Pathfinder integration of health and social care systems

Full Application: Not funded at this stage

The 12 North East Councils wish to progress their digital ambitions by doing the necessary preparatory work to ensure our digital system architecture is ready to plumb into the regional HIE and social care clientele are fully informed about how we will share and use their data.

Supported by ADASS, the North East Councils wish to collaboratively work together to support each other in the progression to integrating health and social care records through an HIE and the Great North Care Record.

With this congruent end-goal in mind, we need to understand a baseline position of all the Councils within the North East to allow us to gather the learning from those further ahead on the roadmap to support those further behind. From initial findings there is a significant juxtaposition between where the majority of Councils are presently and where they aspire to be; a journey significantly greater than our health colleagues will need to make.

There is also very little academic research in how health information exchanges can positively impact upon patients and social care clientele. We will partner with a local University to support us in developing the necessary academic research which will give us accurately measurable and realisable benefits to win hearts and minds of our patients and social care clientele in how we will use their information to improve judgements at point of need.

We intend to develop a concluding report at the end of the project which will outline for the region, and beyond nationally all the component stages required for a Local Authority to overcome the barriers, capitalise on the enablers, plumb into the regional HIE system architecture and eventually realise the benefits to this can bring to social care and public health.


This discovery phase will be managed and delivered through the North East ADASS Reference Group, lead by the North East ADASS digital representative (Service Director Adult Social Care, Gateshead Council). The Reference Group will act as the project group, having representatives from all North East Councils from a variety of disciplines, and also being able to call on individual Council specialists where necessary for technical advice and guidance.

We are building our approach on the lessons learnt from previous failed NHS programmes such as the National Programme for IT and; the former failing to understand the need for interoperability rather than just digitising, and the latter failing the need to build and maintain public trust.

We will commission a local University to conduct our user research, they are already working with the Great North Care Record, so their experience of working with citizens should deliver academic capital into new areas with knowledge deficits. The aim is to utilise this information to support us in developing the public trust so we don’t fail in achieving fully interoperable data so that we have sufficient data to make judgements at the point of need and optimise our customer experience.




Deadline Event/ Activity Milestone
14th December ·         Project kick-off meeting with NE ADASS Group

·         Commence commissioning of academic research within contract procedure rules of host council

·         Consultation with NHS Digital in development of HSCN specifications

Project started
1st February 2019 ·         Initial user research

·         Analysis/ evaluation of Baseline situation

Baselining and user research commencement with University
28th February 2019 ·         User group meetings

·         Collaboration workshops

Consultation and learning
8th March Demonstration of potential future directions Conclusions and recommendations
15th March Event planning to promote findings, possibly link with Great North Care Record Beyond discovery planning
22nd March Final report produced and reviewed by ADASS Reference Group Discovery outputs completed and shared
26th April ADASS review of project outputs and sharing with other regions Post-project sharing with others


Presently there isnt a cost of the problem, but there are significant costs of professional queries to social care because, in example, time is wasted with GP’s calling social care for information which is inefficient. We need to map our benefits aspirations using carefully measured inefficiencies of where health professionals waste Council time in sourcing information which can be clearly remedied by interoperability of data. We have stated clearly once we have our benefits aspirations, we will define the metrics to allow us to measure the realisable benefits. This may be elements like FTE of staff that are presently serving the NHS by providing information.

Meeting the local digital declaration, we will design services that best meet the needs of citizens by having more holisitic and comprehensive data, thus allowing assessors to make better informed judgements at the point of need. We will ensure citizens’ privacy and security is protected, doing user research, and capitalising on existing consent models developed by the Great North Care Record, we will ensure citizens understand the purpose for sharing information, and what we will do with this information to improve the lives of our citizens of the North East. Finally, we will improve value for money by minimising the wasted time sourcing information on clients, improving client experience and quality of life,

We will develop, with our academic colleagues a user research report which will help shape future data requirements and provide us with the necessary information within social care to make an informed judgement at the point of need and ensure our clients do not need to tell their story a number of times. The user research will provide in-depth analysis of what data can and should be shared with our health colleagues, which will in-turn provide new metrics which can be utilised for data analytics.

The North East group of Councils, supported by NE ADASS have a clear timescale to integrating their social care records into the North East Health Information Exchange, and subsequently the Great North Care Record. The North East group of Councils want to develop a blueprint to the ultimate goal of integrating health and social care records, however unlike our health colleagues, there is no existing roadmap to follow to develop this.

