Written evidence submitted by Care England (DTN0033)
Introduction
Care England, a registered charity, is the largest and most diverse representative body for independent adult social care (ASC) providers in England. Our members run and manage approximately 4,000 care services, amongst them single care homes, small local groups, national providers, not-for-profit voluntary organisations and private associations. They provide over 120,000 beds and a variety of services for older people and working-age adults with long term conditions, learning disabilities and mental health needs.
Care England welcomes the opportunity to help inform the Health and Social Care Committee in their inquiry into digital transformation in the NHS.
Given the Government’s overarching commitment to fixing social care and accelerating the integration of health and social care services, voices from the ASC sector must play a central role in the Department of Health and Social Care’s (DHSC) efforts to promote digital transformation. With the Integrated Care Board (ICB) and the Integrated Care Partnership (ICP) scheduled for establishment as legal entities from July 1st 2022, the failure to sufficiently consult with the ASC sector would be detrimental, given digitisalisation’s importance in integrating health and social care services.
Professor Martin Green OBE, Chief Executive of Care England, would be willing to give oral evidence at future Committee meetings. As a critical friend to Government, Care England wants to be part of the solution and is delighted that once again the Health and Social Care Committee is moving the digital transformation agenda forwards.
What progress has been made in digitising health and care records for interoperability, such that they can be accessed by professionals across primary, secondary, and social care?
Improving interoperability between services is central to integrating health and social care services. The Government has acknowledged integration as a key part of their vision for the future of the sector, which has the potential to improve not only the efficiency of services but the quality of care and wellbeing of staff and service users[1]. Establishing widespread digitisation of health and care records is key to ensuring interoperability between health and care services. Digital care records allow for the secure, real-time sharing of information, helping to limit administrative tasks and improve the effectiveness of care. At present, the wider NHS and social care system often fails to provide clear referral routes – an issue which better integration, through digitisation, could help mitigate. Digital records also help make providers and carers more aware of changes to peoples’ needs, allowing them to respond more quickly, and help minimise risks such as medication errors and missed visits.
Despite the benefits of digital care records, the ASC sector continues to be heavily reliant on traditional paper records. While there has been progress in digitising care records, 30% of social care providers are still using entirely paper-based systems, with another 30% being only partially digitised[2]. In their Data saves lives: reshaping health and social care with data (draft) policy paper, the Government committed to working ‘with care providers to accelerate the adoption of digital social care records through the NHS Transformation Directorate (NHS-TD, formally NHSX) Digitising Social Care Record programme for better access and interoperability with Shared Care Records’[3]. The People at the Heart of Care: adult social care reform policy paper outlines a target of 80% of social care providers having a digital care record in place by 2024, to be funded by £150m from the Health and Social Care Levy provisioned to deliver a programme of digital transformation over the next three years[4]. While this commitment is welcome, there are a number of challenges facing the goal.
Firstly, ASC providers must be given a choice in the technology they choose to adopt. There is significant work being undertaken by NHS-TD with the support of Digital Social Care, which Care England is part of, in implementing the take-up of Digital Care Records through ICSs. However, one area of concern that several Care England members have raised is the issue of choice. As ICSs look to deploy digital care records, they must ensure flexibility. Doing so will maintain healthy relationships as the integration agenda moves forward and demonstrate that the NHS is not just forcing a system it prefers onto care providers. There needs to be a consistent approach to the adoption of digital care records. Providers who operate across multiple ICSs will have the burden of learning to navigate multiple systems, which, although they should be interoperable, won’t necessarily have the same user interface.
Although not all care providers have started their digital journey, many have through the adoption of specific e-mar systems or management programmes. There is concern amongst providers that these systems will not be interoperable with the digital care record systems that DHSC and NHS-TD encourage adopting. One solution developed to help support this process and help guide care providers in choosing the right technology systems is the assured supplier list that NHS-TD and Digital Social Care have developed. The suppliers who are on the list meet specific criteria points on the Dynamic Purchasing System (DPS), such as being interoperable with other systems. Making software suppliers aware of this system will help drive digital transformation in the sector. Care providers will not have to worry about purchasing a programme that does not integrate with another. Although software suppliers do not need to be on the assured supplier list in order to be purchased by care providers, it should be their objective, and the DHSC should continue to encourage suppliers to do so.
