LMC email update October 2017.
Date sent: Thursday 12 October 2017
This email covers a couple of important topics namely End of Life Care and the sharing of clinical records. Both of these topics have been areas that the LMC has been involved in representing the profession and over a number of years initiatives in Hampshire in these areas have gained national recognition.
This email largely focuses on work that is ongoing in Hampshire and the IoW but have copied it to all our members as there may be areas of interest to others.
End of Life Care and the new initiative about ReSPECT and Future Care Planning
I once read, that a civilised society can be judged by how it treats its weakest members, including those who are dying.
Recently I attended a joint meeting of commissioners and providers, a relative of a patient who had died of cancer was invited to address the committee to speak about her experience. The story was considered, compelling and very powerful and provided much to reflect on.
Essentially when a person is dying, most want to die at home close to their loved ones, they want to be able to decide how they are supported and cared for and that their wishes are followed. They expect the care provided to them to be co-ordinated, recognising that there may be a number of different providers of that care, GPs, Community Staff, Carers, Palliative Care staff from the hospice or the hospice at home service. It is therefore not surprising that there should be good communication between the providers of care and that there is a shared care plan and good co-ordination of visiting and a clear understanding of each organisations responsibilities.
What was clear when this relative discussed her experience with us was that there was a clear lack of communication, co-ordination, leadership and there was no shared care plan.
This can be achieved by having a Common Health Record that is available to all who are looking after the patient. I would argue that we need to build on the GP record, both TPP and EMIS allow the formation of a shared record with read write capabilities and the ability to message within the patient's record that allows a strong audit trail. In addition we need to be working as a single team which means not just talking about integrated teams but delivering them in reality and ending the artificial barriers that all too often exist in organisation and between organisation.
It is achievable and within the Hampshire Vanguard we have aspired to deliver this, with practices in my locality sharing records with the Community Team and local Hospice. But we need to go much further towards integration and one of my many frustrations has been our inability locally to achieve this full integration but with powerful stories such as the one we heard there is a renewed effort to achieve this for our patients and their families.
We must do better in the future.
I am grateful to my colleague Dr John Duffy, AMD Transformation services for Hampshire Hospitals Foundation Trust (HHFT) for the following information.
- Are you aware of the new National ReSPECT Emergency Care Planning Process?
- ReSPECT captures more information than just a decision about resuscitation, did you know this will eventually replace all DNACPR forms?
- Did you know a patient may have a ReSPECT form and still want to remain for resuscitation?
- Are you aware that the ReSPECT process is part of a national initiative and HHFT is the first organisation in Hampshire to begin using the ReSPECT forms instead of the uDNACPR forms from 25 September 2017 with the aim that all community services feeding into HHFT will do the same in the coming months?
If not please read the email below and review the attachments/follow links.
ReSPECT is a national tool designed to support conversations about personalised emergency care plans between the person and their clinicians. A documented summary of recommendations will aid healthcare professionals to make appropriate decisions about a person’s care and treatment when the person is unable to make or express choices. The process incorporates both patient preferences and clinical judgement. The clinical recommendations also include a recommendation on whether or not CPR should be attempted.
Hampshire Hospitals NHS Foundation Trust stopped using purple uDNACPR forms from 25/9/17 and will use the national ReSPECT form to capture emergency care and treatment plans, including a CPR decision.
The initial roll-out will be using a paper version of the form (attached) and patients will be discharged with their form held in a purple plastic folder, however it is our aim to support our local delivery system partners to also make this transition from using uDNACPR forms to capturing people’s views about treatment escalation on a ReSPECT form. It is very important to recognise that the ReSPECT form captures much more information than just a decision about resuscitation and a patient may have a ReSPECT form and still want to remain for resuscitation.
From the 25/9 the ReSPECT form will be a paper document contained within a purple plastic folder held by the patient following discharge from hospital. The discharge summary will contain a note indicating that a ReSPECT form has been completed. Our ultimate aim is for the ReSPECT form to be attached to the Electronic Discharge Summary in a format that allows it to be uploaded onto GP health record management systems and the Hampshire Health Record.
Advance Care Plans are a more comprehensive, holistic plan. The intention is not to replace these but to capture a short summary of clinical information and decisions crucial to healthcare professionals attending to the patient in the event of an emergency when the patient may not be capable of expressing their wishes. The decision about the appropriateness of a medical treatment ultimately lies with the treating clinician, a patient cannot demand a treatment, however, they may wish to decline investigation, intervention, admission, ITU transfer, CPR etc.
