Feature Content, Interview

Featured interview: Luscii and Maidstone and Tunbridge Wells NHS Trust on virtual wards for acute settings

We recently sat down for a chat on virtual care with Luscii’s managing director, Chris Malone, along with virtual ward matron and hospital avoidance lead Fay Johnstone and ward manager Abigail Scullion from Maidstone and Tunbridge Wells (MTW) NHS Trust. Chris, Fay and Abigail discussed the set-up and implementation of their acute virtual ward, advice on securing clinical buy-in, patient feedback, and more.

The vision for the virtual wards

Fay: Our virtual ward is different in the sense that it is an acute virtual ward model. We cover treatments and monitoring and transfer patients in and out of the virtual ward on a step-up, step-down model, depending on their needs. We take patients from the emergency department if appropriate, and then we also look at patients who are already in hospital to see if we could reduce their length-of-stay by bringing them onto the virtual ward.

The ward was originally set up off the back of the pandemic to monitor chronic obstructive pulmonary disease (COPD) patients by respiratory nurses, but it didn’t have a clinical lead as such. They needed someone with drive in that area. When I came on board, I identified that if we were going to make this work, we needed to involve treatments; we needed to develop it properly into a virtual ward and not just a monitoring service.

Chris: From Luscii’s perspective, our vision first and foremost is to stand together in a partnership. We enable delivery of a digital bridge to facilitate the transfer of information to help the right decisions to be made in the right place at the right time.

We always look at the core challenges in some respect – how do we increase capacity, improve discharge, expand better joined-up healthcare outside of a hospital environment? How can we improve and grow the workforce and help them feel like they’ve got more time to care? These things are always at the back of our mind depending on a clinical team’s requirements. Talking to MTW, it became apparent early in the process that Fay’s vision of taking the service from something fairly standard around monitoring COPD to that acute and A&E focus was quite special, and it very much tied in with those core challenges around increasing capacity and improving discharge.

Set up and implementation

Chris: The key to a lot of this is to step outside that view of a traditional supplier and provider relationship. If you’re not in the room together and you’re not making decisions together, you’re never going to get to the bottom of the problems and solve them. If clinical teams don’t trust us enough to tell us what is happening on the ground, we can’t help.

At Luscii, we are very focused on helping teams conduct digital transformation at scale. We have conducted over 350 remote monitoring pathways in 11 countries. We have incredibly comprehensive implementation plans and stakeholder mapping journeys, we come in and work together with the teams to build and map a care pathways that work for their specific locale and demographics. We don’t believe in throwing the baby out with the bathwater – we want to augment the great work that is being done internally. It’s a question of how we can help to support that, or supercharge it.

Fay: Exactly as Chris says, from our point of view it’s about trust. One thing that I love about Luscii is that they work with you. It’s not a ‘them and us’ situation; we go to them if we are stuck on something and they are very quick to respond. They put time and effort into training so you feel valued as one of their programme designers. They are the experts in regards to what other people are doing because they work with other organisations, so we can bounce ideas off them.

They have also helped us with getting clinical buy-in, as some clinical teams were a little hesitant to digitise elements of their care pathways and required more support in getting them on board. Chris and the team were very open about coming to engage with the teams, speak their language, share evidence and address their concerns. On that note, something that we have found useful recently is to bring in advanced clinical practitioners to help us get patients onto the virtual wards, because they speak the doctors’ language too. We’ve seen referrals go up, moving 12 new patients onto the virtual wards in two days with our ACPs’ help.

Securing clinical buy-in is very personality-based. You need someone very vocal who can drive it. A good way to approach this is to try and get one person on board, to win them over; and then you’ve got someone on your side who can help you talk to their colleagues. We’ve come a long way, so we now have specialties reaching out to us; when they do, I always ask them to give me a lead consultant who is prepared to put their name to it. I want their lead nurses on board, because if they aren’t that can be a major blocker; and I want the general manager to buy into the service too.

Abigail: With regards to implementing the virtual wards, it comes back to working as a team. We work closely with Cecilia, the implementation specialist at Luscii; she’s always at the other end of the phone, and we have meetings every other week to touch base. If we notice a problem or Cecilia does, this regular contact means it is dealt with before it becomes an issue. It’s all about communication. Also, when we build a programme ourselves on the digital platform, Cecilia will check it for us so there’s a sense of having a failsafe.

Chris: It comes back to having the right people in the room – clinical, operational, information governance, and everything else that needs to happen behind the scenes. If you want things to run smoothly, they have to be considered and engaged at the same time, from the offset.

Lessons learned

Fay: The main thing I would say, if I was speaking to somebody who was looking to set up this model, would be: don’t base your patient cohort on what is in the community. The community does a lot of work with long term conditions such a heart failure and COPD, but the statistics for COPD alone show that there is an increased risk of a cardiac event, for an acute virtual ward model it is important to recognise this increased risk factor.

Language is also very important. We had to be careful in how we communicated with our clinicians, with regards to the fact that people coming onto the virtual ward aren’t being discharged – they are being transferred, and if it’s not suitable, they can be transferred back. I think people can get fixated on the terminology used. When we changed our language just slightly, we got a lot more buy-in.

Abigail: When we started this project, we didn’t have a template from anyone else that we could follow. It’s a very different take on the virtual ward than you tend to see in other trusts. We have been learning as we go along and building an escalation pathway. We’ve had to ensure that everyone knows how to run this ‘new’ system even when Fay and I, as senior figures, aren’t there; that’s been a lot of hard work, and you really do need to have trust in your team. You also need to trust that your team will tell you when something isn’t right.

