NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board … · 2016-07-05 · being in a transformation area to: make progress on integration of health and social care, integrated urgent

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NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: ………11……………… Date of Meeting: ……30th March 2016……………………… TITLE OF REPORT:

Bolton Integrated Shared Record

AUTHOR:

Avtar Ubbi, Head of IT

PRESENTED BY:

Avtar Ubbi, Head of IT

PURPOSE OF PAPER: (Linking to Strategic Objectives)

To receive the presentation of the Graphnet Carecentic Business Case which has recently been approved by the CCG Executive.

RECOMMENDATION TO THE BOARD: (Please be clear if decision required, or for noting)

The Board is asked to approve the Business Case within the business case.

COMMITTEES/GROUPS PREVIOUSLY CONSULTED:

CCG Executive

REVIEW OF CONFLICTS OF INTEREST:

None identified

VIEW OF THE PATIENTS, CARERS OR THE PUBLIC, AND THE EXTENT OF THEIR INVOLVEMENT:

Views of the public, patients, carers and staff will be sought in relation to any of the projects, initiatives and commissioning decisions referred to in the business case.

EQUALITY IMPACT ASSESSMENT (EIA) COMPLETED & OUTCOME OF ASSESSMENT:

EIAs will be undertaken in relation to any of the projects, initiatives and commissioning decisions referred to in the business case.

CONFIDENTIAL

Final - Version 1.0 26-February 2016

Integrated Shared Care Record

Business Case

CONFIDENTIAL Bolton Integrated Shared Care Record

Final - Version 1.0 Page 2 of 24 26-February 2016

DOCUMENT CONTROL Document Information:

Document Name: Document ID: Version: 1.0 Location: Issue Date: 26th February 2016 Status: Final Document Owner: Document Author: Stephen Cashman Classification Sign Off Date:

Document History:

Amended by Version Status Date Purpose of change Stephen Cashman 0.4 Draft 28/01/2016 Initial Draft for discussion Stephen Cashman 0.5 Draft 12/02/2016 Revised draft for comment Stephen Cashman 0.6 Draft 24/02/2016 Revised draft for comment Stephen Cashman 0.7 Draft 26/07/2015 Revised draft for comment Stephen Cashman 1.0 Final 26/02/2016 Final version

Contributors:

Name Position Organisation

Reference to Other Documents:

ID Name Location

Reviewers:

Name Version Position Organisation Avtar Ubbi 0.4 Head of IT Bolton CCG Grace Birch 0.5 Ass. Director of Informatics Bolton CCG Grace Birch 0.6 Ass. Director of Informatics Bolton CCG Avtar Ubbi 0.6 Head of IT Bolton CCG Avtar Ubbi 0.7 Head of IT Bolton CCG Avtar Ubbi 1.0 Head of IT Bolton CCG



Contents Executive Summary ................................................................................................................... 4

1. Purpose ............................................................................................................................. 5

1.1 Introduction ................................................................................................................................5

2. Strategic Context............................................................................................................... 5

2.1 Drivers .......................................................................................................................................5 2.1.1 National Drivers ...................................................................................................................5 2.1.2 Regional Drivers ..................................................................................................................7 2.1.3 Local Drivers .......................................................................................................................7

3. Case for Change ............................................................................................................... 8

3.1 Existing clinical systems landscape ...........................................................................................8

3.2 Target benefits of improved information sharing ........................................................................8

3.3 Examples of Benefits Realisation...............................................................................................9

4. High Level Criteria........................................................................................................... 10

4.1 Strategic Fit: ............................................................................................................................ 10

4.2 Functional criteria: ................................................................................................................... 10

4.3 Business / Commercial criteria: ............................................................................................... 11

4.4 Constraints, Dependencies and Risks ..................................................................................... 11

5. Available Options ............................................................................................................ 12

5.1 Option 1 – Do Nothing ............................................................................................................. 12

5.2 Option 2 – Procure and implement a new local instance of CareCentric solution ..................... 12

5.3 Option 3 – Utilise the existing CareCentric platform hosted by GM Shared Services ............... 13

5.4 Option 4 – Utilise the MIG to enable sharing of the patient record ........................................... 14

6. Recommendation ............................................................................................................ 15

7. Procurement Route ......................................................................................................... 16

7.1 Procurement Process .............................................................................................................. 16

7.2 Procurement Timescale ........................................................................................................... 16

7.3 Implementation Timescales ..................................................................................................... 16

8. Funding and Affordability ................................................................................................ 16

8.1 Charging Mechanisms ............................................................................................................. 16

8.2 Contract Length ....................................................................................................................... 16

8.3 Accountancy Treatment ........................................................................................................... 16

9. Management Arrangements ............................................................................................ 16

Appendix 1 – IDCR solution based on the existing CareCentric platform ................................ 18

Appendix 2 – Full Cost Breakdown .......................................................................................... 20



Executive Summary

This Business Case sets out the case for Bolton CCG to invest in the development of an Integrated Digital Care Record for the Bolton locality which is predicated on a number of key national, regional and local drivers. At a national level, NHS England published the ‘Five Year Forward View’ in October 2014. In November 2014, the National Information Board published a framework for action ‘Personalised Health and Care 2020’, outlining their vision for joined up, digital real-time records, data standards, intelligence and patient access to records across care settings.

Personalised Health and Care 2020 states that “Better use of technology and data is a prerequisite for supporting and enabling the key developments needed to reshape the health and care system, which are at the centre of the Department of Health’s vision for health and care and the NHS’s Five Year Forward View, in response to increasing demand and constrained resources.”

At the regional level, the ‘Greater Manchester CCG Primary Care IT Strategic Vision 2015-2018’ was approved by the IM&T Steering Group in June 2015. This strategic vision comprises four overarching principles:

• Connect: connecting infrastructure and systems across GM enabling staff and information to flow dynamically across the region;

• Integrate: providing integrated records and intelligent systems that have the ability to be interlinked across GM and beyond.; single GM wide consent and information sharing model;

• Empower: patients and citizens access to their own information; online access to services and apps;

• Collaborate: inclusive governance and commissioning; innovation hubs and collaborative working.

