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Hertfordshire’s winning approach to care

Resident of Burleigh House with one of the occupational therapists

To the uninitiated, data management, risk stratification and information sharing could appear to be rather dry topics.  But, for patients in East and North Hertfordshire, the intelligent use and secure sharing of data is helping to improve lives.

At a national awards ceremony in March, Local Government Chronicle magazine made Hertfordshire's HomeFirst multidisciplinary ‘hospital from home’ service their ‘Health and Social Care’ project of the year. Judges described the project as “demonstrating true integration with shared belief”, saying that it “delivered cross-commissioning support and integration, developing outcomes for people supported by the whole system.”  

Dr Alison Jackson, a Cheshunt GP who has supported the development of HomeFirst from the start said:

“HomeFirst has enabled GPs to work differently and more proactively.  As part of a wider team of professionals we are helping our patients to have the best possible quality of life. Together we are able to offer patients more individualised care that meets their complex needs in their place of choice, their homes.”

One of the keys to the success of HomeFirst lies in the intelligent use of linked data. It means information can be shared safely and legally, and analysed in a way that delivers insights which lead to positive interventions from clinicians from a range of organisations.   

HomeFirst supports older people, and others with long term or complex conditions, to remain at home rather than going into hospital or residential care. Commissioned by Hertfordshire County Council and East and North Hertfordshire CCG, HomeFirst services are delivered by Hertfordshire Community NHS Trust, Hertfordshire’s mental health trust (HPFT), Hertfordshire County Council and home care agencies.  

HomeFirst performs two functions.  This first is a reactive, rapid response function where health and social care staff respond within 60 minutes to people in crisis. The second is a proactive ‘virtual ward’ case management function. The ‘virtual ward’ identifies people who are at risk of needing to go to hospital, triggering appropriate interventions to avoid admission. The proactive function is dependent on MedeAnalytics’ platform and innovative population segmentation techniques.

This year’s prestigious Local Government Award represents the culmination of the many years that Hertfordshire has spent pioneering genuinely joined up health and care services for the county’s 1.2m population. As a result, the county is forging ahead with the integration agenda. 

Jamie Sutterby, assistant director for health integration at East and North Hertfordshire CCG, explains that joining data to enable real risk stratification for different types of patients is allowing Hertfordshire to better support people at the point when interventions can really make a difference to their lives;

“We are determined to make the most of the opportunities afforded by the NHS Five Year Forward View to provide better care for Hertfordshire people. We talk about care services here and try to see beyond traditional social or health care. Anyone planning joined up care should always start by gaining a detailed understanding of their communities – and that means investing in analysing data from across our area. Thanks to our status as an NHS Vanguard area for our care home improvement work, access to the Better Care Fund and most importantly, a culture of cooperation between our organisations, we have been able to gain a much fuller and more holistic understanding of people in our community. 

Understanding how, why and where people are accessing care services means that we can identify those who could be better supported earlier, before they become acutely unwell. Timely intervention from the right care professional offering the right sort of care is part of our journey towards delivering accountable care to the people of Hertfordshire.

Important developments are also underway. These include plans to better understand patients with mental health conditions, those living in care homes , and people on end of life pathways, so that we can take a more proactive approach to planning care.

In the care home environment, we are now looking at both preventing unnecessary admissions where possible and, for existing care home residents, we are using risk stratification to help people stay healthier and to support care staff.”

Last year, East and North Hertfordshire Clinical Commissioning Group (CCG), in partnership with Hertfordshire County Council (HCC) and Hertfordshire Care Providers Association (HCPA) was awarded Vanguard status by NHS England in the first phase of its enhanced care in care homes sector. 

The ambition is to demonstrate how services can be locally and sensitively joined up to provide more consistent, and better care for elderly people, particularly those living in care homes.
One of the biggest challenges the CCG faces is to link data to track activity across the area’s different health providers, care homes and local authority services.

Joined up intelligence for joined up care 
East and North Hertfordshire CCG is working as part of a wider initiative with CCGs across Hertfordshire, Bedfordshire and Essex to deliver improved business intelligence services across their organisations and local health systems.The challenge was also to specify a facility to join up, through a quality, single source of data, the commissioner and provider organisations across local health economies, providing a user-friendly mechanism to inform and empower frontline clinicians to support their patient care priorities and challenges. 

All GPs, CCGs, their commissioning support teams and acute service providers now have the ability to directly access a single, consistent dataset to support integrated business intelligence, data management and invoice validation activity across individual health economies.

Jamie Sutterby explains the benefits of this linked data approach:

“Hertfordshire County Council is using a patient consent model, communicating with every single one of its clients to request that information can be shared about them person with health professionals. This means that we can start to make full and informed use of this information for the benefit of citizens and patients. The council has now got over 90 per cent of its social care activity linked with an NHS number.

We are now in a position where we can link the data from secondary care with community care and social care, with primary care also now on the horizon. Using and linking this data is also allowing us to improve data quality. This puts us in a great position to improve overall care for our population.”

Proving the concept
A review of the HomeFirst service was one of the first successes yielded from Hertfordshire’s new integrated dataset. The team has been able to prove that costs for patients on HomeFirst have gone down as a result of decreased spending on community and hospital services. Hertfordshire has created a successful business case to increase social care funding, demonstrating with evidence, why this was needed to help keep people out of hospital.  

Data privacy and security
In order to ensure compliance with the essential and fundamental information governance requirement to respect patient confidentiality, Hertfordshire has used MedeAnalytics’ Pseudonymisation-at-Source based data linkage process. 

Developed as an open standard, this process means there is no need to transmit or work with identifiable patient data, but instead use the functionality to link de-identified data at individual patient level. 

This data is stored safely and securely in a business process and methodology that, in the view of the Information Commissioner’s Office and the Health Research Authority’s Confidential Advisory Group, renders it effectively de-identified. 

It means service designers, planners and operational management can access a complete local data set securely in an unidentifiable form to undertake essential service delivery and improvement functions. The encrypted data can however, also be re-identified only by direct care professionals when needed – for example to carry out a case-note review of patients who are being consistently readmitted from a particular care home into A&E. 

This is of critical benefit to frontline staff and their patients to optimise the services that are delivered.

The secure de-identification of shared data yields several benefits: 

  • Commissioners have access to linked, patient-level, unidentifiable data to manage service quality and support service redesign
  • Appropriate health and care professionals can securely re-identify patients to enable early interventions, case-note and care pathway reviews and clinical audits  
  • Secure data can be shared across all partners to support joined up delivery of services, and
  • Using stratification and segmentation models means specific cohorts of patients can be identified and appropriate clinical services can be offered to them as part of a preventative strategy

The HomeFirst initiative, and the wider work in Hertfordshire, amply demonstrate the ability of individual organisations to achieve positive and productive integration while maintaining their identities and individual accountability.  

For Hertfordshire’s population, having better insights from data has led to the limited resources for care being better targeted. 

At a time when care services are under unprecedented pressure, the commitment of all Hertfordshire’s care providers to share data and use it intelligently, combined with MedeAnalytics’ facilitation, proves it is entirely feasible to deliver new models of care that improve people’s lives.