We are disseminating our message directly to Adult Social Care services, Community providers, GP’s, Practice Managers, CCG’s, SCAS, directly to local care homes and directly to paramedic crews. We will be sending an additional email directly to Practice Managers which will contain additional logistical information about where forms can be sourced and how electronic forms can be converted from PDF to word format to enable uploading on to SystemOne/EMIS.
Whilst the LMC is supportive of initiatives that support patients care and help GPs and hospitals to provide better care to patients we must always be mindful of the work involved in transformation. We understand than since the introduction of these forms in HHFT old DNACPR forms are not being accepted and patients are being sent back to their GPs for a complete new set of forms. In our view this is unnecessary and the system should allow a prospective transition from the old system to the new one and there will therefore be a period whereby both forms are being used.
This is the discussion we are having with HHFT at present.
For more information please follow link:- ReSPECT http://www.respectprocess.org.uk/learning
LMC guidance on ACP https://www.wessexlmcs.com/advanceddecisionsadvancecareplanning
Marie Curie guidance on ACP https://www.mariecurie.org.uk/help/support/terminal-illness/planning-ahead/advance-care-planning
Future Care Planning
The LMC has also been supporting work led by Dr Steve Plenderleith, Consultant in Palliative Medicine, which is now part of the Hampshire and IoW Digital Strategy.
Future Planning templates have been available for SystmONE and EMISweb since July 2016 with the LMC encouraging use in November 2016. Activity reports up to August 2017 show 5100 active templates across Hampshire, with many more collecting some Future Planning information. The three East Berkshire CCGs are also using the Future Planning template, supported by a £300k End of Life enhanced payment scheme.
I am aware that some GPs are not aware of the initiative or the really useful templates that are available. For more information and the EMISweb and SystmONE templates that you can download - click here .
Version 2 of the Future Planning template, released April 2017, includes both End of Life and Frailty codes to help practices maintain EoL and Frailty registers.
- Did you know that Future Planning already includes space for you to record treatment escalation planning information in the Avoiding Unplanned Admission section?
- That, with patient consent, all information in the FP template transfers to the National Summary Care Record, where it can be accessed by SCAS or any clinician with the correct permissions on their NHS smartcard (ED, MAU, etc). We already have one example of an Emergency Department in Leeds using Future Planning info to manage a patient’s care.
- That all information in the FP template will also transfer to CHIE (see the next article) where it will be displayed in an easily readable patient Urgent Care view.
- Whilst HHFT are going to use the ReSPECT paper form, the rest of Hampshire are going to continue to develop the Future Planning approach, hence a project is due to start across Hampshire and Frimley STP to add an additional eDNACPR Tab to the FP template. This will allow printout of a readable DNACPR form for patients to hold, but will also be accessible electronically by SCAS paramedic crews before they arrive at a patients home.
- That a Future Planning: My Wishes leaflet will soon be produced for use by any member of the public. Though aimed at a wider audience than just End of Life patients, this leaflet will utilise the same artist and graphics seen in the new AgeUK “Let’s talk about death and dying “ video and leaflet. They are worth a look.
Play the video or follow this link for the AgeUK website and leaflet - click here.
October 2017 - South Central Ambulance Service (SCAS) paramedics are being advised to view Summary Care Record information for 999 calls, where the patient is known, before they arrive on site.
- 3500 patients in Hampshire already have their uDNACPR status recorded in their SCR
- A mailing due to be posted to paramedic crews can be viewed on the Future Planning website along with supporting Paramedic Frequently Asked Questions.
Future Planning BIG CLINICAL MESSAGES for GPs, that arise from SCAS starting to use this data in anger.
- SCAS cannot see a patient’s Future Planning information unless that patient has consented to share to the SCR. Please add their consent at the start of the FP template
- The Anticipated problems boxes on the Avoiding Unplanned Admission TAB of the FP template are where clinically rich, outcome altering, treatment plans should be recorded.
- If you complete a uDNACPR please also tick the uDNACPR box on the Avoiding Unplanned Admission TAB of the Future Planning Template, then SCAS will know it exists
The Hampshire Health Record (HHR)
The widespread introduction of practice based electronic healthcare records took place in the late 1980's and early 1990's. Towards the end of the 1990's there was aa move to build on this success and to try to improve patient care and safety by sharing these records with other healthcare professionals who were providing care to these patients.
In April 2000 the Central Hampshire ERDIP (Electronic Records Development and Implementation Programme) was one of a number of national pilots to develop a better approach to the sharing of information to benefit patients. The LMC has been very involved in the establishment, development and governance of this and the evolution into what we have today which is now called the HHR. I was part of the group that established the governance framework at the start of this project in 1999 and this group included the GMC, the Information Commissioner's Office, the Strategic Health Authority and the PCT (I represented the LMC and also the BMA).
