For a recent HTN Now webinar on the role of digital in delivering neighbourhood health, HTN was joined by an expert panel including Fay Johnstone, acute virtual ward matron at Maidstone and Tunbridge Wells (MTW) NHS Trust; Mayur Vibhuti, chief digital, data and intelligence officer at Kent and Medway ICB and Surrey and Sussex ICB; and Saleem Haider, people participation lead for digital at East London NHS Foundation Trust.
Our panellists tackled key areas including national guidance and models, what “good” looks like for digital in neighbourhood health, challenges, approaches, and practical examples.
We started out with some introductions, with Fay telling us about her role as clinical lead for the acute virtual ward at MTW, overseeing 60 additional acute beds. “We’re slightly different, in that we don’t do step-up, step-down, like a lot of the models are doing,” she explained. “It’s literally that we care for patients in their own home with IT and the facilities to deliver care in that way rather than a traditional acute bed.”
“As people participation lead for digital, I have the unique privilege and honour of working alongside our service users so we can engage with them and bring them to the table when we’re looking at digital capabilities, ensuring their involvement from design to delivery,” Saleem told us. “And it’s been a fantastic journey so far.”
Mayur highlighted his background as a GP, and his prior role as CCIO for Kent and Medway ICB, up until taking on a new role as chief digital, data and intelligence officer for Kent and Medway as well as Surrey and Sussex ICB around two months ago.
The role of digital in neighbourhood health
Saleem talked about the wider context of digital and neighbourhood health, and the ambitions to engage on a deeper level with communities. “One of the things we’re finding is that different people have different definitions of what neighbourhoods are, and local authorities, the voluntary sector, and even trusts themselves are struggling with having that common view of a neighbourhood centre, a neighbourhood environment, and so on,” he said. “Moving forward, I think there’s more work to be done on agreeing to a common definition.” While there are pockets of good practice, they tend to be confined to environments that are much more coordinated already, he observed.
“From an ICB perspective, strategic commissioning means that you’re now commissioning for the whole population,” Mayur highlighted. “If I take Kent and Medway as an example, there are two million people there, and what we’re trying to do is link people up through their records, through a shared care record, and then run the Johns Hopkins risk stratification tool through that.” What that tool will do is assign every member of the population a score between 1 and 11, with 10 and 11 being more closely related with frailty, he shared. “When you drill down to the neighbourhood level, that enables that geography, which might be the equivalent of a PCN, a single neighbourhood, to be able to identify those people in their postcode, to decide how to deliver services that meet the needs of their population.”
Those needs can vary massively in the span of just five miles, Mayur continued, “so as well as having that data-driven information, it’s also important to communicate directly, listen to what people actually want, and that’s where our voluntary care sector organisations in that geography are helpful”. From a digital angle, giving everyone access to the population health dashboard, having tools like the Joy platform to provide a directory of services in the area, and having central hubs capable of directing healthcare services, whether they be step-up or step-down from hospital, is key. “People at the higher end of the score range are more likely to benefit from things like remote monitoring, and those at the lower end can probably be redirected to other services such as community pharmacy or general practice,” he noted.
Ultimately, it’s moving away from the organisational model of care, which sees people go to one organisation for one thing, and another organisation for something else; toward wrapping care around the person, according to Mayur. “Then, it’s reconfiguring the services and using technology to enable that care journey to be as slick as possible, with information moving with the patient, all the way from the NHS App being the front door, right back to the home clinical systems of the organisation, allowing everyone to see the same thing.”
Practical examples, challenges, and approaches
On how the virtual ward at MTW came about, Fay noted that she used to be a matron for ED, and during that time there were many patients she saw who were “acutely unwell but stable”. With that cohort of patients in mind, the possibility emerged that with the right coordination in place with community partners, treatment could be delivered in the home. “We monitor them using a digital platform, engage with ambulance crews, and provide things like oxygen weaning, antibiotics, for patients with a NEWS of 5 or less. We provide equipment so they can do their own observations, we have daily board rounds, and we generalised our ward, so we’re general medicine, general surgery, general orthopaedic – it’s more about that NEWS score and how acutely unwell they are.” When it comes to step-down, that’s where Hospital at Home comes in, and care is handed over, she added.
Sharing with us some details of a mental health neighbourhood clinic launched in East London as part of a national pilot, Saleem acknowledged that as well as being a space within the local community for people to visit that is better connected to GP practices, it has enabled much more of a hub for other periphery services to get involved with. “There’s a lot more collaboration and coproduction taking place, and it’s a great place to signpost people to available services,” he said. “As part of our digital inclusion activities, we’ve been training service users to become digital champions, and we’re starting to post them to local centres. We’ve just established a digital hub in the neighbourhood centre, which allows for much more personal support, and the relationship and trust that it has developed has been so invaluable – it’s moved from just helping people with their devices to much, much more.”
Thinking outside of the box has been central to overcoming issues around digital exclusion for the virtual ward, Fay detailed, with the team looking at things like asking relatives to help out with uploading observations, and purchasing tablet devices that can be sent out to patients who might not have a smartphone. “The only challenges we have now tend to be around borders, because KCHFT provide the treatment, and they have slightly different borders,” she said. “As far as the monitoring, we can monitor anybody, from anywhere; we can provide the doctor oversight anywhere; it’s the treatment that’s become the challenge for us. We’re hoping to get to a place where the systems follow the patients, rather than us trying to access different systems to get information we need – it still feels a bit disjointed at the moment.”