NHS England has approved a single, combined Digital Roadmap submission for all organisations in Greater Manchester.

At the local level, improved information sharing across care professionals is a vital enabler to achieve improvements to health and social care in Bolton. The ‘Bolton Health and Care 5 Year Locality Plan’ and the ‘Bolton Quality Contract 2015-2016’ build on ‘Personalised Health and Care 2020’ and The ‘Greater Manchester CCG Primary Care IT Strategic Vision 2015-2018’ and identifies a number of commitments and aims that can only be fully realised if the right information is available to professionals, with the right access permissions, at the right time, and if patients can access information about their own care Four options have been considered: Option 1 – Do Nothing Option 2 – Procure and implement a new local instance of CareCentric solution Option 3 – Utilise the existing CareCentric platform hosted by GM Shared Services Option 4 – Utilise the MIG to enable sharing of the patient record The paper goes on to recommend option 3 for the following reasons:

• Reduced implementation costs • Reduced recurrent costs of a shared instance; • Reduced costs associated with procurement process; • Reduced time to implement solution;



• Access to information on Bolton residents through links to providers established by other localities on the shared CareCentric instance;

• Shared support costs through GM Shared Services; • Knowledge sharing between localities within GM; • Potential further benefits in economies of scale in working with partner CCGs.

By utilising the existing GM Shared Services platform a cost saving of 46% over 5 years can be achieved. This give a five year cost of approximately £2,094,433 versus £3,876,405.

1. Purpose

1.1 Introduction

This Business Case details the proposal to invest in an integrated digital care record (IDCR) solution for the Bolton locality

The participating organisations are

Bolton Clinical Commissioning Group (CCG) Bolton Council (LA) Bolton GP Practices Bolton NHS Foundation Trust (FT) Greater Manchester West Mental Health NHS FT (GMW) Out-of-Hours Service (BARDOC) North West Ambulance Service (NWAS)

The proposed solution will enable the integration of information from a number of sources, relating to the care of a patient and enable this information to be viewed by authorised health and social care professionals involved in the care of that individual.

2. Strategic Context 2.1 Drivers 2.1.1 National Drivers At a national level, NHS England published the ‘Five Year Forward View’ in October 2014. In November 2014, the National Information Board published a framework for action ‘Personalised Health and Care 2020’, outlining their vision for joined up, digital real-time records, data standards, intelligence and patient access to records across care settings.

Personalised Health and Care 2020 states that “Better use of technology and data is a prerequisite for supporting and enabling the key developments needed to reshape the health and care system, which are at the centre of the Department of Health’s vision for health and care and the NHS’s Five Year Forward View, in response to increasing demand and constrained resources.”

The framework goes on to state that “if we are going to transform the way information is used across health and care, then we need to deliver radical transformation in the following areas”

• ‘enable me to make the right health and care choices’; • ‘give care professionals and carers access to all the data, information and knowledge they

need’; • ‘make the quality of care transparent’;



• ‘build and sustain public trust’; • ‘bring forward life-saving treatments and support innovation and growth’; • ‘support care professionals to make the best use of data and technology’; • ‘assure best value for taxpayers’.

The framework outlines the following targets and milestones which have particular relevance to this proposal:

• “From March 2018 all individuals will be enabled to view their care records and to record their own comments and preferences on their record, with access through multiple routes including NHS Choices”;

• “We will enable all citizens to have a single point of access to all transaction services, including booking appointments and online repeat prescriptions for all care services”;

• “All patient and care records will be digital, real-time and interoperable by 2020. By 2018 clinicians in primary, urgent and emergency care and other key transitions of care contexts will be operating without needing to use paper records”;

• “The NIB will work to drive up adoption and optimisation of mobile technologies that enable healthcare professionals, service users and carers to collaborate effectively in the organisation, delivery and evaluation of care in community and home care settings”.

The Health & Social Care (Safety & Quality) Act 2015 came into force on the 1st October 2015. One of the main aims of the Act is to support the 7th Caldicott principle ‘The duty to share information can be as important as the duty to protect it’. This duty relates to sharing of information for direct care purposes within Health and Adult Social Care services. A further requirement of the Act is to ensure that health and adult social care organisations use a consistent identifier (the NHS Number) for sharing data for the direct care of a patient.

In December 2015, NHS England published further guidance in ‘Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21’, outlining what is required to be delivered in 2016/2017.

Of particular relevance to this Business Case are the following:

6.1 New models of care and general practice

Overall 2020 goals: Significant measurable progress in health and social care integration, urgent and emergency care (including ensuring a single point of contact), and electronic health record sharing, in areas covered by the New Care Model programme. 2016-17 deliverables: New models of care covering the 20 percent of the population designated as being in a transformation area to: make progress on integration of health and social care, integrated urgent

and emergency care, and electronic record sharing. 7.2 Technology Overall 2020 goals:

Support delivery of the National Information Board Framework ‘Personalised Health and Care 2020’ including local digital roadmaps, leading to measurable improvement on the new digital maturity index and achievement of an NHS which is paper-free at the point of care. 2016-17 deliverables: Make progress in delivering new consent-based data services to enable effective data sharing for commissioning and other purposes for the benefit of health and care.



2.1.2 Regional Drivers Information Sharing (or ‘interoperability’) programmes are in place or developing in many localities across Greater Manchester (GM), in line with the national agenda to improve care through the use of information technology

This proposal will support the vision outlined for GM Devolution and Healthier Together, which aims to reform primary care, go further in integrating health and social care services and reform hospital care by joining hospital teams across GM, moving to a model of specialist and local general hospitals system.