A further point worth noting is that the transition to digital care records necessitates a focus on cyber security as a matter of urgency for the Government. While £150m has been provisioned for digitalisation in social care through the Health and Social Care Levy[5], the plans lack detail on how measures to ensure cyber security will be implemented. The implementation of mandatory data collection via the National Minimum Data Set (NMDS), which is set to begin on July 1st 2022, only strengthens the case for widespread efforts to promote cyber security. The May 2017 WannaCry ransom attack nearly crippled the NHS and given the decentralised nature of the ASC sector, which consists of over 17,000 organisations involved in providing or organising ASC[6], the risk of a similar attack is substantial. With providers lacking the resources to defend themselves, the Government need to play a leading role.
At a fundamental level, digitisation costs money which can be difficult for providers to justify investing given wider cost pressures. A sector wide discussion is required about the sustainability of the market, the true cost of data and the development of the workforce. Although the Government is making funds available to help build digital infrastructure within ASC, without addressing wider funding issues the extent to which ASC providers can plan and invest in the future will be severely limited. Care England has also repeatedly called for financial support to be supplied to providers to support the mandatory data collection. This fund would help providers complete the data requirements needed without putting additional pressure on an already overburdened workforce.
What progress has been made on making data captured for care available for clinical research through digital transformation?
Clinical research provides a route to better understanding the provision of health and care services and how the delivery of care can best suit service users. The UK’s clinical research sphere includes the NHS, university and research institutes, the National Institute for Health Research (NIHR), a strong life science section and medical research charities[7]. Between them, these bodies aim to create insights into data that provide us with new clinical options and improved care pathways.
This level of research is also being conducted at a provider level. CoProduce Care, for instance, has recently investigated how the wider use of data in social care has the potential to both improve the delivery of care and create exciting employment opportunities within the sector. By using AI machine learning to understand survey responses of those with learning difficulties, autism and/or mental health needs accessing care, their pilot project found that machine learning is an effective tool for understanding the needs of service users[8]. Not only this, but the process of collecting information could create a new ‘Feedback Advocacy’ Specialism role in social care, creating the potential for care workers to develop new digital skills and diversify the career options available in social care. This is a prime example of the innovative role that research can play within health and social care.
Clinical research can only be conducted to the extent that those involved have access to relevant data. The Government has announced a commitment to making researchers ‘able to safely and easily access data to provide innovative solutions to health and care issues,’[9] to be achieved by:
The government have listed a range of measures to achieve these aims, including ‘producing a consistent and clear glossary of terminology and legal definitions’ and ‘progress towards creating at-scale data assets that bring together different types of health data to develop new tools for prevention, diagnostics, and clinical decision-support’[10].
While Care England welcomes these commitments, NHS-TD’s plans demonstrate an attitude that excludes social care. In order for social care data to be used in clinical research, providers must be involved and treated as equal partners. This will promote integration and aid commissioners and researchers unfamiliar with social care to gain a greater understanding of the technicalities of the sector. Omission will only promote fragmentation and disparity between health and care services will continue to limit the quality of care available to service users.
As previously mentioned, the Government are also implementing mandatory data collection via the National Minimum Data Set (NMDS) from July 1st 2022. While the Government have been clear that providers will have some level of access to this data set, its benefit for care organisations remains unclear. The Government need to clarify these benefits for providers, as well as provide financial support given the administrative burden entailed by data collection.
How can the creation or exacerbation of digital inequalities be avoided when implementing digital transformation?
The inequalities in access to and use of digital tools within health and social represents an enormous barrier to the benefits of digital transformation being realised and must be addressed, rather than simply prevented from worsening further.
During the pandemic, those unfamiliar with digital tools were less able to rely on support increasingly delivered online or stay in touch with those close to them. In social care settings, the digital divide is particularly salient. The ASC workforce is disproportionately older than in other sectors[11], not to mention that older people, along with those with learning disabilities, are the primary service users in social care.
