For HTN Now, we hosted a panel discussion on virtual wards and the future of remote patient care, with guests Tara Donnelly (director of digital care models at NHS England), Sam Jackson (clinical services manager for the Virtual Health Hub at Hampshire Hospitals NHS Foundation Trust) and Jamie Innes (product director at Inhealthcare).
To begin, a question was posed to Tara. Can you set the scene from a national perspective – what’s happening centrally, in terms of the past few years and the current agenda?
Tara: The position, in terms of digital home care across England, has changed really markedly over the past three years. There’s now a digital home care service in every ICS. That’s really significant. The pandemic was a huge accelerant; it led to a very different awareness around hospitals, safety and infections control issues. Outside the hospital, it also led to many people using digital tools in their personal lives – often for the first time. Technology has got better, and cheaper as well. We’ve seen a real sea change.
It’s important to say that whilst virtual wards are a really important part of digital home care, it’s much more than that. The programme that we have helped support includes home or remote monitoring for long-term conditions. It includes vital sign monitoring in care homes, which is really critical to keep people well in the place that they call home.
70 percent of hospital beds include people with long-term conditions, so it really matters that we are getting strong result from sites in the management of major healthcare conditions like COPD and heart failure. We’re seeing figures like 50 to 60 percent reduction in readmissions to hospital for those who are supported through a digital tool.
The success we’ve seen so far has been achieved through a lot of hard work, with clinicians redesigning pathways and working with responsive technology providers. At the centre, we could set a vision for this and we were able to provide some quite significant funding which was as much for project teams as it was for the technology itself. It really is about change management.
We’ve also worked in partnership with regions, ICSs and frontline services, supported by the Innovation Collaborative for Digital Health – a really lively community of people who are very generous in terms of sharing their materials and resources. Yesterday I looked and we’d had 10,000 downloads or views on documents about building a business case for local sustainability. People don’t have to start from scratch, they can learn from others who are ahead in a particular area. There are lots of resources on the collaborative and I would really encourage people to join.
Sam, can you take us through your work in Hampshire in terms of your virtual wards project and where you’re up to today?
Sam: At the start of the pandemic we recognised the need to support residents in care homes and in April 2020 we launched a remote assessment tool for care homes to access. Clinical staff could complete their observations and provide RAG-rated scores remotely. If clinical concerns were raised from those scores, they had clinical experts on the other end of the phone to help, whether that involved making decisions about a resident’s care or deciding how best to support carers. Carers are often isolated, working late and looking for advice on what to do about a problem, so they often end up calling 999 or 111 in those situations. Actually, just being able to have a friendly conversation with a nurse, physio or pharmacist will be able to solve those relatively simple issues.
The project is also about recognising who needs to come into hospital and when. Can we bring people in sooner to access the right care so that they can reduce their length of stay, associated challenges, the need for use of intensive care beds? It’s also important to recognise where palliative care is best received. Are we making sure that people are dying in the place that they wish to die rather than coming into hospital unnecessarily, or dying in the emergency department due to lack of resources?
We originally launched to about 76 care homes; we now support 280 across a lot of Hampshire and the Isle of Wight. We’ve dealt with nearly 8000 patients over that period, and we’ve seen a good reduction in the numbers of patients turning up to the emergency department and reduction of GP pressures. We’ve become a one-stop shop for care homes, providing a single point of access where we triage out as necessary but treat using our own resources where we can.
Off the back of that, we launched another service within virtual health called the Clinical Communication Centre. We recognised that lots of people were coming into hospital unnecessarily because general practice or community partners couldn’t speak easily to secondary care clinicians. A lot of GPs are hugely stretched with really short periods of time to assess patients. If they can get through to the right person for advice, we see a reduction in the need to send people into hospital to mitigate the risk on general practice.
Equally, we need to recognise where bringing people into hospital is the right thing to do, and if they do need admitting, it’s better to send them directly to the ward that they require than sending them through a complicated process where they speak to lots of different people in lots of environments. We’ve looked at streamlining that: getting the right person to the right place to see the right member of staff.
We’ve opened the service up to paramedics and trialled a ‘call before convey’ pilot. Paramedics who would have initially brought their patient into the emergency department will call us and we will see if we can triage them into a suitable setting. Can we get them into a virtual ward, can we bring them straight into a ward, can we give the paramedic advice which enables them to safely leave the person at home? Of the people that we saw, 30 percent of them who would initially have gone to the emergency department went down a different pathway.