We would like our University partners to develop our benefits aspiration and benefits realisation model which will include pecuniary and non-pecuniary benefits:


    • Improved customer/client experience- tell us once approach
    • Reduction in non-value adding activity by social workers/support staff chasing health information
    • Essential Information available at point of need
    • More responsive and flexible services
    • Reduced pressure on health staff from demands by social work for information
    • Improvement in culture of sharing with health and social care
    • Improved security of data sharing rather than reliance on letters/fax/email
    • Cashable savings- reduction in postage, business support staff, better commissioned services

This project will be highly pertinent to others, working across a large geographical region with cross boundary and Trust areas, it is collaborative in its very nature, involving partners and 12 Councils. Despite the LHCRE areas pathfinding in this work, there are many Councils across the country that will be invited to be involved in the tail-end of the process once the NHS elements are resolved. Having a blueprint to develop the roadmap to integrating health and social care will become highly prevalent amongst Councils, ergo its relevance to others will become paramount, especially when we factor the academic research behind the project, coupled with a regional testing ground of nearly 3.6m people.

As this project is backed by NE ADASS, the demonstrable results can be shared amongst ADASS leads and also ADCS leads and can be applied within their Councils. The user benefits can be translated back to other Councils in the knowledge that this has been tested in a diverse population with a large geographical footprint across many NHS trusts, CCG’s and GP surgeries.

The end-report will become a standard operating procedure for Councils to follow to interoperability and integration with NHS partner organisations, providing health and social care realisable benefits.


This discovery project will culminate with a concluding report produced by our academic partners which will detail the blueprint to achieving success in the integration of data across health and social care, but focused upon the benefits for social care. The business case will include the benefits aspiration and the metrics for benefits realisation.

This report will detail the user research that has taken place, what the results have shown

  • identify and consider key stakeholder requirements from data sharing between health and social care. Report to provide guidance as to what information should be shared with rationale as to why. Capture current user experience and understand what impacts these are having. Produce a set of needs for each stakeholder, understand what barriers may exist for each stakeholder.
  • Benefits mapping/case- desktop and specific case studies with councils. Understand what nature of problem is- what are challenges from not data sharing, what benefits are expected to be, try to produce estimate as to scale across the region for savings- cashable and non-cashable.
  • Recommendation report- report to provide assessment of regional position of councils, identify any specific barriers, identify enablers, provide a draft project plan for delivery for an exemplar and recommend possible approach for implementation, estimated costs for implementation, provide recommendations as to what model of connection would work for regional HIE

The report will describe the alpha journey and what needs to take place on the roadmap to achieving interoperability with the regional HIE, and what can be developed beyond in terms of predictive analytics and the wider implications for public health planning.

Our users will be social care (adults and children’s) clients, primary, secondary care, GPs, social workers, mental health trust, North East Ambulance Service, business support staff, social work assistants, service commissioners, CCG, Public Health.

We will commission a local University to conduct our user research, they will act as a critical friend type of role and will help analyse an evaluate the baseline position. The University will lead participation in group meetings and run collaboration workshops to help draw themes and knowledge.


The research objectives would be:

  • Identify key stakeholders and when and where they would want to access health/social care data within the business processes
  • Defining stakeholder data requirements
  • Production of set of needs
  • Understand what barriers may exist in gaining consent to share information
  • Understanding consent and any other IG barriers we may need to overcome.
  • Defining a baseline for our benefits aspiration and the corresponding metrics to allow us to measure realisable benefits.

Engagement with the key stakeholders and users will be imperative to the success of this project, and will negate any risks or barriers we may face when we begin to share information. These lessons learnt from previous NHS projects are paramount to ensure our users understand what we will use their information for. We can capitalise on the engagement work the Great North Care Record have already conducted, albeit this was specifically aimed at health.

We would like to take on any training and support available from the LDF and its partners, and we will ensure any training given will be shared amongst the NE Councils, thus further expanding knowledge and expertise across the whole region.

Linking us into LHCRE learning from a social care perspective would also be highly beneficial.

Gateshead Council wholeheartedly believes in developing its digital interoperability with its strategic partners to better the lives of its residents and support them to thrive. With this in mind, Gateshead bid for the LGA/ NHS Digital funding stream in June 2018. The bid was rejected because we already knew what we wanted to achieve as an outcome. The bid followed the same methodology of capitalising on having resource to free-up capacity to allow the developmental work and discovery to progress. As we were unsuccessful, we formed a reference group to meet to establish if we could share learning amongst the NE Councils. It was quickly established that none of the Councils had progressed greatly into having all the necessary system development to be able to directly plumb into an HIE at present, nor did they know where to begin the journey.