The HHR has developed hugely over the last 17 years and has saved countless lives and improved the quality of care provided to the population of Hampshire. The LMC has played a critical part in the development of the HHR. The most complete electronic health records are held by general practice and therefore the establishment of a shared record has little value without the GP record. Very early on the leaders of the ERDIP project recognised that the LMC had the "power" to recommend to GPs to support the project or if the LMC were not supportive the probability would be that GPs would decline to upload data. In those early days there were are number of challenging meetings where the LMC made it clear where the boundaries lay in terms of such a project being acceptable to general practice.
What information does the HHR hold?
The Hampshire Health Record (HHR) contains key information from hospital, general practice, community care and social services. This includes feeds from over 95% of GP practices in Hampshire.
Acute care clinical correspondence from:
- University Hospital Southampton
- Portsmouth Hospitals NHS Trust
- Hampshire Hospitals
- Royal Bournemouth and Poole
- St Mary's IoW
Community and Mental Health information from:
- Solent Health
- Southern Health
Information from the independent sector:
- Care UK (Southampton and Portsmouth)
Investigations (pathology & radiology) from:
- University Hospital Southampton
- Portsmouth Hospitals NHS Trust
Social care information from Hampshire County Council:
Use of HHR
This has increased, from 17,000 patient documents viewed in December 2016 to over 40,000 in July 2017.
For most users, the ability to log on from within their main systems has removed the need for separate user names and passwords resulting in a huge increase in usage across the patch.
Single Sign on for GP Practices using TPP - Single Sign On means that users no longer need to use a separate user name and password to log into HHR. You can now view HHR data by clicking a link from within the client record in SystmOne.
Contact the HHR team at firstname.lastname@example.org to find out more and to start the set up process.
The Single Sign On functionality is already used by staff at the Acute Trusts listed above, SHFT, GP OOH services, and all EMIS Web GP Practices and as of September 17 is also available to staff working for SCAS and Hampshire County Council
The Hampshire population is approximately 2,000,000 and there are over 3,000,000 patient records on the HHR.
The HHR is one of the largest databases of combined healthcare records in the world. It has and continues to be a valuable source of data for research. The information held in a secure data repository is encrypted. Any analysis is done using pseudonymised data and therefore is not patient identifiable (and is compliment with the ICO).
HHR becomes CHIE!
2017 will see a major upgrade of the HHR software that will provide a new, modern user interface, allowing data to be viewed by type.
Following that upgrade further work will follow facilitating dynamic care planning and enabling access via mobile devices.
It has become clear that the HHR name needs to change. This is because it is no longer just restricted to Hampshire, nor restricted to health information, nor just a static record. HHR will therefore be changing its name to: Care and Health Information Exchange or CHIE. The new name better reflects the wider area that the system covers and our ambitions to do more. Watch this space for further news about dates for the launch of CHIE!
The Isle of Wight Clinical Executive Committee have just announced agreement of a new project to feed data to the HHR from IoW GP practices, IOW NHS Trust and IoW Local Authority. This exciting expansion of the system will enable users of the HHR across the Isle of Wight plus colleagues in Hampshire and Farnham to access data for Isle of Wight patients (dependant on role and relevance).
The inclusion of the IoW highlights the fact that the system doesn’t just cover Hampshire, and also demonstrates that it is isn’t restricted to health information or just a static record.
Help and support
A full set of help and support materials, together with further information about the HHR can be found on a dedicated website for professionals.
Find out more here please note this link will only work if you are using an N3 connection. This website contains a lot of useful information including data sources/users, user guides, consent (and IG) guidance. ?
The LMC continues to support the HHR because we believe that the benefits to patients far outweigh the risks. We will continue our involvement so that we are able to be fully informed of developments and ensure we are able to represent the interest of GPs.
What are the recent developments?
Rolling out access to nursing homes - Successful pilot involving 3 care homes and 8 individual users. Work is now on-going to prepare to rollout on a larger scale.
Sharing Imms data electronically - Since the beginning of September, new immunisation data from 57 EMIS GP practices across Hampshire is now feeding into the Child Health Information System (CHIS) via HHR. Testing is continuing, (with those EMIS GP practices that have given permission for their data to be extracted from the HHR), and there are about another 60 practices expected to join the project by November. The TPP GP practices will follow shortly after, as well as a feed of historic data from earlier in the year.
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)
Attached file: 2017_04_27_ReSPECT_LondonPolicy v1.0.pdf
Attached file: 2017_04_29_ReSPECT A4 Leaflet v1.0.pdf
Attached file: 2017_04_29_ReSPECT Form v1.0.pdf
Attached file: ReSPECT handout.pdf