The ‘Greater Manchester CCG Primary Care IT Strategic Vision 2015-2018’ was approved by the IM&T Steering Group in June 2015. This strategic vision comprises four overarching principles:

• Connect: connecting infrastructure and systems across GM enabling staff and information to flow dynamically across the region;

• Integrate: providing integrated records and intelligent systems that have the ability to be interlinked across GM and beyond.; single GM wide consent and information sharing model;

• Empower: patients and citizens access to their own information; online access to services and apps;

• Collaborate: inclusive governance and commissioning; innovation hubs and collaborative working.

NHS England has approved a single, combined Digital Roadmap submission for all organisations in Greater Manchester.

NHS England has produced the Digital Maturity Assessment tool for acute provider organisations to self-assess their readiness for the developments and changes required in order to implement the 2020 Vision. This will be used to give a baseline for the Greater Manchester IM&T Digital Roadmap.

Greater Manchester Health and Social Care Devolution have started to develop IM&T plans which broadly follow the aims of the GM CCG Primary Care IM&T Strategic Vision.

All of the above aims and initiatives are in line with the national strategic aims which will be mapped to the CCGs IM&T Strategic objectives

2.1.3 Local Drivers Improved information sharing across care professionals is a vital enabler to achieve improvements to health and social care in Bolton. The ‘Bolton Health and Care 5 Year Locality Plan’ and the ‘Bolton Quality Contract 2015-2016’ build on ‘Personalised Health and Care 2020’ and The ‘Greater Manchester CCG Primary Care IT Strategic Vision 2015-2018’ and identifies a number of commitments and aims that can only be fully realised if the right information is available to professionals, with the right access permissions, at the right time, and if patients can access information about their own care including:

• Population Health – with shared care records enabling planning at a micro level; • Population Segmentation – to enable planning for the services needed to be commissioned

to effectively meet the needs of the population in Bolton; • To meet the commitment made in ‘The Five Year Forward View’ that, by 2020, that there

would be “fully interoperable electronic health records so that patient’s records are paperless.



3. Case for Change

3.1 Existing clinical systems landscape Health and Social Care in the Bolton is provided by a number of local organisations using a range of information systems as demonstrated in the following table. Services to patients resident in the Bolton area are also provided by a number of other healthcare organisations across the Greater Manchester area. This landscape is subject to change as the Healthier Together programme gains momentum.

The following table summarises the provider systems and services to be included in Phase 1, which are covered by this Business Case.

Systems/Services – In Scope for Phase 1 Source System System Supplier

GP Systems Vision (Hosted) INPS SystmOne TPP EMIS Web EMIS

Bolton Council – Social Care – Adult Moving to Liquid Logic (Sep 2016) Bolton Council – Social Care - Children Liquid Logic Liquid Logic Bolton NHS FT – Community Lorenzo CSC Bolton NHS FT – Acute Lorenzo CSC GM West Mental Health NHS FT PARIS Civica BARDOC - OOH Adastra Advanced Health & Care NWAS ERISS “In House” development DOCMAN Vault (Cloud-based) Docman PCTI Solutions

Systems/Services – Identified as Out of Scope for Phase 1 Source System System Supplier 5-19 Service (Bridgewater) TPP Community TPP Bolton NHS FT – Maternity E3 Maternity IS EuroKing Maternity Software NHS 111 (NWAS) Adastra Advanced Health & Care Bolton Hospice* iCare Software Medical Informatics Child Health (Vaccs& Imms) CSC-HSW Moving to CarePlus (SystemC) Electronic Document Transfer (EDT) Docman PCTI Solutions *Information feed from the iCare system is out of scope. However, it is envisaged that clinical staff will have access to the IDCR through a clinical portal.

3.2 Target benefits of improved information sharing The range of benefits that are sought and enabled by improving information-sharing across care teams can be summarised as follows:

• Greater integrated working within community care teams, and between acute, community, urgent care and social care, to improve the appropriateness and timeliness of interventions and to improve patient safety;

• Facilitation of combined assessment processes following the ability to view previous assessments carried out by different care professionals;

• Reduced conveyances by the ambulance service; • Reduced A&E activity and fewer unplanned admissions; • Improved discharges and reduced excess bed days; • Reductions in inappropriate referrals to outpatients and for repeat and otherwise

unnecessary diagnostics tests; • Time saving by clinicians and social care professionals; • Improved medicine utilisation through better reconciliation.



For patients • More informed patients, able to make more informed choices; • Safer care for individuals across care settings; • More appropriate, timely care; • Improved health outcomes; • Observe patients’ needs regarding End of Life(EOL) and Care Plans; • Co-ordinated delivery of care across services and providers; • Reduction in adverse events; • Improved patient experience; • Avoid unnecessary diagnostic interventions; • A reduction in episodic care; • Reduced risk of medicines interactions and improved patient safety; • Time spent with clinicians and care professionals will be more appropriate and of

improved value, rather than the need to repeat facts unnecessarily.

For clinicians and care professionals • Greater collaboration enabling the delivery of more efficient, effective care; • Access to a greater range of patient information at point of care; • Reduction in time spent looking for information freeing up additional time; • More efficient medicines reconciliation; • Improved data quality of records due to increased transparency of the record.

For commissioners • Greater opportunities to create and monitor care pathways; • Reduced costs associated with avoided acute (re)admissions and diagnostic tests; • Greater workforce efficiency- less time spent looking for information; • Enabling delivery of overall strategy as increase to care provided closer to home or in

the most appropriate setting leading to reduction.

3.3 Examples of Benefits Realisation While the overwhelming consensus is that a shared care record will deliver significant benefits there is little published data on benefits realisation. The following are examples of estimated or reported benefits following the introduction of a locality shared care record.

Shared Care Record support for EPaCCS A Shared Care Record for Bolton is essential for the delivery of an effective Electronic Palliative Care Co-ordination System (EPaCCS). The most recent data from 2012 indicates that for every 25 deaths (~1% of total Bolton deaths) that take place in community instead of hospital a saving of up to £37,000 per year could be achieved. An increase from the reported incidence for Bolton of 40.17% to the NHS England average (44.7%) could save up to £148,456 per year. An increase to the National Council for Palliative Care’s target of 56% could save up to £568,898 per year.

