Joining the Health and Social Care Dots with Data

The Health and Social Care Bill, introduced earlier this year to organise care as Integrated Care Systems (ICS), is a positive step for integrating health and social care. The bill appears to have more teeth than previous attempts and gives social care a statutory seat at the table with its health partners.

We have all seen how the Covid experience has brought both health and social care into the spotlight like never before. Social care’s key role, and its problems, appear to be receiving greater recognition.

In a similar vein, Covid has also highlighted how data can be used to identify those with needs and how effective technology and data can underpin joined-up health and social care services.

Data-led Initiatives

Effective use of data has been critical during the pandemic and is considered one of the success stories, so it follows that it is at the heart of the government’s latest care strategy. NHSX’s ‘What Good Looks Like’ framework and its Unified Tech Fund encourage data-led initiatives to support health and social care improvements at an ICS level.

The framework covers six strands:

• The ICS intelligence platform – local ICS-wide shared care records and intelligence platforms with fully linked datasets (including primary, secondary, mental health, social care, and community data) to enable population segmentation, risk stratification and population health management.
• Care redesign - using data and analytics to redesign care pathways and promote wellbeing, prevention and independence (for example, identifying patients for whom remote monitoring is appropriate).
• Care models – the creation of integrated care models for at-risk population groups, using data and analytics to optimise the use of local resources and ensure seamless co-ordination across care settings.
• Access for staff - ensuring frontline staff in an ICS have the information they need to do their job safely and efficiently at the point of care, including an ICS shared care record.
• Access for organisations - ensuring organisations across an ICS provide a consistent and cost-effective approach to remote consultations, monitoring and care services.
• Insight - ensuring that local ICS and place-based decision-making forums, including PCN multi- disciplinary teams, have access to timely population health insight and analytical support.

It’s a big to-do list. It will rely on creating a joined-up approach between health and social care, which can seem overwhelming, but Rome wasn’t built in a day. It is achievable if taken one step at a time, and evidence of this can already be seen across the country. We have put interfaces in place between social care systems and health systems, for a number of our customers, which are in live operation, facilitating more collaborative working.

“Many care systems have successfully fulfilled steps one and two and are already underway with population health programmes thanks to the power of overlaying whole ICS shared records with a population health management system.”

System C worked with Graphnet whilst joining up these health and social care systems. Together, the companies form the System C & Graphnet Care Alliance - a group of companies with common ownership providing integrated IT solutions to the UK health and social care market. The Care Alliance has created a blueprint for supporting ICSs to achieve the government’s vision for health and social care integration based on our successful implementations.

It’s focused on three fundamental areas:

• Sharing and integrating data across the ICS.
• Sending messages and managing workflow across the ICS.
• Analysing data operationally and at citizen cohort level across the ICS.

Many care systems have successfully fulfilled steps one and two and are already underway with population health programmes thanks to the power of overlaying whole ICS shared records with a population health management system.

The Power of Data

The analysis of data at a regional level enables organisations to intervene earlier with targeted action for people who show signs of risk or deterioration. Large data pools, combined with real-time updates, are powerful. Covid has changed people’s attitudes to sharing data and proven how effective it can be, particularly when health and social care workers need to know what is happening in their region now, rather than six or 12 months ago. Quality real-time data has a crucial role in supporting future healthy populations.

Reactive to Proactive Social Care

One cohort that this data can be used to support is older people and those with complex needs. Councils can use the data to deliver targeted proactive support, which has the potential to reduce hospital visits and enable people to remain at home and independent for longer.

Working closely with our partner company, Graphnet Health, we have developed an Adults’ Early Support approach, using proven technology to analyse data from across a range of systems and identify those at risk of crisis, deterioration or long-term residential care. Importantly, we can look for people who are not currently known to social care, but who are likely to be soon, unless some early support is provided.

These cases can be sent into the Liquidlogic Adults’ Social Care system (LAS) workflow for early assessment and support. The system includes locally configurable algorithms to highlight risk ratings, supporting social care teams in prioritising cases.

Liverpool, Knowsley and Wirral councils are embarking on an early support pilot to deliver intelligence-driven social care with the system. Services are responding to unprecedented pressures by thinking differently and devising new approaches. Early support can delay people coming into long-term services and prevent avoidable admissions. This sort of work is right in the sweet spot of the ICS agenda.

CIPHA, Insight, Action!

The pioneering CIPHA (Combined Intelligence for Population Health Action) programme has helped services make huge strides in joining the health and social care dots. In the first days of the pandemic, two Cheshire & Merseyside Covid-19 resilience cells identified the need for a real-time analytics platform to manage the crisis and drive a strong recovery. This platform was mobilised in just three months across 40 organisations and 359 GP practices and has been central to the region’s response and recovery, including virtual ward programmes. As a result, it is being extended elsewhere across England.

The use cases for CIPHA’s dashboards, which cover capacity and demand, epidemiology and population stratification, are growing rapidly. CIPHA is integral to the smart testing that informs UK policy and helped to play an important part in the national Events Research Programme for safe unlocking after Covid-19 restrictions. The three early support pilot customers in Merseyside are now leveraging this approach for social care.

Integrated Care is the change we need

The ICS model to join up health and social care could be the vehicle to trigger the transformation that has been sought for many years. And it’s important that it is different this time because there is no time to lose, the backlogs are too great, and the funding is too tight. We need to change the way we work to drive us out of crisis recovery and deliver better care beyond that.

Sharing data across health and social care can play a fundamental enabling role in identifying people who need support. It can then help to manage and monitor the effectiveness of that support, which is good for the recipients and good for the system. Sharing and analysing data in this way could be the catalyst needed to add dynamic proactive care to the traditional reactive model.

The system is now under such pressure that it’s forcing us to think differently. We’re looking at how early support and prevention can help mitigate people coming into long term services - how we can prevent all avoidable admissions. - Martin Farran, former Director of Adults’ Services & Health, Liverpool City Council

David Grigsby is Managing Director of Liquidlogic

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