Recommendations regarding e-discharge

1. Adapt General Practice systems, processes and workflow to better meet GP needs.
2. Drive wider adoption of the standard in Secondary Care and specialist providers of care (e.g. gender identity clinics).
3. Encourage joint system working (primary care, secondary care, patients) facilitated by ICS’s.
4. Improve e-discharge standards and documentation to make it easier for suppliers and implementers to follow.
5. Review and streamline assurance and conformance processes.
6. Establish programme, leadership, governance and incentives to lead the change programme required.
7. Recommendations for other related programmes.

Recommendations for other transfers of care and for standards and interoperability generally are included in the detailed recommendations below.

To be successful, the proposed approach must include the following key features:

• Collaborative leadership and governance including all key stakeholders (ICS, NHS E and programme teams, software suppliers, PRSB, techUK, INTEROPen) and taking a ‘whole-system’ approach.
• Strong involvement from Integrated Care Systems ensuring local ownership and fir for purpose solutions.
• Focus on clinical continuity and better outcomes for patients.
• Clinical and technical support to enable problem solving and rapid removal of barriers. 
• Pilot deliverables will be assured and shared for national benefit.

• Over one in three, 39%, have had their NHS care cancelled or postponed two or more times this year. This has included hospital operations, tests, scans, outpatient appointments, and community health service appointments.  
• Nearly one in five (18%) of the respondents have had their care cancelled or postponed at the last minute, which the NHS defines as on the day of or on arrival to an appointment. And almost half, 45%, experienced a cancellation with between one- and seven-days notice. 
• Two-thirds of the respondents, 66%, said cancellations to care had impacted their lives, reporting ongoing pain, worsening mental health, worsening symptoms, and disrupted sleep, among many other problems.  

NHS pressures widen existing health inequalities

• Disruptions to care disproportionately affect certain groups, widening existing health inequalities. People who have greater health needs are still facing serious barriers to timely care, and they are also more likely to be more affected by cancellations of care. 
• Unpaid carers, 84%, and neurodivergent people, 83%, were more likely to report negative impacts of cancelled care on their lives, followed by people on low incomes, 80%; and those from minority ethnic backgrounds, 75%.  
• Groups who were more likely to have had two or more NHS postponements or cancellations included disabled people, 52%; neurodivergent people, 51%; and people on lower incomes, ethnic minorities and LGBTQ+ being affected the most, 49%, respectively.  

The survey also found:  

• More than three-quarters, 79%, of the respondents said the NHS had offered them ‘very little’ or ‘no support’ to manage their mental health risks.
• More than half, 52%, said they hadn’t been offered support to manage their medical condition during the new wait for care, 24% had had ‘a lot’ or ‘some’ support and 21% said ‘a little’ support.
• One in seven,15%, were told their care had been cancelled due to industrial action in the NHS, while nearly a quarter, 24%, believed strike action was the reason, though they had not been told this. 
• Nearly half, 41%, said their care was cancelled for another reason; and 20% didn’t know why. 

Healthwatch calls to action

• Collect and publish official data on cancellations to understand what is driving non-clinical, clinical or patient-led reasons for delays; 
• Use this data to reduce the high number of last-minute cancellations; 
• Offer more significant support to those most affected by new delays, especially with mental health needs; and 
• Improve administrative processes and communications to close the gap for those who are left in limbo with no new date. 

1. The health board must consider its responsibilities in line with the NHS Wales Putting Things Right process. This is to establish whether timelier responses could have been given following the two formal complaints it received, and whether it is assured that updates were given appropriately throughout the course of the complaint investigation. The health board should set out what action will be taken to ensure that in future, people are communicated with in a timely manner when raising concerns.
2. The health board must maintain the record keeping audit process, to assure itself that the standards expected for record keeping, are consistent and are being maintained in the immediate and long term. Particularly within its vascular services, but also across the health board. This includes record keeping for all members of the MDT.
3. The health board must explore the reasons for reported inconsistencies in the implementation of the Diabetic Foot Pathway across its three acute sites.
4. The health board must consider and address the issues reported to us regarding the lack of clinical areas at YG, to review patients pre and post operatively.
5. The health board must consider the comments and findings in this report regarding staff culture and the perceptions of different teams. This is to establish whether there is learning, or development required to improve the working relationships across all teams, to support a positive working culture.
6. The health board must consider the comments made by staff regarding the ongoing issues following the implementation of new pathways. This is to establish whether the pathways need to be revised, or further action is required for compliance with the pathways as appropriately.
7. The health board must ensure that all staff are completing all aspects of the consent process as applicable and are documenting this within the relevant clinical records. In addition, further consent process audits must be undertaken and continue on a regular basis, with feedback provided to all staff and actions implemented as applicable.
8. The health board must ensure that: a) All clinical record entries are filed in chronological order; b) Surgical operation records are filled promptly after the surgical procedure.
9. The health board must address the issue where we found examples of misfiling an incorrect patient clinical record, in a different person’s record.
10. The health board must ensure that clinical documentation entries are signed with the clinician’s name legibly printed for identification of the author.
11. The health board must ensure a process is in place to evaluate the sustainability of its vascular service support from UHNM to determine what arrangements will be in place once current agreements end in 2024.