Support for Long Term Care Planning The Manchester Shared Care Record has carried out an analysis of 2,044 patients on a long term care plan, covering an 18 month period. The results of this analysis showed:

• Overall activity was reduced by 8% and costs reduced by 9%, which equated to a savings of £361K;

• Greatest savings were in Emergency Admissions, which show a 15% reduction in activity and 8% reduction in cost;

• Overall the costs savings in Emergency Admissions accounted for 58% of total savings achieved;



• The largest percentage reduction was in A&E Attendance, both in terms of activity (19%) and cost (17%);

• Patients are involved in shaping their plan; they can control access to information and influence the type of care they receive, which improves their outcomes and experiences;

In addition, feedback received from primary care has reported: • a reduction in calls and administrative time spent on requests for information from other

care providers and patients; • less time spent searching and chasing information from hospitals; • availability in MDTs of live information from other organisations, previously not known to

the GP such as updated personal and relationship information, recent A&E admissions, and near real-time hospital investigations and results – richer, updated and more informed care planning.

Admissions, Discharges & Tests

A further study from an unidentified NHS organisation on the impact of deploying a shared care record reported:

• Statistically significant reduction in decision to admit patients to hospital o 9% reduction;

• Statistically significant reduction in the number of pathology and radiology tests o Reduced X-ray exposure;

• Statistically significant reduction in average length of stay in hospital o 1.7 days average.

4. High Level Criteria Based on the drivers and requirements for improved information sharing across health & social care teams, the following high level criteria for appraising options have been developed:

4.1 Strategic Fit:

• In line with the GM Primary Care IT Strategic Vision, particularly with regard to delivery of integrated care records in the Bolton locality and across GM;

• Demonstrably able to support the integrated models of care desired in the local health and social care system;

• Supports delivery of patient safety and productivity benefits relating to Urgent Care, Long Term Conditions, Mental Health, Planned Care, and joint care delivery across health and social care.

• Meets the 7th Caldicott Principle: “The duty to share information can be as important as the duty to protect patient confidentiality” o Health and social care professionals should have the confidence to share information

in the best interests of their patients within the framework set out by these principles. They should be supported by the policies of their employers, regulators and professional bodies.

4.2 Functional criteria:

• Patient-centric record view from multiple data sources, including connectivity with Social Care;

• Scalable to include additional services in the future (as consumers and providers of data).



• Enables all Information Governance requirements to be met, including Role Based Access Control;

• Can provide Patient Portal functionality; • Can provide Read-Write Care-Planning functionality; • Auditable; • Enables deployment with single-sign on and context-sensitive launching. • Enables selected data to be shared with Single View hub (either via portal or direct from

source systems); • Views are configurable for different settings, including restricting and filtering data

viewable according to the care-setting requirements.

4.3 Business / Commercial criteria:

• Organisationally acceptable for all key stakeholders – buy-in and alignment with IM&T plans;

• Flexibility for future development; • Commercially and contractually viable, and compliant with SFIs; • Addresses requirements in forthcoming Digital Maturity guidance on Interoperability; • Timescale: able to realise benefits of improved information sharing in a phased

approach; • Affordability.

4.4 Constraints, Dependencies and Risks No constraints or dependencies have been identified at the time of preparing this Business Case

General Risks The following high level risks have been identified:

Risk Mitigation A lack of detail regarding clinical systems in use at Bolton FT could impact on provision of patient information to the IDCR from the FT and making the shared record available to FT staff

Assumptions have had to be made for the purposes of preparing the Business Case, which need to be confirmed.

Information Governance issues with data sharing between organisations limits provision of patient records into the IDCR and consequent benefits realisation

Early engagement with all stakeholders is necessary to ensure an understanding of the benefits of the IDCR.

Lack of engagement from partner organisations in providing and supporting links to IDCR.

Requirement for ongoing senior level commitment to the project from partner organisation, which is disseminated within organisations

Required resources, which may be needed in provider organisations to develop links to the IDCR are not available

Need to identify the costs as part of project initiation and work as a health economy to minimise

Ongoing funding to support and develop IDCR solution in future years has not been identified

Discussions through IM&T partners and realise benefits from transformational change

Realisation of benefits to justify the overall cost of solution is not achieved

A Benefits Realisation Plan needs to developed during project initiation



5. Available Options The following options outline the upfront and recurrent costs over a contact lifetime of five years covering the systems and services listed for phase 1 in the table on page 7.

5.1 Option 1 – Do Nothing Doing nothing is not an option. The only way to achieve the ambitions highlighted earlier in this Business Case, are through the implementation of a digital shared record solution.

5.2 Option 2 – Procure and implement a new local instance of CareCentric solution This option would involve the procurement and implementation of a local instance of the CareCentric solution from Graphnet Health, as the core element of the Integrated Shared Care Record.

Additional functionality, enabling provision of “real-time” data from GP systems to CareCentric, would be provided by procurement of the Medical Interoperability Gateway (MIG) solution from Healthcare Gateway Limited. Docman Vault from PCTI Solutions will be used to make documents available from GP clinical systems to CareCentric.

A detailed description of the proposal is provided in Appendix 1.

The following table summarises the overall costs. Detailed breakdowns of supplier costs are provided in Appendix 2.

Year 1 Year 2 Year 3 Year 4 Year 5 Total CareCentric £774,250 £588,000 £588,000 £539,250 £489,250 £2,978,750 MIG £33,110 £29,210 £29,210 £29,210 £29,210 £149,950 Docman Vault £22,450 £22,450 Infrastructure Costs Hardware, Licensing & Support

£150,000 £35,527 £35,527 £35,527 £35,527 £292,108

Support Costs Bolton Locality Business Systems Manager

£44,146 £44,146 £44,146 £44,146 £176,584

GMSS System Administration

£29,597 £29,597 £29,597 £29,597 £29,597 £147,987

Implementation Team £97,200 £97,200 GMSS Implementation Support

£5,376 £5,376

Total £1,117,983 £726,481 £726,481 £677,731 £627,731 £3,876,405

CareCentric costs are to procure a local instance from Graphnet Health. This would require a full tender process under EU procurement rules, involving additional cost and time for the procurement process.