We aren’t going to change the emergency department just by launching one service, but it’s part of the portfolio of services that are available to try and reduce pressure on the hospital.
Then there are our virtual wards. We launched our virtual wards in January 2021 due to pressure on inpatient beds, where patients were clinically stable and well within themselves, but they had abnormal observations. I think the telephone is an under-recognised bit of digital technology – we started off with just ringing people to make sure that they’re okay and they’re safe at home. If they are deteriorating, are we recognising those signs sooner? Are we bringing people back into hospital or can we ask them to see their GP? Do they need medication sending out?
We now run nine different virtual wards for different specialties. There are lots of different clinicians involved. I think the fact that it is multi-speciality is definitely a strength. It’s linked to our Clinical Communications Centre, it’s linked to our telemedicine service for care homes. All of the staff are involved in all of the services, so they’re thinking in different ways, they’re listening and thinking more analytically.
Combining those three services together offers a huge amount of benefits. Overall, in the last three years, nearly 24,000 people have used the Virtual Health Hub. 12-13,000 of those have been in the last year and we expect that to continue to grow.
Jamie, can you share one of your customer projects and talk us through some of the technical perspective?
Jamie: Our Oximetry@Home service was deployed throughout Wessex during the COVID-19 pandemic. It was the largest Oximetry@Home deployment across the country and we had over 25,000 patients being deployed on the service, with various different evaluations demonstrating its effectiveness across multiple providers in the region.
Through the service we were able to monitor patients with long-term conditions and help patients feel reassured that healthcare professionals are routinely reviewing their measurements and that they can act in the event of deterioration. The service demonstrated savings for local health and care services which received increased contact and activity from patients at a time when resources were very stretched.
In terms of technical challenges, I’d say a key one was how you were going to integrate the data that is captured by patients back into GP and community record systems. How can you natively integrate with SystemOne and EMIS Web? It’s around ensuring that there was full visibility of that data set across the different circles within the health service, and ensuring that the data is there for evaluation purposes later on.
One of the main process elements that we took away and have since used with all of our virtual ward programmes is around starting small and iterating based on feedback from healthcare professionals and patients. We’ve worked with various different consultants where we’ve implemented a ‘start safe and small’ programme and then expanded based upon learnings and impacts.
Approaches and lessons learned
Sam: I think the first, simple approach is to work with the willing. Virtual wards are a really different way of working, especially for hospital doctors. They’re used to having the patient in front of them and being able to make decisions based on that. Asking people to make their decisions without seeing the patient in person is a big change.
We started off by proving the concept and how it works by expanding the Oximetry@Home programme that Jamie was talking about. We pulled the data from that and showed that it was safe and presented it at various forums within the hospital, and we asked anyone who was willing or interested to come and talk to us.
We started working with the frailty team to see if we could discharge frail patients sooner but also safer. It’s a complex cohort due to the co-morbidities and patient needs and they tend to have a slightly higher readmission rate. We launched a really small service where three of four clinicians could refer into the service and we started taking two patients a week, calling them up on a daily basis with really clear and bespoke goals. We would run through those two patients on a weekly basis with the team to discuss what was going on and raise any challenges.
The responsible consult wanted a lot of feedback to start with, but after we ran about 20 to 30 patients through that virtual ward they saw that results were positive. We opened it up to the next stage, so anyone within our hospital dealing with frailty could refer patients into the service. We set a clear market; once we had 200 patients coming through the virtual ward, we would review our safety again. That review showed that it was safe, effective, it was reducing length of stay and readmissions and there was no danger to patients. The data indicated that there was a reduction in mortality at 30 days, and we got brilliant feedback from patients and carers too.
From there, we opened it up to the entire hospital so that any clinician could refer in. The marker for a review moved up to 500 patients. We’ve moved on from there, setting regular markers to ensure that we are hitting our targets and key performance indicators from an operational perspective, but making sure it works from the patient perspective.
So we’ve taken more of a virtual hospital approach, really. I’d emphasise the importance of setting clear goals and targets and undertaking proper stakeholder engagement. Get feedback from patients and get them involved. It’s taken us about three years to get to this stage, it isn’t a particularly quick process and it’s been been a lot of hard work. Jamie mentioned it earlier; it’s about starting small, proving that you’re safe, and then going again.
