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HTN Now: Delivering innovative new models in community healthcare

For HTN Now, we were joined by a panel of experts for a live discussion on delivering innovative new models in community healthcare. Delving into the dynamic landscape of community healthcare delivery, and exploring key strategies for a successful transition to a remote-first model, we discussed how by harnessing software and the media types that we use in everyday conversations, we can deliver this approach at scale and across a broad range of community pathways.

Our expert panellists included Nick Cross, executive medical director at Wirral Community NHS Foundation Trust; Becky Sutton, chief operating officer at Nottinghamshire Healthcare NHS Foundation Trust; Kumbi Kariwo, equality and inclusion project lead at Birmingham Community Health Care FT and chair of the Midlands Digital Shared Decision Making Council for Nurses, Midwives and AHPs; and Peter Hansell, co-founder of Isla.

Innovation in community healthcare 

Peter kicked off the session by offering a brief introduction to Isla, revealing how the motivation behind the company was borne from his personal experience of his father’s MS and the care he received. He said of his father’s care: “He had a lot of support from acute providers, from primary care, from community care teams right through to social care people who would help him to get showered in the morning and get to work; but what became very clear was that a lot of that was very disconnected, and so really no single person in that process had a very complete understanding of how he was doing. And so we started Isla to address that challenge and to create a dramatically better visibility of patient’s conditions and the way that they’re developing.”

Peter also talked about the technology involved in Isla and in managing this kind of visibility, considering first how the tech helped with observation and analysis: “We connect up the inputs and flow of information from a very wide set of stakeholders – that might be anyone from the patient themselves, family members who are supporting them, the wider community –  and then through into community care, acute care and primary care.

“There are two real use cases. The first is that we empower clinicians to capture and structure information when they’re delivering care in the home, so that enables community nurses to conveniently capture things like images, video, sound recordings, and complete assessments and so on. We focus on doing that very broadly across the community care organisation, touching most specialties within the organisation, and to enable that we’ve built a web application which you can access through the browser, but which is also available offline so that we have that seamless workflow, even in rural communities. The second use case is enabling and empowering patients to self-manage or self-report on their condition. Patients and the people who support them receive a link via e-mail or SMS, there’s no need to download or install an application, and typically they can complete the submission in less than a minute.”

On beginning to join up all of the information from different clinical teams, Peter added: “That’s where Isla’s platform becomes very powerful, because we can link up that kind of longitudinal view of a patient’s pathway and their condition across their entire care journey – we can see when the next message is going to go to a patient, when the next visit is scheduled for, if we’re expecting a clinician to capture a set of information updates, where patients are not responding to those links, and we can start to intervene. That gives us a much better single source of truth and a way to understand a patient’s condition. We can start to structure the information, understand patterns in that data, and give clinicians that help with their clinical decision making.”

Moving on to highlight some of the benefits and use cases of the Isla platform, reinforcing its role in helping support decision-making, improving understanding of conditions, and supporting planning. He noted: “We’re seeing a massive reduction in travel, which saves time and money, and there’s also an opportunity to make sure we’re planning for the right staff to be attending for each visit.

“In Nottinghamshire, we’ve been able to connect up that discharge planning process from acute right through into community providers, saving 30 minutes per patient because we have a video-based understanding of the patient’s journey. In wound care, we’ve seen a 75 percent reduction or deescalation of same-day demand – places like care homes being able to submit photographs of patient’s conditions means that rather than the trust responding by immediately sending somebody out, we’re instead able to review that, give the right advice, the care plan can begin, and we can go ahead with the care visit that was already planned. On financial benefits, typically we see recurrent financial savings of between 250,000 and 400,000 annually; in clinical impact we see a reduction in time taken to get specialist input by 63 percent.”

Use cases, benefits, and delivering digital change

Peter handed over to Nick, who talked about his experience of implementing the ISLA platform at Wirral Community NHS FT, saying: “I’m a GP by trade and the executive medical director for Wirral Community Health and Care NHS FT. Research and innovation sits within my executive portfolio, which I’m quite happy about, as it’s something that I’ve got a real interest in.