MIG costs are based on a three year term and relate to provision of links from GP clinical systems to the CareCentric instance, estimated on a registered practice population of 303,000. Procurement of the MIG would be via the GP Systems of Choice Lot 3 Framework Contract, removing the need to run an OJEU procurement.

Docman Vault costs are based on a practice population of 175,000, covering the 34 practices using INPS Vision and EMIS Web. PCTI, the supplier Docman Vault, has plans for the product to be made available as part of Docman 10 through the GPSoC Framework. There



is currently no mechanism for linking SystmOne with Docman Vault. TPP are in discussions with HSCIC regarding interfacing SystmOne with the Docman solution.

Provider organisations may wish to develop and implement additional links to feed data to (or consume data directly from) CareCentric. However, these costs are not covered by this Business Case.

GM Shared Services Costs

There is no formal service offering from GM Shared Services to cover implementation and ongoing support of an IDCR solution. There have been difficulties with establishing costs in individual areas (infrastructure, implementation PM support and system administration) within the time available to prepare the Business Case. Where possible, estimates have therefore been included the cost summary above.

Training

Training for users of CareCentric is provided by Graphnet Health in the form of Train-the-Trainer and is included in the quotation from Graphnet Health, as part of the Programme Charges.

5.3 Option 3 – Utilise the existing CareCentric platform hosted by GM Shared Services This option would involve the procurement of Bolton-specific user interfaces and organisational links for the existing CareCentric solution hosted by GM Shared Services, as the core element of the Integrated Digital Care Record. This solution currently provides a platform for the three Manchester CCGs. Trafford CCG is in the process of co-localising to this platform.

Additional functionality, enabling the provision of “real-time” data from GP systems to CareCentric, would be provided by procurement of the Medical Interoperability Gateway solution from Healthcare Gateway Limited. Docman Vault from PCTI Solutions will be used to make documents available from GP clinical systems to CareCentric.

A detailed description of the proposal is provided in Appendix 1.

The following table summarises the overall costs. A detailed breakdown of supplier costs is provided in Appendix 2.

Year 1 Year 2 Year 3 Year 4 Year 5 Total CareCentric £239,250 £294,250 £289,250 £244,250 £244,250 £1,311,250 MIG £33,110 £29,210 £29,210 £29,210 £29,210 £149,950 Docman Vault £22,450 £22,450 Infrastructure Costs Hardware & Licensing £35,527 £35,527 £35,527 £35,527 £35,527 £177,635 Support Costs Bolton Locality Business Systems Manager

£44,146 £44,146 £44,146 £44,146 £176,584

GMSS System Administration

£29,597 £29,597 £29,597 £29,597 £29,597 £147,987

Implementation Team £97,200 £97,200 GMSS Implementation Support

£5,376 £5,376

Total £468,511 £432,731 £427,731 £382,731 £382,731 £2,094,433



CareCentric costs are to procure additional functionality for the existing platform from Graphnet Health using a Framework or existing contract.

MIG costs are based on a three year term and relate to the provision of links from GP clinical systems to the CareCentric instance, estimated on a registered practice population of 303,000. Procurement of the MIG would be via the GP Systems of Choice Lot 3 Framework Contract, removing the need to run an OJEU procurement.

Docman Vault costs in Year 1 are based on a practice population of 175,000, covering the 34 practices using INPS Vision and EMIS Web. PCTI, the supplier of Docman Vault has plans for the product to be made available as part of Docman 10 through the GPSoC Framework. There is currently no mechanism for linking SystmOne with Docman Vault. TPP are in discussions with HSCIC regarding interfacing SystmOne with the Docman solution.

When compared with Option 2, significant savings would be achieved on implementation and recurrent costs with this option, whilst still delivering the same objectives.

A full tender process, which would involve significant cost and time to complete, would not be required for this approach as procurement could be achieved by using an existing framework or through the contract held with Manchester CCGs.

Procurement of the MIG solution would be using the GP Systems of Choice Lot 3 Framework Contract, removing the need to run an OJEU procurement process.

Provider organisations may wish to develop and implement new links to feed data to or receive data directly from CareCentric. However, these costs are not covered by this Business Case.

GM Shared Services Costs

Manchester CCGs hold the contract with Graphnet for the GM Shared Services instance of CareCentric. GM Shared Services have an SLA in place with Graphnet for support. The support arrangements between GM Shared Services and the Manchester CCGs for CareCentric are covered by the wider SLA.

There is no formal service offering from GM Shared Services to cover implementation and ongoing support of an IDCR solution. There have been difficulties with establishing costs in individual areas (infrastructure, implementation PM support and system administration) within the time available to prepare the Business Case. Where possible, estimates have therefore been included the cost summary above.

Training

Training for users of CareCentric is provided by Graphnet Health in the form of Train-the-Trainer and is included in the quotation from Graphnet Health, as part of the Programme Charges.

5.4 Option 4 – Utilise the MIG to enable sharing of the patient record A further option considered was to use the MIG as the underpinning solution to provide a shared care record. This solution would allow ‘real-time’ transient links between GP clinical systems and enabled provider systems. However, the solution does not current provide links to a number of the provider systems used within the Bolton locality, nor does this solution meet the business intelligence requirements outlined above.



One such locality that has used the MIG as the basis for sharing patient records is Wigan. However, Wigan CCG is now in the process of procuring Graphnet’s CareCentric solution to provide as a separate solution to support their strategic objectives.

It should be noted that the MIG serves only to present information at the point it is accessed. No local copies of the information are held by the viewer and therefore the information view can be seen as volatile.