Tara, in your experience in terms of scaling virtual ward programmes, how do you think this can be done effectively?
Tara: I think if people are just beginning a digital home care project, it’s about putting your best people on it. Go where the clinical energy is and pay attention as a leadership team.
Ultimately this is a project of change, it’s not a technology project. The technology is relatively straight forward, we’re happy that Inhealhcare is a great product and there are others available that are also great. The technologies are there as an offer; it is really about changing processes that people have been working on for 20 years, in some cases.
It’s a big change, but also in terms of scale, we currently have 162 tech enabled virtual wards across the country. So there will be many people in the audience who aren’t at the beginning and they’re probably thinking, ‘what’s next?’
About 4000 beds a day are being provided to people with frailty or acute respiratory infection, which are the two conditions that were first mandated. There will be people wondering about which conditions to go to next, which is absolutely the sort of bottom-up enthusiasm that we want, when clinicians get these tools in their hands and they begin to recognise the different areas the technology can work for them.
I also think there’s an opportunity to learn from others who have done more. If your interest is in heart failure, there are wonderful things happening here and in Leicester, so I would say look at the Innovation Collaborative. People have been enormously generous in this community in terms of sharing and that can help accelerate the next stage.
One of the most important things is for these digital services to become more visible in the public and clinical mindset, so the the first time someone hears about virtual wards isn’t when they or someone close to them is offered it. I’m delighted to see how much more mainstream coverage there has been recently. There have been lots of pieces on the BBC, ITV, some pieces in The Times and The Telegraph. The Prime Minister talked about virtual wards a few weeks ago which is helpful in terms of making this part of mainstream care.
It’s about how we move both the size and the number of wards we have on offer, but also the depth of what they cover. We’ve seen really interesting things happening, for example the development of paediatric hospitals at home. I think that’s the sort of thing that comes next, in terms of scale.
Jamie: A really good example of a service that incorporates this has been some of the respiratory work that we’ve done with Hampshire and Isle of Wight. It’s about taking into account that not all patients are the same and not all patients need the same level of care, and that care needs can change.
That’s why you need the ability to step patients up or down between different types of monitoring. With the services that we’ve developed with Hampshire and Isle of Wight as an example, healthcare professionals can change the frequency of monitoring and escalate patients onto more continuous monitoring steams. They have the ability to move patients between different pathways as their care needs change and that can include the use of continuous monitoring devices.
It’s also about using softer options within the pathways, so that healthcare professionals can engage with patients, initiate to a messaging or functionality such as a video conference, or just pick up the phone to the end user – just so they can get in contact with them and talk them through what might be their current challenge. Those step up step down models are really key within your virtual ward programme, enabling you to take into account those different levels of the population that you’ve got to manage and changing patient needs over a period of time. It’s about being able to adapt to that and still provide some continuous wrap around care for patients, even after they may leave the virtual ward programme.
What are some of the challenges?
Tara: There are a number of challenges, but this is also the solution to so many huge challenges that the NHS faces around urgent emergency care pathways, bed capacity and dealing with the elective backlog. I think the challenges are much smaller than the issues that need to be addressed.
Commonly, people will talk about workforce – of course you need a great workforce to run a virtual ward, but it makes much more efficient use of clinical expertise. A group of clinicians can look after a much bigger group of patients, at around a third of the cost of running a physical ward. It depends on the model and there are costs, we’re creating more beds, so that is going to cost more than the previous situation – but not as much as it would be if those beds were real bricks and mortar.
We haven’t really talked about this yet, but patients absolutely love it. You’re keeping people where they want to be at a smaller cost and you’re making better use of clinical time. There have been some great examples of people positively engaging with the programme – there’s a film about a retired nurse who has returned to nursing work on a virtual ward. You can see that becoming much more normal. Rather than retiring early, people will choose to stay and work in a different way. People are finding it very motivating.
The team at Norfolk and Norwich has had no staff sickness on their virtual ward at all. We quizzed them a bit about their experiences and they said that they love doing the work and find it really rewarding and flexible. If there’s an issue – for example a childcare issue – somebody could still manage to work from home, but to get to a place of no staff sickness at all is really quite an achievement isn’t it?