• Targets have improved what was targeted. There is good evidence that the performance management regime in England, of which high-profile targets were an integral part, reduced hospital waiting times and improved exam results. Following the introduction of this system in the English NHS from 2000, the waiting times for elective procedures fell much faster than in Scotland, Wales and Northern Ireland, which had different performance management systems. In schools, the Welsh government’s decision to stop the publication of school league tables – which had effectively set a target for schools to outperform each other – led to students in Wales lagging behind those in England by the equivalent of almost two GCSE grades per student per year. There is also one good example of targets boosting overall performance and improving outcomes for service users. The four-hour A&E waiting time target resulted in a 14% reduction in the proportion of people dying within 30 days of attending A&E because of a reduction in waiting times for time-sensitive but hard to diagnose conditions, such as those suffering from strokes.
• Improvements in what was targeted were partly the result of gaming In hospitals, data was reclassified or manipulated, patients were left waiting in ambulances or on trolleys, and appointments that did not contribute towards meeting an explicit target were cancelled in pursuit of waiting time targets. In education, schools focused on pupils at the C/D grade boundary – at the expense of pupils far above or below this threshold – in response to the target for pupils to achieve five or more GCSEs at grades A*–C. Improvements may also have come at the expense of overall performance. For example, targets probably encouraged the government to provide disproportionate funding to hospitals at the expense of other, potentially more cost effective, approaches to improving population health, though it is hard to draw firm conclusions.
• Targets appear to be effective at raising minimum standards but not at driving excellence In health, the gradually decreasing elective waiting time target had most impact on the longest waits, and the scrapping of school league tables in Wales had no effect on the top quartile of Welsh schools, only the bottom three quarters, with pupils in the poorest performing and most disadvantaged schools seeing their exam performance suffer the most. Conversely, targets, by constraining staff, can create a culture of compliance that discourages innovation and prevents adequate services from excelling.

• Reducing the unintentional harm caused by healthcare is a fundamental priority.
• Prioritising safety enables a more engaged workforce.
• Reducing the risk of harm is a pre-requisite for high performing, productive and financially sustainable health services.
• Quality healthcare cannot be delivered without consideration of safety.
• Improving safety is linked to reducing healthcare inequalities.

The report focuses on seven areas where action is required for Integrated Care Boards to deliver effective system safety:

1. Culture
2. Leadership
3. Systematic Management
4. Model of Care
5. Lived Experience
6. Health Inequalities
7. Innovation

• Professor Ted Baker (Chair) Former Chief Inspector CQC, Chair Health Service Safety Investigations Body Special Advisor for Aqua.
• Helen Hughes Chief Executive, Patient Safety Learning
• Professor Maggie Boyd Former Regional Clinical Quality Director (Midlands and East), Executive Coach & Principal Consultant, Special Advisor for Aqua
• Dr Cheryl Crocker Patient Safety Director, Academic Health Science Network
• Dr Matt Hill National Clinical Advisor on Safety Culture, NHS England Consultant Anaesthetist for University Hospitals NHS Trust Plymouth
• Dr Lisa Riste Aqua Lived Experience Panel
• Danielle Oum Chair for Coventry and Warwickshire Integrated Care Board
• Tracey Herlihey Head of Patient Safety Incident Response Policy at NHS England
• Peter Ledwith Programme Manager for Safety, Aqua

The Conversation

Our panel discussed a wide range of topics covering safety within Integrated Care Systems and the factors affecting it.

• Integrate technology into the overall patient journey, focus on improving the existing system and address the immediate challenges. 
• Ensure relevance and suitability by co-designing the systems with the users, patients, care teams, and the other stakeholders if they will be involved in the care delivery process.
• Focus on the clinical specification of the disease while designing the tools. 
• Develop an inclusive design with the help of the consumers to ensure all the pain points are addressed.
• Minimise selection bias by including marginalised community segments to ensure inclusivity.
• Implement comprehensive training and provide continuous technical support and improvement.
• Extend patient education beyond digital literacy to include health literacy to promote and encourage healthy behaviour in society.
• Incorporate training of caregivers and family members to promote better disease management. 
• Include care teams and clinicians in the training and support programmes to ensure that key player understands how best to use the tools and data-driven systems.  
• Ensure health data is stored and shared securely and ethically
• Include transparent data policies in the overall project guidelines that are available to the patients. 
• Educate the patients so they understand when and how to give consent to information sharing. 
• Develop comprehensive, transparent, and inclusive policies and guidelines promoting equal access. 
• Encourage reimbursement schemes of digital tools and virtual care.
• Built-in flexible financial and payment models to reduce the cost of care.