MIG would therefore need to be used in conjunction with other solutions to achieve the overall objective. That is to say that local systems across the locality would still need to feed into a central repository with MIG providing the real-time view of GP data.

This option was therefore discounted on the basis that separate systems would be required to achieve the overall objectives.

6. Recommendation The recommended option is Option 3, Utilise the existing CareCentric platform hosted by GM Shared Services.

Developing a Bolton Integrated Digital Care Record using the existing platform hosted by GM Shared Services would have a number of advantages:

• Reduced implementation costs • Reduced recurrent costs of a shared instance; • Reduced costs associated with procurement process; • Reduced time to implement solution; • Access to information on Bolton residents through links to providers established by other

localities on the shared CareCentric instance; • Shared support costs through GM Shared Services; • Knowledge sharing between localities within GM; • Potential further benefits in economies of scale in working with partner CCGs.

The following table illustrates the developing landscape of implementations of CareCentric in the GM area

CCG CareCentric Implementation GM Sector Bolton

North West

Salford Hosted at Salford Royal FT (GP extracts and Acute data) including diabetes and emergency care summaries

Wigan Implementing a CareCentric instance for GP practice extracts to allow data analysis and risk stratification.

Bury

North East Heywood, Middleton and Rochdale Oldham Manchester North Manchester CCGs – have shared instance, which

Trafford CCG is in the process of joining. The Manchester instance hosts GP data and acute, mental health and social care. Integrated Care Plans (including EPaCCS). In the process of being accessed by OOH and discussions with NWAS regarding integration are currently underway Trafford Hospital – currently have an older version of CareCentric, which supports clinicians in Trafford Hospital.

Manchester Central

South and Central

Manchester South Trafford

Stockport Hosted at the Leigh datacentre – holds GP practice, acute and social care data. Stockport EPaCCS, medication and cardiac summaries. Accessed by

Southern



OOH Tameside and Glossop

Patients attending care settings outside Bolton locality There are approximately 570 spells per month on average from Bolton patients going to UH South Manchester NHS FT, Central Manchester UH NHS FT and Pennine Acute NHS FT, which includes all types of inpatient and day case admissions. .The CareCentric platform hosted by GM Shared Services has existing links to these providers, which will enable the sharing of information relating to these spells of care.

Child Health SystemC, a clinical system supplier which is part of the same group of companies as Graphnet, has recently secured the contract to replace the existing CSC-HSW child health systems in Bolton, Tameside and Glossop and Stockport with their CarePlus solution. Agreement has been reached with Graphnet to provide links to CarePlus as part of the proposed CareCentric solution.

7. Procurement Route 7.1 Procurement Process

• Procurement of CareCentric will be using a single tender waiver; • Procurement of the Medical Interoperability Gateway will be via Lot 3 of the GPSoC

Framework; • Procurement of Docman Vault will be using a single tender waiver.

7.2 Procurement Timescale Procurement would be progressed on approval of the Business Case.

7.3 Implementation Timescales Work to develop an implementation plan will commence once the procurement process has been initiated but will involve a phased rollout of different functionality from 3/4 months to 2 years

8. Funding and Affordability

8.1 Charging Mechanisms No charging mechanisms have been put in place at this time. However, further discussions will take place on approval of the Business Case.

8.2 Contract Length The proposed contract will be for an initial three years with an option to extend for a further two years.

8.3 Funding Arrangements For accounting purposes, funding sources have been identified from the Better Care Fund subject to approval by the Commissioning Partnership Board.

9. Management Arrangements

Management arrangements will be developed as part of the Project Initiation Document on approval of the Business case.



10. Recommendation The Board is asked to:- Support and approve option 3 noting that the Better Care Fund is the expected source of funding subject to approval by the Commissioning Partnership Board.



Appendix 1 – IDCR solution based on the existing CareCentric platform The proposed solution for a Bolton Integrated Care Record is outlined in the diagram above.

CareCentric

The core of the overall solution will be provided by CareCentric, which acts as an integration engine and data repository, enabling information on patients to be brought together in a shared record and accessed by health and care professionals in a number of different care settings. Demographic information on patients registered with Bolton GP practices is provided by a Patient Master Index (PMI) linked to the NHS Spine. Patient information held in CareCentric is initially populated and then updated nightly, against the PMI, from GP clinical systems by overnight feed.

Provider organisations will be able to contribute to the shared record of registered patients held in CareCentric. In most cases this information will be updated in real time

Medical Interoperability Gateway (MIG)

Unlike many of the clinical systems used by provider organisations, which provide information in “real-time” to CareCentric, information provided from GP clinical systems is updated on a nightly basis. To supplement this information feed, it is proposed to procure additional functionality using the MIG. This would enable users of CareCentric to access a transient view of the basic MIG detailed care record dataset (currently DCR v1 but will be upgraded to DCR v2) from GP clinical systems. This information is not stored in CareCentric.

Docman Vault



The above solutions do not provide access to clinical documents. Docman Vault is a cloud based solution for electronic document storage, which can be linked to the CareCentric. Currently this solution is available as a separate product but it is intended for this to be an integral part of the Docman EDMS when Docman 10 is released and will then become available on the GPSoC Framework.

Viewing the IDCR held in CareCentric

Viewing of the IDCR can be achieved in a number of ways:

• CareCentric Gateway (Clinical Portal)

CareCentric Gateway is an Electronic Health Record and portal which presents users with a unified view of the data held in CareCentric

• CareCentric Gateway (Embedded)

CareCentric Gateway (Embedded) provides an embedded view of the CareCentric clinical portal. Integrated Single Sign-On enables clinicians to call patient records securely and seamlessly from within their existing systems – within patient context and without having to log on again.

• Mobile Access to CareCentric IDCR

CareCentric Mobile is a clinical portal which sits on top of CareCentric enabling access to the electronic health record for authorised users on smartphones and tablets. It gives care professionals access to patient data wherever they need it, whether at various locations within a hospital or GP practice, at other hospitals, in the community or at home. CareCentric Mobile supports IOS, Android, Microsoft Surface and works with Wi-Fi, mobile networks and off-line.

