HTN recently caught up with Fay Johnstone, acute virtual ward matron at Maidstone and Tunbridge Wells (MTW) NHS Trust, and Christopher Malone (Chris), commercial growth at Luscii, to discuss how tech is supporting neighbourhood health.
Chris shared his background, from his decade of experience as a medical negligence lawyer, to his role with Luscii actually solving some of the problems he encountered during that time. He explained the company’s decision not to follow a hierarchical structure, and outlined his recent transition from MD to work on commercial growth. “The way we structure ourselves as a company reflects in how we deliver to systems,” he considered, “because we work in quite a free way of pulling together operational teams that can work on digital transformation at scale.”
For the last several years, Chris told us how his focus has been on digitising healthcare pathways and delivering patient-centric care at scale. “From Luscii’s perspective, we’re trying not to be a tech provider that offers a bunch of digital tools and then steps away; we’re more like the infrastructure that sits between all the building blocks that make up the system. We need to be the cement that joins up different care pathways, and for neighbourhood care, it’s working to align those remote monitoring systems and looking at how we organise them locally.”
Luscii’s clinical-facing dashboard and patient-facing app cover multiple condition pathways, with over 150 different conditions, according to Chris, “as if you’re going to deliver any kind of virtual or hybrid model of care, you need to have a multiple condition approach. You could start with a general hospital approach, and then configure to fit with what systems themselves require.” The key is that flexibility Luscii can provide, he continued, in order to grant care teams the ability to organise themselves locally and design remote care around that.
Fay took us through her hybrid role as a matron, a GM, and the development lead for the virtual ward at MTW. “We’ve just won an award for our nursing model,” she said, “and I’ve got a very competent team, especially Abbi, who is my ward manager, maintaining the safety of that model.”
Commenting on how she came to nursing “quite late”, Fay shared that she quickly worked her way up, crediting her problem-solving attitude and ability to turn around challenging areas. “I was asked to set up the acute frailty unit at Tunbridge Wells, and then once that was on its feet I was asked to go to ED to try and improve performance there by looking at alternative pathways. Once that was finished, I reached out to one of our directors and asked to take over the virtual ward.”
When she initially took over, the virtual ward was mostly being run by the respiratory nurses, Fay said, “and it wasn’t taking any risks – it was more of a step-down model for monitoring patients in the background”. The goal she was given was to develop a model capable of releasing acute capacity, Fay went on, and that resulted in an acute virtual ward caring for patients who would otherwise be in hospital. “Thanks to the technology and the platform, we’re able to provide real hospital-level care, with acutely unwell patients being nursed at home. We reached out to our community colleagues to provide treatments for us, as there was no point in duplicating that service, and we’ve bridged the gap between acute and community.”
Reflections on the 10-Year Plan and neighbourhood health model
Chris considered how the 10-Year Plan “makes explicit what has been implicit for years” when it comes to neighbourhoods as a unit of care. “We’re still at the embryonic stage of figuring out what that looks like – the system offers the ‘what’, and it’s up to Fay and colleagues to look at ‘how’ to make it work amidst siloed working, financial structures that create contractual barriers, and data that doesn’t flow, preventing partners from working together at scale,” he said.
“It’s a good focus, but we shouldn’t lose sight of the fact that it’s system-wide working under a different name,” Chris went on. “It’s about population accountability, MDT working, and getting teams to structure themselves around a patient-centric piece of care, delivered at the right time, in the right place.” It then comes down to how best to support those teams, looking at how an acute trust can plug into a community trust, what happens when you add in a primary care team, and starting to measure outcomes. “It builds on what we’ve been trying to do for years, but gives a clearer focus and permission to organise care at neighbourhood level, and it does help focus those within a system to put some financial resources behind it,” he added. “Our job will be to test and evaluate that to enable that finance to become business as usual.”