Chris: Some members of the Luscii team went to visit the staff at the virtual ward to see how they were getting on and it was lovely to see the nurses working in the hub, remotely monitoring patients. We chatted with them and something that struck me was how much the nurses were enjoying the work. They were pleased that it allowed them to be upskilled in different areas of nursing and practice. A lot of the time, if we hear about the NHS workforce it tends to have a negative slant; so it was really nice to hear them talk about how they genuinely enjoy doing that work.

Abigail: We do hear a lot of comments from our staff about how nice it is to video call the patients and check in on them. When you’re a patient on a ward, it’s very different now to how it used to be, particularly for the older patients when they look back on what they remember. The current pressures mean that it can be difficult for staff to stop and have a chat, but the virtual ward model allows that to happen via our video calls. Because we’ve got the time, the care becomes more holistic in nature – back to the principles upon which the NHS was started.

I’d also say there’s a learning around not generalising with age ranges. Our 80+ cohort is actually the most compliant on our virtual ward and we’ve often found that they enjoy using an iPad and remotely chatting with the team.

Measuring success

Chris: In terms of statistics, between October 2022 and October 2023, we’ve saved 1,521 respiratory bed days, which has led to cost savings of £532,000. We have saved 126 general medicine with cost savings of £441,000, and 174 haematology bed days which saved £133,000. On top of that, there have been 348 frailty bed days saved, resulting in savings of £121,000. 

Fay: We measure success in a few ways with our KPIs around quality improvement and length of stay, monitoring exactly as you would on an inpatient ward and taking into account family feedback, abiding by audits, and so on. Our official reports are on a monthly basis, but for Abigail and myself, we are tracking on a daily basis. As Abigail mentioned, we keep patient safety at the forefront of our mind; we monitor instances and near misses and look into trends and themes, as well as keeping an eye on risk registers and how we are managing those.

Abigail: It’s about the human factor too – we’ve had some amazing real life feedback from patients, for example telling us that the virtual ward has given them their life back and they’ve been able to spend quality time with their families instead of being long-term inpatients. We recently had a haematology patient who told us he loved it; he could have someone come and take his bloods without leaving his front room. Another patient, the oldest we have had on our virtual ward, was 103; he went home and we were able to give him two weeks of feeling well before he was palliated. It’s not all about everyone going home and living a wonderful life forever, because unfortunately, that’s not going to happen. Some of our patients are really sick. But we can give them that time with their loved ones, and at the end of the day, we are doing this for them. Yes, we cover all our governance and we make sure our KPIs are right, but sometimes stories from patients really remind us of why we are doing this. If they are telling us we are doing it right, then that means something.

Fay: We had another young patient with a haematology issue who was really poorly but wanted to self-discharge because he just didn’t want to be on the ward. We went and had a frank conversation with him, and his driver for wanting to leave was that he knew that he was dying and he just wanted to see his two-year-old’s birthday. We offered him care on the virtual ward and he got what he wanted. He had four weeks in our care and two weeks without medical care, and his children and step-children have those memories to keep.

Abigail: It’s the same for our older patients. So often, they just don’t want to stay in hospital. We facilitated an older patient today by getting in touch with her care home and asking if they’ll support us with her if we take her onto her virtual ward. They said that if we can get her oxygen and anticipatory meds, then they can care for her – so she’s going home. She’s 93, and she’s where she wants to be. That’s why we do it.

Chris: I think it comes back to the point Abigail made about the staff on the virtual ward getting the chance to deliver holistic care and get to know patients. Our ethos at Luscii is ‘space for care’ – that’s what we are trying to achieve. This is a really clear example of that.

Plans for the future

Fay: With our acute virtual ward model, I think the world is our oyster. We can go as far as technology can take us, as long as we keep up that patient safety. The more tech we can bring on board, the more risk we can potentially take.

I would like to build a reputation for our virtual ward, to continue to build on our clinical engagement, and to expand so we can bring in more patients.

My other aim is ‘joining up the dots’. Abigail and I both have a passion for accident and emergency care, and the staff in those departments are incredibly busy. Emergency care is completely different to general medicine; so why are we using ED for patients requiring medicines and surgeries? Why are we not joining up the dots and working with our community colleagues to bypass ED, so that they can focus on what they are supposed to focus on – delivering  accident and emergency care. If a patient is appropriate for a virtual ward, I want us to be a part of the chain of communication so that they come to us rather than bouncing between GPs and ED.

Chris: At Luscii, our vision is to facilitate this at ICS level, right the way across the system. We want to help join those dots. The flexibility of our platform enables different teams to work in different ways, with the possibility of creating protocols to suit each area. We want to help bridge the gap towards proactive healthcare, so we can put things in place for the next generation who are coming along and will otherwise face the same problems that we are facing now.

We are breaking barriers, slowly, but we are getting there. It is a real change and we need to keep thinking like that. Imagine in the future if we could close a ward and really do things differently?

Abigail: I would love to see our work develop into a blueprint for an acute virtual ward that other trusts can follow and replicate, wherever they are. A lot of work has gone into this, and compiling all of our knowledge and experience into one place would be really valuable.

Many thanks to Fay, Abigail and Chris for joining us and sharing their experiences.