Future developments

In the future, it would be possible to use the CareCentric IDCR to deliver a Patient Portal.



Appendix 2 – Full Cost Breakdown Option 2 – Procure and implement a new local instance of CareCentric solution



Option 3 – Utilise the existing CareCentric platform hosted by GM Shared Services



Medical Interoperability Gateway (MIG)

Docman Vault

GM Shared Services – Implementation Support

Unit Number Year 1 Year 2 Year 3 Year 4 Year 5 Total303,000 £29,210 £29,210 £29,210 £29,210 £29,210 £146,050

£2,600 1 £2,600 £2,600£1,300 1 £1,300 £1,300

£33,110 £29,210 £29,210 £29,210 £29,210 £149,950All prices plus VAT at prevailing rate

Medical Interoperability Gateway (MIG)Patient PopulationConsuming System ImplementationProject ImplementationTotal

Unit Number Year 1£0.07 175,000 £12,250£300 34 £10,200£600 10 £6,000

£28,450All prices plus VAT at prevailing rate

Patient Volume LicenseHosting ServiceOnsite ReconfigurationTotal

Docman Vault

Rate Hours Year 1£22.10 150 £3,314.70£27.49 75 £2,061.74

£5,376.44Engineering & Consultation - Networks

GM Shared Services Implementation SupportEngineering & Consultation - Desktop



GP Shared Services – Infrastructure Costs

Description Unit Cost Qty Total Comments AdditionalStorage Total (GB)

Application ServersApp Server - CareCentric Gateway Web Server £987.28 3 £2,961.84 60 180App Server - CareCentric Gateway Interface Server £987.28 2 £1,974.56 150 300App Server - CareCentric Mobile (Rapport) Server and RavenDb £987.28 2 £1,974.56 1200 2400App Server - CareCentric Testing (Web + Interfacing) Server £987.28 1 £987.28 1200 1200

SQL ServersBase Windows Server £987.28 2 £1,974.56 0 0SQL DB on shared server £500.00 0 £0.00 0 0SQL Server 2 Core - Test £1,000.00 1 £1,000.00 1200 1200SQL Server 4 Core - Live £2,000.00 2 £4,000.00 Active/Passive 1820 3640SQL Server - CareCentric Testing (SQL) Server £987.28 1 £987.28 0 0

Additional Storage (1GB) £2.77 7100 £19,667.00 Includes off site replication 7100

SSL Certificate £628.95 0 £0.00

Security: Data Centre Security £5.75 0 £0.00

Security: Network Security £2.56 0 £0.00

TOTAL £35,527.08

Notes:Based on the spec document from Graphnet Health (INC0352188) All prices Exclude VATAll prices per annumCosting does not include any figures for SSL certificates or security.



Glossary of Terms A&E Accident and Emergency CCG Clinical Commissioning Group DCR Detailed Care Record EDMS Electronic Document Management System EDT Electronic Document Transfer EOL End of Life EPaCCS Electronic Palliative Care Co-ordination System EU European Union FT Foundation Trust GM Greater Manchester GMW Greater Manchester West Mental Health NHS FT GPSoC GP Systems of Choice - provides a contractual framework to supply IT

systems/services to GP practices and associated organisations in England

HSCIC Health & Social Care Information Centre IDCR Integrated Digital Care Record IM&T Information Management & Technology LA Local Authority MDT Multi-Disciplinary Team MIG Medical Interoperability Gateway NWAS North West Ambulance Service OJEU Official Journal of the European Union – publication in which all tenders from

the public sector which are valued above a certain financial threshold according to EU legislation, must be published

OOH Out of Hours PMI Patient Master Index SLA Service Level Agreement SSO Single Sign-On – a session/user authentication process that permits a user to

enter one name and password in order to access multiple applications.

Integrated Digital Shared Care Record

Local people tell us they assume that we already share their information.

They are surprised that when they go to hospital that the doctors and nurses can’t see their GP record.

Having a simple system for sharing information should ensure that patients receive safe and appropriate care in the right place at the right time. This system will be underpinned by having the right information governance process in place along with patient consent..

50 GP Practices

Bolton FT Acute

Services

NHS Bolton CCG

BARDOC Out of Hours

Service

Bolton Council Social Services

Bolton FT Community

Services

GMW Mental Health

Services

NWAS Ambulance Service

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?

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? ?

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Existing Landscape

CareCentric

CareCentric

CareCentric

CareCentric

Use Case 1 – Unnecessary Resuscitation Hilda is an End of Life Care patient most likely in her final days of life. Her GP has done all the paperwork including a Statement of Intent and a DNACPR form, both of which are in the nursing folder. They have the phone number for the out of hours district nurses if they need any advice. Due to a particularly busy day, no one has added Hilda to the Ambulance computer system, ERISS. Hilda is aware of this but does not feel comfortable with it, and so the folder is kept out of sight in the bedside drawer. She is now completely bedbound, but a member of her family is always in the house with her. One Friday evening, Hilda is being looked after by her son Jon, when her breathing becomes raspy, and she becomes unresponsive. Hilda’s breathing causes Jon to panic and call 999, who dispatch an ambulance.

1. The paramedics arrive to find Hilda unconscious and Jon distraught. Unable to find the DNACPR, they must attempt to resuscitate, even though it is clear Hilda is palliative care.

2. The resuscitation attempt is unsuccessful. Because the SOI is not found, there is no evidence of an expected death. The police are called and Jon must give a statement while Hilda’s body is taken to the mortuary.

3. Hilda’s GP finds out about this on Monday, and now must participate in an inquest for the coroner despite the death being expected and an SOI completed.

