Implementation: getting started

This section highlights 3 areas of the transition between inpatient hospital settings and community or care home settings for adults with social care needs guideline that were identified as a focus for implementation. It explains the reasons why the change needs to happen (given in the box at the start of each area). The section also gives information on resources and examples from practice to help with implementation.

The challenge: improving understanding of person‑centred care

See recommendations 1.1.1, 1.1.2, 1.1.3, 1.1.5, 1.3.3, 1.3.6, 1.4.6, 1.5.7, 1.5.14, 1.5.24, 1.5.29, 1.5.30, 1.5.31.

Providing person‑centred care can ensure that:

  • everyone with care and support needs is recognised as an individual and as an equal partner who can make informed choices about their own care

  • when a hospital stay is needed, people who need care and support continue to experience a seamless service that suits their needs and meets their goals for care, rather than the needs of services

  • carers are recognised for the understanding they bring about a person's life and preferences, and are given the support they need to sustain their own wellbeing

  • practice is safe and effective, this in turn can reduce the long‑term costs associated with poor quality care.

Managers and practitioners working in multidisciplinary hospital‑ and community‑based teams need to develop a common understanding about person‑centred care. That way they can better organise services around the needs of each person, especially as they transfer between care settings. But current pressures on services can mean that they feel unable to offer personalised care and support.

What can health and social care managers and practitioners do to help?

  • Use resources that focus on how to improve this area, such as:

  • Use this guideline, along with the 'Care Act 2014: statutory guidance for implementation' and resources such as NHS England's Commitment to carers, to understand your responsibilities towards carers in their own right, as well as the role that families and carers play in helping people making choices about their care.

  • Use this guideline in local forums, and with national bodies involving health and social care practitioners, to review the knowledge, skills and competencies they need to provide person‑centred care and support.

  • Understand and consistently apply the Accessible Information Standard to provide information in formats that disabled people and, if appropriate, their carers and families, can understand. This standard will also help you ensure that people receive the right support to help them to communicate.

The challenge: ensuring health and social care practitioners communicate effectively

See recommendations 1.1.4, 1.3.1, 1.3.2, 1.3.3, 1.4.1, 1.5.3.

Good communication systems enable:

  • improved coordination of care and, therefore, a better experience for the person and improved outcomes

  • practitioners to have a clear understanding about people's health, social care and support needs and preferences and the role practitioners need to play to promote wellbeing

They might also enable more efficient and cost‑effective use of resources.

Poor coordination of care, and poor communication between and within teams, can lead to poorer outcomes and a poor experience of care. Local health and social care organisations need to establish communications protocols, procedures and systems. These should make best use of technology to enable data‑sharing between all practitioners involved in the care and support of people in the area (subject to information governance protocols).

Protocols for sharing information with people, their families and carers also need to be established to ensure that all communication arrangements are understood and used by all relevant practitioners.

What can health and social care managers do to help?

  • Understand the law on information sharing in health and social care and ensure staff are trained in the subject. See the Health and Social Care Information Centre's Rules for sharing information and the Care Quality Commission's Code of practice on confidential personal information.

  • Consider how practical examples of using technology and innovation to improve coordination can be applied locally, for example:

    • An electronic palliative care coordination system (EPaCCS) can help practitioners share a person's end‑of‑life care needs and preferences. An economic evaluation of established EPaCCS early implementer sites (by NHS Improving Quality) showed that these systems helped up to 80% of people who were included in the system to die in their place of choice. It was also claimed that EPaCCS saved the NHS money by reducing acute hospital admissions and bed use.

  • Take forward proposals in the National Information Board's framework for action, Personalised health and care 2020: using data and technology to transform the lives of patients and citizens. Use its case studies as examples. The aim is that all care records will be digital, real‑time and interoperable by 2020. In the meantime, keep up to date with the Health and Social Care Information Centre's Transfer of Care initiative. This is testing improvements such as secure email between care homes and hospitals, standards for electronic discharge notices and improved use of technology in the home.

The challenge: changing how community‑ and hospital‑based staff work together to ensure coordinated, person‑centred support

See recommendations 1.2.1, 1.2.2, 1.3.3, 1.3.7, 1.3.8, 1.5.1, 1.7.1.

Changing working practices across multidisciplinary teams is likely to lead to:

  • a better experience of transitions between hospital and home and improved wellbeing for people with care and support needs, their carers and families

  • greater job satisfaction

  • more efficient and cost‑effective use of resources

To achieve person‑centred coordinated care for people moving between care settings may need changes in culture and local practice.

Managers need to assess the factors affecting integrated working in their areas, and motivate and support practitioners to adopt attitudes and behaviours that support person‑centred approaches. Changing attitudes can be challenging, particularly if there are pressures on staff time and resources, and local capacity (or knowledge of alternative sources of support) is limited.

What can health and social care managers do to help?

Need more help?

Further resources are available from NICE that may help to support implementation.

  • Annual indicators for use in the Quality and Outcomes Framework (QOF) for the UK. See the process and the NICE menu.

  • Uptake data about guideline recommendations and quality standard measures.

  • National Institute for Health and Care Excellence (NICE)