In terms of implementing digital technologies in health and care settings, the relative lack of digital skills among social care staff is a significant barrier. Research has shown that ‘45% of providers express concern that care staff [lack] digital skills,’ and that ‘23% of care home staff cannot access the internet consistently at work’[12]. This is fundamentally an issue of funding and resources. Training staff comes at a cost that many ASC providers are simply unable to bear within a context of chronic underfunding from local authorities and central Government. This leaves many social care staff inadequately trained in the use of digital tools and unequipped with the skills required to enable them to use technology in an effective, safe, manner. The high turnover rate among ASC staff further reduces the incentive for providers to invest in digital skills and training. While staff may be willing to incorporate more technology into their daily responsibilities, they must be supported in doing so. Government funding to support the development of digital skills among social care staff is insufficient and recent reforms, such as the increase in NI contributions for staff and providers, will only serve to worsen the ability of providers to fund such development themselves. The NI hike alone will have an approximated impact of circa £600m per year on the ASC sector[13]. By contrast, NHS employees and businesses have exemptions on these NI contributions and will not face comparable pressures[14].
The disparity in treatment between NHS and social care, which are subject to very different attitudes and cultures among those in Government and the wider public, must be addressed at a fundamental level if significant improvements are to be realised. With better digital skills across the board, brought about by Government investment in the training of care staff, the ASC workforce would be better placed to support those in need of care to enjoy the benefits of digital tools. In turn, this could help reduce inequalities in how people experience later life, should service users be supported in using tools to help reduce social isolation, for instance.
Conclusion
Digital transformation represents an enormous opportunity to improve the effectiveness and quality of health and social care services. However, there are a number of challenges that must be addressed if the true potential of digitalisation is to be realised.
Care England would recommend the following priorities to the Government for the realisation of their digital agenda:
Promoting interoperability between health and social care services is key to furthering the integration agenda, but in order for these changes to be successful NHS England and DHSC must provide greater funding and support to the sector. Providers are facing unparalleled financial pressures preventing them from delivering the programme of digital transformation, with current funding provisions from the Government being insufficient. Unless wider funding issues facing the ASC sector are addressed, the extent to which the benefits of digital transformation can be realised will be severely limited.
In order for digitalisation to improve the effectiveness of care and deliver clear benefits to all involved, a sincere collaboration between all relevant stakeholders in the health and social care sector is an absolute necessity. While the establishment of ICBs and ICPs represents an opportunity to facilitate said collaboration, assurances must be provided that ASC providers will be properly consulted along the way. Failure to do so will be detrimental and will limit the ability of technological innovations to make care more effective and deliver improvements to the service user. A consistent approach to ASC providers must be adopted by ICSs nationwide, with flexibility offered in terms of the technologies ASC providers are allowed to adopt.
Furthermore, to achieve digital transformation in the NHS that incorporates social care, Care England recommends a focus on the creation of value. We have found it beneficial to talk in terms of digital transformation being a change project with the necessary project management systems in place. A core part of the project management must be ensuring that digital transformation creates value, and this value can be determined in one or more of three ways:
If all digital transformation can be viewed in this light of value creation, then it will set a great base for the digitisation of the health and care system.
The Government must recognise the extent to which financial constraints are impacting ASC providers’ ability to further the digital transformation agenda. This applies to the digitisation of care records, the training of staff and providers’ ability to comply with mandatory data collection. Care England has repeatedly called for financial support to this end, which would help providers pursue digital goals without placing additional pressure on an already overburdened workforce. As the data demand increases and social care organisations become more digitised, the Government must also ensure that adequate funding is provided to address cyber security concerns.
June 2022
[1] Department of Health and Social Care, Joining up care for people, places and populations, February 2022.
[2] Department of Health and Social Care, Data saves lives: reshaping health and social care with data (draft), February 2022.
[3] Department of Health and Social Care, Data saves lives: reshaping health and social care with data (draft), February 2022.
[4] Department of Health and Social Care, People at the Heart of Care: adult social care reform, December 2021.
[5] Department of Health and Social Care, People at the Heart of Care: adult social care reform, December 2021.
[6] Skills for Care, The size and structure of the adult social care sector and workforce in England, July 2021.
[7] Department of Health and Social Care, Data saves lives: reshaping health and social care with data (draft), February 2022.
[8] CoProduce Care, The Health Foundation Data Project, March 2022.
[9] Department of Health and Social Care, Data saves lives: reshaping health and social care with data (draft), February 2022.
[10] Department of Health and Social Care, Data saves lives: reshaping health and social care with data (draft), February 2022.
[11] Skills for Care, The state of the adult social care sector and workforce in England, October 2021.
[12] Department of Health and Social Care, People at the Heart of Care: adult social care reform, December 2021.
[13] Care England, How to Build Back Better, November 2021.
[14] Department of Health and Social Care, Build Back Better: Our Plan for Health and Social Care, March 2022.