“There are lots of exciting opportunities about how we can disrupt the traditional way of providing care and improve outcomes. Firstly, it’s really helpful if the digital and innovation agenda is woven into all your trust’s organisational strategies, and primarily that demonstrates recognition at the highest level of your organisation, which is crucial when we’re looking at transforming at scale. I’m sure many of you, like me, get loads of emails every week about new shiny products and the benefits that they could bring to your trust, but it’s absolutely not practical to be able to follow up on each of those, so be very clear about what your trust’s strategic and operational priorities are, because that’s going to help you prioritise the areas that you want to focus on if you’re looking for digital solutions. Be really clear from the outset what problem it is you want to solve, because it’s an opportunity to bring people together to seek solutions.”

Nick also discussed the importance of taking a clinically-led and digitally-enabled approach from the beginning, and of getting the right team in place to support the project. On next steps, he shared: “Then it’s time to look at options, appraisals, about the potential of running pilots to prove the concept – is it going to solve the problem, what will be our return on investment? Don’t underestimate the energy that’s going to be needed or the hard work required, because in my experience it’s seldom a smooth journey for something to be embedded.

“Lastly, once you’ve decided on your solution, how are you going to embed it to maximise its use and to get uptake? Again, don’t underestimate the challenges of scaling-up and behavioural change of getting everybody to use it in the same way across a workforce or a large team, and it may be that you need to consider turning something off in order to direct them down that route that you’ve decided is going to create some good results.”

Becky then took over, to share some of her own experiences from Nottinghamshire, saying: “I work for Nottinghamshire Healthcare Trust as their chief operating officer. A couple of things to add for me – I think there are some successes around getting the people that deliver the care and the people that receive the care involved early on. We engaged a lot of clinicians on the frontline about Isla, and I think we got some really interesting ideas about innovation by doing that, but I think they ultimately used it in very different ways than we originally thought.

“We originally went in thinking it might be able to help with wound care, with the potential to take pictures and share that with our tissue viability teams; but actually some of the things that people identified have been things that we never even thought about, like triaging patient referrals, the stroke pathway, and actually how using those bits of technology can really encourage people on that journey of health improvement by seeing the progress that they’ve made.

“I think choosing kit that is not disease-specific has always been a real bugbear to me, and actually what you’ve got to look at is which solution is going to help the majority of patients, and can be adaptable, and scaled at pace. Getting those business cases through and being able to articulate the benefits is key.”

Kumbi took the lead on the discussion of inclusivity, equality and accessibility, saying:”I’m a learning disability nurse by background, and more recently I was the first chief of nursing fellow working with our adult teams. I’m based in Birmingham, which is very diverse, and when you look at ethnicity, we’re now a 50/50 city. We’ve also got the youngest population if you’re looking at cities across England, but we’re also starting to get an ageing population, so we’ve got a real mix.

“As part of my role we look at the Equality Act 2010, looking at the 9 protected characteristics, and whether our service is fit for purpose. We’ve been looking at what working solutions we can put in place, and we started to look at quality improvement, so what can we do in the immediate future that can impact patient’s lives? We’ve got 87 commonly-spoken languages, so the minute you have an app that has instructions on it, for us we’ve already hit a barrier.

“When we were looking at Isla, we actually looked at 10 providers, and we came up with our must-haves based on our communities, things we needed in terms of functionality. Our first focus was on wound management, but actually we’ve now gone into speech and language therapy, into physiotherapy, and it’s now being used as an MDT tool. When you’re dealing with complex cases, and if English is not a patient’s first language, and you’re asking them to articulate what a wound looks like, a picture speaks a thousand words.”

Motivation for change and future plans

We asked Peter about his insights from his experience with roll-outs across multiple different trusts and organisations, in terms of motivation and drivers for adopting change. He said: “I think the big drivers are that the health system is full of solutions and apps, but we are one of the ones that has a very wide breadth of application, so I think that’s crucial for digital teams who are managing the implementation of new technology. The more that you can do with one solution, the better. The NHS probably now more than ever, is hungry for solutions that work, and solutions that you can evidence the impact of. We have an excellent delivery team who work very closely with each of our community partners, and who are writing-in the detail of how much time we’re saving, what that means financially; and that gives us a really strong evidence base.”

We next asked Nick to share a little bit about his current community care delivery process, and how he sees this developing in the future. He shared: “I think it is generally a very exciting time to be involved in healthcare in its broadest sense, and when we look at AI, when we look at smart devices, smart dressings for wound care, and then start to merge those with the Internet of Things, the options are really endless.