Without a Shared Care Record

24/03/2016

Use Case 1 – Unnecessary Resuscitation Hilda is an End of Life Care patient most likely in her final days of life. Her GP has done all the paperwork including a Statement of Intent and a DNACPR form, both of which are in the nursing folder. They have the phone number for the out of hours district nurses if they need any advice. Due to a particularly busy day, no one has added Hilda to the Ambulance computer system, ERISS. Hilda is aware of this but does not feel comfortable with it, and so the folder is kept out of sight in the bedside drawer. She is now completely bedbound, but a member of her family is always in the house with her. One Friday evening, Hilda is being looked after by her son Jon, when her breathing becomes raspy, and she becomes unresponsive. Hilda’s breathing causes Jon to panic and call 999, who dispatch an ambulance.

With a Shared Care Record 1. The paramedics arrive to find Hilda unconscious and Jon distraught. Through the shared care record, they have found out on their way that Hilda is a palliative care patient and has a DNACPR form.#

2. When asked, Jon can’t remember the DNACPR form, but remembers that nursing notes are in the bed side table. The paramedics find the form and the SOI, and administer pain relief to ease Hilda’s pain.

3. Hilda passes away peacefully. As the SOI evidences this was an expected death, the coroner does not need to be involved and no post-mortem is required.

24/03/2016

Use Case 2 – Unnecessary Admission Mr Smith is a 91 year old man with COPD, heart failure and osteoarthritis, and early signs of dementia. He is very frail and lives alone, but is visited daily by a district nurse, who is his key worker. Mr Smith is prone to panic attacks due to breathlessness, but knows to call the District Nurse Evening Service, who talk him through an pre-agreed plan, helping him relax and use his inhaler. All this is documented on the GP’s and nurse’s respective systems. His nurse has created alerts on Adastra, so 111 know to send an Out of Hours Doctor instead of an ambulance in most scenarios, but they do not have any up to date medication or care plan information. One evening, Mr Smith has an exacerbation but can’t find the District Nurse Evening Service phone number, and calls 111 in a panic. Seeing on Adastra that he has a care plan, 111 route the call to BARDOC who send a doctor to Mr Smith.

Without a Shared Care Record 2. As the doctor is unfamiliar with Mr Smith and has no information about his normal state of health, the doctor believes it is best to admit Mr Smith due to his extreme frailty, breathlessness and agitation.

3. Mr Smith is admitted, deteriorates further and loses his confidence to return home alone. He then stays in hospital a further three weeks, while social services attempt to find him a suitable nursing home bed.

1. The doctor arrives and attempts to help Mr Smith. However, he is becoming increasingly agitated and the doctor does not have access to the Advance Care Plan stored on GP and Nurse’s computer system.

24/03/2016

Use Case 2 – Unnecessary Admission Mr Smith is a 91 year old man with COPD, heart failure and osteoarthritis, and early signs of dementia. He is very frail and lives alone, but is visited daily by a district nurse, who is his key worker. Mr Smith is prone to panic attacks due to breathlessness, but knows to call the District Nurse Evening Service, who talk him through an pre-agreed plan, helping him relax and use his inhaler. All this is documented on the GP’s and nurse’s respective systems. His nurse has created alerts on Adastra, so 111 know to send an Out of Hours Doctor instead of an ambulance in most scenarios, but they do not have any up to date medication or care plan information. One evening, Mr Smith has an exacerbation but can’t find the District Nurse Evening Service phone number, and calls 111 in a panic. Seeing on Adastra that he has a care plan, 111 route the call to BARDOC who send a doctor to Mr Smith.

With a Shared Care Record 2. The doctor is concerned at Mr Smith’s frailty, but through looking at his GP and nurses notes, the doctor understands this is his normal state and does not admit the patient.

1. The doctor arrives and attempts to help Mr Smith. Through the shared care record, the doctor is able to see the care plan for helping Mr Smith and succeeds in calming him down.

3. An unnecessary hospital admission is avoided thanks to correct and up-to-date information being available to out of hours doctors.

24/03/2016

Use Case 3 – Patient with a Care Plan Eris is 85 and lives alone with a care package in place. He is diabetic, has high blood pressure and leg ulcers managed by District Nurses, and had a hip replacement 8 years ago at Royal Bolton Hospital. Eric’s nephew looks after him and helps him , making sure he gets and takes his medications and driving him to his various appointments. One Friday night, Eric has a fall in the shower and cuts his head. He has a pull cord installed in his bathroom, which he pulls and an ambulance is sent to his home. No one can get hold of Eric’s nephew to let him know. Eric is admitted to A&E by midnight.

Without a Shared Care Record 2. Eric’s wound is treated. He’s moved to the EAU and waits there until Monday. A care package can’t be arranged until the nurses return to work on Friday.

3. Eric is frustrated that he can’t return home and loses confidence in the services that are looking after him. His nephew finds out Eric is in hospital and has to visit to see Eric and find out what about his injury and the care he’s received.

1. The care package information and Eric’s medication is all on the GP and District nursing computer systems, which no one can access. Eric has bloods taken and a CT scan, and he is anxious about why no one knows what medication he is on.

24/03/2016

Use Case 3 – Patient with a Care Plan Eris is 85 and lives alone with a care package in place. He is diabetic, has high blood pressure and leg ulcers managed by District Nurses, and had a hip replacement 8 years ago at Royal Bolton Hospital. Eric’s nephew looks after him and helps him , making sure he gets and takes his medications and driving him to his various appointments. One Friday night, Eric has a fall in the shower and cuts his head. He has a pull cord installed in his bathroom, which he pulls and an ambulance is sent to his home. No one can get hold of Eric’s nephew to let him know. Eric is admitted to A&E by midnight.

With a Shared Care Record 2. After being treated and he has recovered, it is now Sunday. Hospital staff can see that a care plan is in place and what medication Eric needs to take, so ensure he gets this.

3. A care package is arranged based on what is known about Eric’s community care. Eric is able to return home confidently. Eric’s nephew finds out he has been to the hospital and can see all Eric’s medication and treatment in Eric’s online care plan.

1. Hospital staff in A&E access Eric’s Integrated Care Record and find out his medications, and so can efficiently treat Eric with minimal risk.

24/03/2016