There are challenges but they are completely within our gift to resolve and I’m more worried of the outcomes if we don’t seize the opportunity. This is really an opportunity to make the NHS much more sustainable and available for people in the future.
Jamie: As Tara highlighted, a lot of the time the technology tends to be the challenge and sometimes getting that clinical buy-in, in terms of the delivery of the services.
It becomes more of a challenge because you’re trying to change people’s well-established ways of working, the ways that they’ve been brought up and taught how to deliver care. You’re trying to change established ways of working that people have had for 20 years or more and that tends to be more of the challenge.
In terms of technical challenges, integration can be a common theme that we come across in lots of different areas and lots of different clinical systems where they want to get the different data sets involved. It’s very important at the beginning of your virtual ward programme to ensure that integration is built into that service design; to have a really clear set of requirements about what data is going to shared with what systems. It’s not just about continuity of care and visibility across the health system. It’s about reporting and data analysis – you need to be able to ensure that you can report and demonstrate the effectiveness and evaluate these virtual wards once they’re in place.
Another challenge we often see is surrounding inclusivity, ensuring that the services are as inclusive as possible for patients. Whenever you design a virtual ward programme, you need to be looking at how you can be inclusive and provide mechanisms for patients or carers to engage in a virtual ward programme. We don’t want to exclude anybody from being part of a virtual ward, we want to promote it as a way of delivering care to anybody within the health service.
What does the future look like for your projects going ahead?
Sam: Growth, I think, is the most important thing. As it stands at the moment, with somewhere between 60 and 70 beds at Hampshire, the idea is to get nearer to 200-250 by the end of the year. We want to continue to manage thousands of people remotely and virtually, and create a virtual hospital managing multiple specialties.
The other thing is to have our staff rotating. A lot of the work is behind computers and is on the end of the telephone, and you’ve got clinicians who are so inherently desperate to put their hands on people and deliver patient care – whether that’s putting a stethoscope on somebody’s chest or from my perspective, using my physiotherapy skills. It’s about ensuring that we make our workforce resilient and looking at how we can keep their clinical skills up. As such, something to look into is whether we can start to look at rotational posts within the hospital that we currently work in, and can we look at some cross-organisation rotational posts?
We work with Southern Health; they are our face-to-face provider for the virtual wards and I think it’s really important that you continue to rotate within key and specialist areas. That’s the big thing for the next two years – making sure that the staff that we currently have, who have been working with us for three years, are able to use their hands-on skills without having to work a bank shift on a different ward. For this to be a sustainable way of working, we need to explore how we keep those roles hands-on. Otherwise our turnover of staff is going to be pretty high. So that’s growth, in terms of numbers that we’re looking at but also maintaining and enhancing the skills of the staff that we have.
Tara: I think we will continue to grow and become part of mainstream care. I’d like to see hospitals become places that you go to if your surgery can’t be done as a day case, or if you need a very high intensity input and not really for anything else, anything else can be managed from home.
I’d like to see a reduction in the number of crises and exacerbations that people have, because we’re able to give them specialist advice thanks to digital tools. I’d like everyone with the most common long term condition in England, which is hypertension, to be able to home monitor and share the results with their practice – to be looked after and get results as stunning as the Inhealthcare deployment in Surrey. We’ve seen the amount of home blood pressure monitoring increase, its gone up by 170 percent but I’d love that to just be the defacto way that people keep on top of their care.
Jamie: I think we are going to see the continued evolution of virtual wards, and I think that’s really going to lead into the hospitals without walls – basically, wherever you reside as an individual, you can receive the care that you need.
Personally I find the wearable technology market really exciting. I think that wearable devices are really primed to dramatically change the way that we deliver healthcare services and continuous monitoring devices will become the norm. That will give healthcare professionals a wealth of data to allow them to make further informed judgments as to the appropriate treatment for patients. I can also see those wearable devices changing that step up step down model, allowing healthcare professional to change the frequency of monitoring for patients.
I also think that the transformation we are seeing in healthcare will lead into social care services, with an opportunity to really reduce face-to-face activity in that industry – which is really struggling to recruit staff and reinvent the way that it delivers services.
Thank you so much for Tara, Sam and Jamie for joining us; you can view the full session below.