“I feel that our ability to virtually wrap around people in their own homes in a non-intrusive way is really starting to gain some traction. Integrating a visual care record alongside or within the electronic patient care record, is something that’s particularly exciting for us as a trust, but also access to that longitudinal data, the physiological data linking that with kettles, with toilet flushes, with mobility monitoring in peoples homes, can provide a very detailed picture of health and long-term conditions.

“For children and young people’s services, again, so many opportunities for them to remain healthy and active – linking in with their smartwatch data, linking that into the electronic care record, again providing really powerful data and research opportunities. Automation and AI in clinical decision-making is a huge growth area. There’s already a CQC-approved virtual AI-driven physiotherapy service, for instance, so that can enable the physios to concentrate on the really complex stuff, while other stuff can be managed in a different way.”

Becky discussed her advice for anyone looking to implement a digital-first model, saying: “I think the biggest thing is starting small, but with a big ambition. You’ve got to get people with the passion and the energy – these things are really hard work, and it’s easy to give up when you get one barrier in the way. It’s easier to start with the people that want to do this, rather than the ones that don’t. You will bring them on board ultimately, so start small, build a team around you that are as passionate as you.

“Think about how you build that case for change early on, how you can sell the narrative to say, “Actually, we can’t recruit all the district nurses in the vacancies we’ve got, so we’re going to use that money a little bit differently”; but you also need that clinical voice, to help you do some of that, because like we’ve already spoken about, people will be worried that we’re replacing them with an IT solution. Actually it’s not, it’s enabling the care, it’s allowing them to do things that we really need them doing, not some of the basic things, and it’s promoting self-care, it’s back to that bigger picture, because if we don’t get people helping themselves, I just don’t think we’re ever going to have a workforce big enough.”

Research on wound care and future directions

Kumbi shared with us some of the findings from her research on wound care for darker skin tones, saying: “Two years ago, we started looking at darker skin tones. We did a baseline assessment to understand how comfortable and confident our staff were, and what we went on to learn was that traditionally, all skin care was based on white skin tones, and so whilst staff had some understanding on darker skin tones, there was nothing actually set in our training.

“I’ll give an example – on my skin you will never see redness, so you’d probably come in and classify me as low risk, but in the meantime, my wound is developing, and then it’s, “OK, Kumbi has a pressure ulcer”. So what we were saying is, at stage 1, 2, 3; you’re probably seeing indicators, but you haven’t been taught them. We’re now starting to learn what those indicators are, and I think when it comes to looking at digital interventions, if your current clinical practice is not right, those mistakes follow on into your digital practice.

“AI is very much machine learning, and so if you’re teaching it with errors, it’s going to tell you errors. Researchers are saying that within a few years, 90 percent of our workforce will be using digital technology to deliver their roles, so these are the types of conversations we need to have.

“You also need data, and so we tend to have a lot of takeaway, or digital solutions where we input data, but actually when it comes to taking it out, it’s very much stuck in the digital ether, so how are we ensuring that the solutions we have allow you to see the data that you’re using?”

“We looked at Isla, and one of the things is that you can see the photos on the timeline, so whether there is 1 week or 16 weeks worth of images, it’s very easy to see, compare and justify. One of our cases within tissue viability actually went to a coroner’s court, and the outcome changed because they were actually able to show the images that they’d taken on Isla, and that helped to demonstrate the care that had been delivered.

“What we wanted was a technological solution, where we can start to take images of darker skin tones, because what we realised was that we didn’t have consent for photos, so whilst we had a lot of images, none of them were consented, so we couldn’t use them for training, we couldn’t use them for research. With Isla, one of the things we said from day one was that we need all our photos consented for 3 purposes: clinical purposes, research, and AI. Going forward, patients can opt-in to what level of consent they’re comfortable with.

“We’ve now changed our strategy, so now darker skin tone is actually considered a high risk, which means anyone who’s got a darker skin tone within our city now actually has a higher level of scrutiny, because we’re recognising that late diagnosis. It took a learning journey, and now our tissue viability team are champions, so they’re the ones taking it forward. It’s given them the ability to open a dialogue and to work together in changing the care.”

Our panel then moved on to take questions from our live audience.

We’d like to thank our panellists for taking the time to share their insights and experiences.