“From a clinician’s point of view, this is exactly what we want; the barriers are the systems,” Fay acknowledged. “We’ve got platforms that we can use that can deliver it, but we’ve got so many different systems – that and getting people to think differently is the biggest challenge.” In essence, neighbourhoods is simply embracing more joined-up working, she continued, “and you might not be saving any money as such, but you will be releasing capacity somewhere else – it’s getting everyone to see the vision and being brave enough to try it”.
The biggest opportunities to come out of the neighbourhood conversation are the chance to look at working differently and the chance to start to think differently, Fay noted. “I think you can deliver hospital-level care at home, if we think outside of the box and stop thinking this is the way it has to be because this is how it has always been. When the NHS first started, who said we had to cohort all these sick patients? We used to deliver care in patients’ homes. The biggest block is winning those hearts and minds, and stopping medicalising conditions like frailty – growing old isn’t a medical condition, and we’re medicalising it.”
Chris highlighted the need to start with different pieces before plugging them together. “The acute was where we started, and then there was a bit of a step down into Kent Community Health and alignment with that community model; then if we plug in the primary care units we can start bringing in mental health, third sector, all the players that need to be in the room to surround care around the patient. Proactive anticipatory care is the big step at the moment, moving from reactive episodes into ongoing oversight of risk – that’s when Fay’s team gets that oversight from the tech, starting to understand where that risk sits in the system, so you can manage the clinical, operational, and all the things that need to occur to have a good hospital running process.”
Neighbourhood health in practice
“Patients don’t normally need one clinician, they need a coherent team around them, and whilst we’ve been working in MDTs for years, superpowering those with tech is exciting,” Chris told us. “If done with the right teams and the right pathways, remote monitoring can reduce unnecessary contact for patients, focusing attention only where it needs to be. We talk about providing space for care at Luscii, taking away a lot of the admin burden for clinicians and doing some of that heavy lifting, to allow time to care for the patients that really need it.”
Fay agreed about giving clinicians time back to care and removing some of the additional tasks that could be handled elsewhere. “Who said a nurse needs to do observations? As long as the platform is giving you that information, then your clinicians can be released. We’ve got one trained nurse to 20 patients, whereas on a ward it’s one trained nurse to eight patients – that nurse is now streamlined to focus on what they have been trained to do, rather than messing around with machines that aren’t working in the hospital.”
After considering lots of different platforms, Luscii was identified as being the one that best fit with the needs of the service, Fay explained. “If you’re looking for an acute model, it’s going to be Luscii, because it’s the most adaptable – it’s not just sticking an armband on patients and seeing how they get on – where there’s an anomaly, we’ll react.” Patients are actually asking to be moved back to the virtual ward, she went on, “and if we can use tech to fill the gap and stop patients ending up in ED, that’s what we should be doing”.
Chris shared that feedback from nurses has been positive, with those he spoke to highlighting upskilling opportunities and the chance to cover a vast range of conditions. “The biggest thing for us with Luscii is how adaptable the system is, because a lot of other virtual wards are very condition-specific,” Fay explained. “For me, it was the other way around. Let’s generalise it, general medicine, general surgery, general orthopaedics, then review those pathways to see what conditions we could home in on.” An example is haematology, she went on, “but general gives us the biggest bang for our buck because that’s how we’ve got so many patients out – if we were to do condition-specific we might only have three or four patients, but today we have 60, that would otherwise be in hospital”.
Learnings from the MTW implementation
What helped to get MTW’s implementation off the ground was her existing connections in the community and acute sectors, Fay advised, as well as the decision to start off with general. “We were constantly getting pushed toward heart failure, but when we went with a general approach, heart failure patients were the most risky, and represented some of the bad outcomes. That’s not to say anything would have been different had they been in an acute hospital, because we provided the same level of care, but it didn’t help with perceptions.”
Luscii helped build specific questions to support the consideration of what patients would be suitable for the service, Fay told us, which she considered had helped get the nurses to think about the condition, rather than just the patient. “For example, if a patient has COPD, and they’re on a COPD pathway rather than a COVID pathway, those questions will be different – you don’t expect a COPD patient to have stats above 88, so you wouldn’t panic, whereas if it was somebody with COVID you’re going to flag that.” Where there are conditions that continue to pop up, that’s when you have the opportunity to build more condition-specific pathways.
