Implementing a single unified health system to create a dynamic single service

The Cardiff and Vale NHS Trust (C&VT) is a sizable organisation. The result of several mergers in recent years, the last of which was between the local community and mental health trust and the acute trust, the University Hospital of Wales, the trust is now the third largest in the UK.

Since the mergers Cardiff and Vale has brought all the diverse systems of the other trusts together and forged their own identity and drivers, with an over-riding strategic goal, the enablement of services. They have formulated very advanced in-house solutions, not just in terms of IT but also in terms of their general and management infrastructure and in the way they use technology to really improve services.

Eighteen months ago, to enable the trust to develop a single service model based around multi-disciplinary working for its mental health and community services, Cardiff and Vale signed a contract with in4tek for the Paris system and took delivery of the first shipment of the system in April last year. By October they had the first go-live with community mental health teams, in February this year the entire community service was implemented and now crisis resolution and home treatment teams have just finalised their implementation. The plan is to seamlessly link general community and mental health with the new model of acute services being introduced in Wales.

Project manager for the Paris implementation, Peter Landstrom, said it was recognised that within this mental health client group it is rare to have a single agency involvement. “External service involvement, with social services and police for instance,” he explained, “is a regular consequence, and that involvement, no matter how minor, should have access to shared, accurate and up-to-date clinical and patient information.

“There needed, therefore, to be a more generic view of the patient and to meet this challenge the trust decided to create a dynamic single service, to come as close as possible to creating a single patient record across the entire trust and locally within individual services. Our vision for the project is about clinical information. It’s about providing better clinical information for all staff and the clinicians involved. That benefits the patient, helps staff do their job better and more safely and ultimately it helps improve the service.”

A clinical service leading the information

The result of this information that is now generated is that the trust has, for the first time, a clinical service leading the information rather than information demands leading the clinical practice. “This is crucial and difficult to get right sometimes,” Peter said. “We are a clinical service needing a clinical solution with clinical benefits and we had to get us working effectively as an organisation, with all the disciplines that are involved. As a multi-disciplinary organisation we had to focus on delivering a unified effective service and communicate as part of a patient team.”

With a key part of that multi-disciplinary team, in terms of mental health, very often social services, touching on police, the courts and probation services, the trust now has a health unit permanently based in the prison for its forensic service. Peter believes that the project is now linking into the wider service and being patient focused. It is allowing other organisations a single point of contact and not having information silos.

He explained that there are two local authorities, two sets of social services, within the trust area and they are not co-terminous. So from a business point of view they are quite separate organisations with their own accountabilities and priorities, and with different systems. “The common denominator across all of these services being the patient, the client, the person and it is all about linking all that together. It would be lovely to say we had a single system but we don’t,” Peter observed. “And I don’t think this is a problem that can be solved locally. It doesn’t really happen in England, they have multiple systems to look after the same patient.

“But this project is not just about implementing an IT solution and implementing the change that goes with it, it is also about looking at the processes that fit around that. And, actually it’s OK to hold separate information as long as there are processes and procedures, understandings and communications. That can be talking, or some fancy electronic interfacing, or that can be people bringing people and processes together. What we have found with Paris is that we have an enabler; the system has opened up unexpected avenues and is leading us in directions that would never have been considered before.”

He said that, because of the disparity of systems and procedures, when the solution is weighed against what actually needs to happen it is at times necessary to have “off Paris process” which, although triggered by Paris and with an end result entered into Paris, may not be directly administered by Paris. But it is still part of the implementation because it is still part of the goal of unified service and assessment, with a single patient record and multi-disciplinary and multi-organisational working. “Paris has given us the freedom and the framework on which to hang everything that we need to do,” Peter added.

A very worthwhile journey

“Although, when we first unpacked it, it was very clear this was not an off the shelf product that would immediately sort out our problems, it was more a Lego set that needed to be built and what was going to be built was going to be determined by us. And ultimately the journey that Paris has taken us on, albeit longer and harder than anticipated, has been very worthwhile. It has forced us to look at our services, processes and accountabilities and that has been as valuable as the actual implementation of the system.

“Things like observing how our nine community teams worked and seeing that they all did things slightly differently, even though they were the same sort of sort of thing. This gave us the opportunity to make a generic process and to say, this is how we are going to do this, and this way will fit onto Paris and fit onto the system.

“And that, for the patient, has been very worthwhile because regardless of whether they live in an affluent area or a poor area, or move from one side of the city to another, they will receive exactly the same service, procedures and processes irrespective of whether or not they are visited by this or that consultant, or this or that team. This is exactly what we have been striving for. The trick is to read that generic process in best practice, to take the elements that the teams have developed and incorporate that into the wider process. This has all been enabled by the implementation of a single unified system.”

In a huge step forward C&VT has just gone live with their two crisis teams. These teams, for the first time, will cover the whole of the City of Cardiff. The teams have responsibility for assessing patients in acute crises to decide who may need hospitalisation or home treatment. They will also work with acute patients in hospital wards to enable these patients to return home quicker than was the case until recently.

The crisis teams are a 24/7 service and, for the first time, are on line with access to all community patient information throughout Cardiff regardless of day, time or week and regardless of location. This has dispensed with the previous situation where if, for instance, they had a call from the police or A&E referring to a possible or attempted suicide, they were completely information blind, with no knowledge of who the key worker is, or the medication, or the risks and care plans, or their relapse profile. Now, enabled by Paris to cross service lines, they are armed with all that information and are now in a position to intervene more quickly and effectively to the benefit of the patient.

Generic community and mental health services linked

“This is key,” commented Peter. “It is really positive and the teams are very excited about it. In less than a year we will have implemented all our generic mental health community services and at the end of this year we will be looking to start our patient wards. Which again will just link up the entire pathway for any patient regardless of where they enter the service, in crisis in the community or wherever. It is going to be one single pathway with different levels of service all team-led rather than the patient having to move through different levels of service.”

The scope of the Cardiff and Vale project is enormous. It covers all mental health and support services within Cardiff, (with the exception of the Child and Adolescent Mental Health Service) and all community services within the trust area. This includes district nursing and specialist district nursing, health visiting, very specialist clinics and acute response teams (ARTs). ARTs, again, work from the acute hospital and intensely manage patients to either prevent admissions or affect early discharge.

The project also embraces all community child health services and all the child health therapies that go with it, which is a huge service and again absolutely key. In fact the only thing excluded are acute ward-based services.

The trust is currently actively engaged in discussions with its social services partners to see how all staff can work with a single electronic solution to the benefit of the patient/client. All partners can see the attractions of moving in this direction and as a result the trust is considering more robust solutions as to how that single patient point is managed. This is all part of the long-term project that will see Paris assuming a much more strategically important role within the trust.

Already 97% of the trust’s consultants are actively logged on or engaged with using Paris, recording notes, recording case plans. “And this, at the end of the day, is what it is all about,” Peter stated. “Because it is relevant, because it gives them what they need, it proves that Paris is very much capable of being tailored to suit both health and social care environments, either separately or to facilitate their integration.”