful things about data is it allows you to look at different areas and make those comparisons.

    Incentivising GPs and the role of the ICS's

    For example in south London, south west London do particularly well in terms of the number of CMC records they’ve created. So you can look at some of the models that they've put in place over the last, let's say five years, that have really led to that. For example they incentivised GPs to do some of this work, so you saw a really big increase in that they've got a really established enhanced health and care homes programme and End of Life care programme within their Integrated Care System (ICS).

    Again, they're really driving that work forward from a ICS strategic point of view, so having data allows you to look at factors such as where’s doing well? And ask questions like 'What are they doing?' 'Who’s lagging behind and 'what might be the reasons for that?'

    The quality of the record

    And then one of the other things that the HIN has really been focusing on is thinking about the quality of the record. Creating a record is one thing that's really important, but the record is only really as good as the information that's in it. 'How do I make sure that the information that I include in that record is of quality and is useful?' 'Does it make sense as a kind of complete picture?'

    The HIN developed a checklist of the non-mandatory information that would be most useful to clinicians. And then from that we've done some work with south west London to try to refine that. Again, we pulled together a steering group with various clinicians from south west London to look at how can we use something like a checklist to drive up and standardise the quality of CMC records. This is so they are a useful, high quality, advanced care planning record.

    "Creating a record is one thing that's really important, but the record is only really as good as the information that's in it."Fay Sibley

    What would you say has been the biggest challenge in setting up more CMC records?

    Fay:

    I think capacity of the workforce to really do this, is the biggest challenge. As Lucy said, at the moment the vast majority of CMC records for care home residents are created by GPs. But GPs are an incredibly over-stretched workforce and it's not a quick five-minute job. It can take up to an hour to really have a meaningful conversation and then translate that into a record and publish that record. When you start talking about thousands of records across London, that's thousands of hours of GP time.

    Who else can support the programme?

    But I think the thing that may help us around that is understanding who else within the primary care and community services workforce can support this work.  Care homes themselves absolutely play a vital role and can feed into the record and do some of the data entry and have the conversations, but also, say, palliative care teams often do this kind of work; hospices, they've got brilliant teams that can support with this. Voluntary sector organisations; Macmillan, Marie Curie and GP practices are now starting to grow their workforce. Through the Primary Care Networks, we've now got paramedics working in GP practices. We've got highly skilled nurses that are really, really knowledgeable. There is a growing pool of professionals who could support the creation of urgent care records.

    Getting patients and their families involved

    We’ve also got an opportunity through MyCMC potentially as well which is something that was set up to be a patient-led record. Somebody would initiate that record for themselves, and there are roles within a GP practice where that could be a supported process, so social prescribers for example have the potential to be able to support somebody, even living in a care home, to initiate that record. People have a bit more agency. This includes setting up a record in mental health care homes and learning difficulty care homes. It may be appropriate sometimes to use MyCMC.

    Lucy:

    I take your point on capacity in terms of creating and maintaining those care plans. Once the plan is there,  it’s fairly easy to update and maintain it and we've seen that with some of the care homes that have been using it. They include it as part of the weekly rounds when the GP comes along, they include it at the Multi-Disciplinary Team (MDT) meetings that take place. And actually it's not too much work once the initial plan is filled out. In some of the more successful care homes using CMC the biggest thing, is just being engaging with them, and that's quite difficult to do from a commissioning perspective.

    Resource challenges

    I work in a very small commissioning team of just two. We’re covering the whole of London, including all health and care organisations across London.  So between us, it's very difficult to do that engagement. CMC does have a very strong engagement team, and they are successful, but they're still quite a small team for the whole of London. Some of the more successful care homes have been the ones that the CCG has provided resource, such as project support officers that have literally been hand holding those care homes to support them with all sorts of digital maturity aspects, like the Data Security and Protection Toolkit (DSPT) compliance and also, they've been really helpful with getting the care homes access to CMC.

    I think engagement is one of the biggest success factors, but also a huge challenge. I think there's such a variety of resources across London. I know some STP's simply just don't have the resource to hand hold care homes with it.

    Care homes 'left behind'

    I think care homes have been left behind a little bit in terms of digital maturity. That's one of the key things - being able to have access to a computer, good internet, the IG (Information Governance) - all in place.  I think that they've been a bit left behind. I don't know what the historical reasons behind that are, but I think the digital maturity side of things is a big challenge for some care homes, especially the smaller ones.

    Fay:

    I would agree wholeheartedly with that around the kind of digital maturity aspects.

    And I think there's lots of reasons. Obviously, many of them are private providers. Historically, social care hasn't received the same level of funding as the NHS. It perhaps hasn't been seen as a priority or our job.

    Equality of access to care

    But I think when we talk about and think about equality of access to care and the world that we now live in, and the fact that many health services have been forced to, at least in some ways, move to a more virtual remote delivery then actually it's no longer the responsibility of social care alone because we're denying people access to the care that they have a right to.

    I think that's probably why there is such an increased focus throughout the pandemic on getting care homes up to that basic level of digital maturity; that same digital standard that we would expect of our NHS.  It's not easy, and I think one of the reasons we started the dashboard was because at the beginning of the pandemic, what we didn't know is what we didn't know (i.e we didn't know whether this home in Southwark had Wi-Fi even, or if they even had a laptop and that information wasn't anywhere). There were no agreed datasets around the care homes. There was no kind of central repository to go to and just put in the care home name and it will bring that up, so we didn't even know how to support them, because we didn't know what they had to start with. So that's part of the reason we initiated that dashboard work because we were like how we can support the central government functions - health and social care, public health and other involved organisations?

    This was a joint interview that took place remotely in April 2021.

    NB: Fay Sibley was speaking in her previous role as the HIN's Head of Healthy Ageing.

    Table showing number of care home residents in London with a CMC plan

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