“When we came in as Luscii and looked at what Fay and the team were doing, we designed remote monitoring into the service, not alongside it,” Chris detailed, “and that’s how we got around structural challenges like funding flows, because that’s still one of the biggest blockers. The funding doesn’t follow the patient on their journey from acute to community or elsewhere. Some of its blocked by contractual walls – teams would like to work together, but those tend to stand in the way. Fay and the team have got a way of being able to smash those down, and that’s where they’ve been successful in increasing hospital avoidance, attacking that flow challenge, and so on.”
What would be a good next move would be to think about how to expand that hub and spoke model into a wider place-based approach in line with the neighbourhood health model, Chris stated, “and it’s about how we can really maximise those other teams that are out there in the community”.
Benefits realisation
Since the beginning of the implementation, the team has looked after more than 4,000 patients, according to Fay, none of whom have needed to go to a community bed because they have deteriorated. “With the acute, we’re counting benefits relating to falls, pressure, damage, mobility, and the KPIs that in hospital would point to good care,” she outlined, “and if anything that has shown that the virtual ward is a safe alternative, or even safer when you compare it to the performance of an acute ward in a hospital.” Work is underway with SBRI to illustrate benefits, she added.
Fay also shared an example of a patient story illustrating the benefits of the virtual wards approach: “We had a patient in haematology who was in his 30s, and who had been unhappy on the wards. He was coming to the end of his treatment, and he was aware that he was going to pass away. We asked him how we could help, and he said he just wanted to go home and see his daughter for her birthday, which we were able to help him do because of the technology and the model we’ve got. That just shows how powerful this model can be.”
An early evaluation recorded that 94 percent of patients reported positive impact on their wellbeing, and 91 percent valued being at home, Chris noted. “ROI is also what is going to be more significant to systems at the moment, and we’re working at about four-to-one or five-to-one value.”
The technology isn’t the service, it’s the coordination layer that allows multiple teams to act as one, Chris said. It offers a single source of truth to support decision making. “From our perspective, it’s about building something that’s trustworthy, that supports situational awareness of where patients are on their journey, and that allows for interventions to be made where needed. All those things appear with that level of technology and flexibility, added to collaboration and shared visibility.”
“The technology helps evidence our decisions and assessments as clinicians,” Fay explained, “because now we can present a week’s worth of observations and say why we have come to a certain decision for a patient and what they need next.”
Next steps
Fay talked about hopes of working more closely with Kent Community in the future, and encouraging a wider view of what services are available that can help to meet patient needs. “What a lot of patients need isn’t ED, it’s a geriatrician,” she said, “so they could be mapped into one of our SDEC areas or another appropriate service that already exists, rather than resorting to ED over and over again. I would like community to come on board a bit more, and I’d like people to consider using platforms like Luscii that are out there to help support them.”
For Chris, the outcome of the evaluation with SBRI will help drive direction of travel. “There’s a lot of uncertainty at the moment around ICSs, but as the dust settles, there should be a lot more understanding of how places will work with one another, and what potential there is for sharing wider hub and spoke models,” he noted. “I would like to see the hub that Fay has grown so far doing a lot more community sharing, step up, step down, plugging in pharmacy and primary care, and moving away from pathway-based remote monitoring to population-based remote monitoring, or population-based care.”
Chris also discussed Luscii’s new partnership with Graphnet around population health metrics and shared care records. “With that, we’re going to start looking at proactive care, and reaching in and pulling rather than it always being pushed. I’d also like to see us embed that remote care from frailty into long-term conditions and post-acute follow-ups a bit more widely. What a neighbourhood looks like will be defined over the next 12 to 24 months, and hopefully ICBs will put their budgets together in a way that allows them to do it effectively.”
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