“We live in a world of workarounds in healthcare,” Mayur agreed. “Fundamentally, a shared care record is a workaround, because data doesn’t transfer between clinical systems, but we’re trying to make it a little bit more interactive in our system with ReSPECT forms and complex geriatric assessments that anyone in the system can do or add to.” The single patient record should help, he considered, as patients will be able to see their entire record through the NHS App. “That’s the cultural shift we’re moving toward, with people themselves as the holders of their record, and I think that’s all positive, the question is how we get systems to talk to each other in the meantime,” he went on.
“There is a role for suppliers in this, because sometimes they might not be very keen to have open APIs where they can exchange data with other systems, as they see the world in a competitive way, but I think there are two options: go for a bigger slice of the cake, or simply build a bigger cake,” Mayur considered. The way to move forward, he suggested, could be to let suppliers know that they are welcome to deploy their technology, but only if it can operate with existing systems that are already in place. “Over time, we will get there,” he said. “And ideally, if the single patient record gets there first, then that’s great.”
The role of tech and data
The systems and the processes are just not ready yet for people to be able to push information out, unless it is already defined within the clinical care pathway for remote management, such as with kidney dialysis, Saleem shared. Another key factor is that patient engagement platforms are still not rolled out everywhere, meaning that appointment management, which is one of the most important parts of accessing healthcare from a digital perspective, is still not nationally available. “Where that does happen, though, and where we see it baked into the existing pathway, we’ve seen some really positive results,” he added.
Fay’s team use what they call a “hospital in a box” kit that goes out to patients, with a blood pressure cuff, a thermometer, and a pulse oximeter. “We’ve got strict criteria, and I have Band 6’s that assess patients as having the capacity and ability to use the equipment that we’re giving them,” she told us. “We also get agreement from the patient that they will engage with the twice daily video calls, so we can get a visual on them.” If any issues arise whereby someone is not comfortable or confident using the equipment, nurses can be sent out to their home to do observations as an alternative.
Patients are able to send messages to or video call the team 24 hours a day via a digital platform, according to Fay. “We have patients asking doctors to go back onto the virtual ward – they don’t want to be admitted. There’s more I’d like to do to empower patients, and I think we should have leaflets and posters up everywhere letting people know this is an option, we have the same governance processes as hospitals, and so on, because overall we get very positive feedback.”
Mayur considered the potential for AI: “Everyone I speak to in the care delivery world says there’s as much risk now as there ever has been, because of the levels of waits we have and the levels of burnout in the workforce. For that reason, there’s arguably a huge risk in doing nothing, and not trying to figure out how to bring AI into the equation, as it’s happening all around us. We need to have good digital clinical safety and a plan for post-deployment monitoring, as the technology is moving so quickly.”
Public engagement work prior to a rollout of AVT highlighted that patients were largely happy for it to be introduced if it saved clinician time and gave them more face-to-face contact, on the basis that they knew what was happening with their data, said Mayur. Being transparent and explaining where AI is being used and what that is going to look like is important, he noted, “and that means that we as a workforce need to skill up in our own understandings”. The area for the biggest gain is probably in care navigation, he put forward, “and we currently do that with humans making a lot of decisions that maybe aren’t standardised across the patch, so from a productivity, efficiency, and patient satisfaction perspective, the best thing we could probably do is let people know where to go if they feel unwell, all the way through to getting an appointment booked”.
Whilst there is potentially an opportunity to integrate AI with the virtual ward, that would mean that it needs to grow, Fay explored. “Due to the acuity of the patients, we’ve got nurses there 24 hours a day, and if you wanted to reduce that oversight, then you’d need to have an element of AI to do the thinking for us, to have measures in place so certain things will alert a doctor or an ambulance straight away,” she said. “In a perfect world, where all the systems talk to one another and we’re completely digital, AI would be exactly like Mayur was saying, signposting and taking that patient where they need to go, almost like a filter system.”
There is a gap at the moment at the neighbourhood level relating to working cross-organisationally, Mayur observed, in terms of people from a community trust, district nurses, physios, social workers from the local authority, and those in general practice. “There’s no piece of software that enables all of those people to be able to work together, unless they’re physically co-located, which in some geographies will be difficult and not very efficient,” he shared. “Companies out there are trying to fill that gap and plug into our existing clinical systems in order to give a neighbourhood view, and then thinking about how we can message each other rather than filling out referral forms, having lots of duplication, for something that would have been a ten-second conversation.”
Looking ahead
Neighbourhood health is about having relationships where they are required by people needing continuity, Mayur continued, and working together for those cohorts across the patch. Some kind of solution is required to help join up that care, he suggested, “and shared care records don’t quite do it, because you can’t communicate person to person, and it’s bit of a space race at the moment in terms of who is going to get there first with the best solution”.
There are two main things that need to happen to drive neighbourhood health forward, according to Saleem: improving workforce digital skills and patient participation. The digital academy is making progress, but that needs to come to fruition and enable new technologies coming through to be pulled, as opposed to pushed through, he said. On patient participation, there is a necessary shift that needs to happen in changing culture toward seeing patients as partners and drawing on their lived experience to help get things right the first time. “Patients are a huge advocate in supporting what’s taking place in your local healthcare organisation, and that information will diffuse naturally into the local community,” he shared.
Current metrics for measuring success are currently too clinically or condition focused, Saleem continued, but there is the potential to enhance things like PROMs and PREMs. “Digital inclusion is struggling in the sense that we should be growing out of simply finding how many people are on digital inclusion programmes, and moving toward impact and health outcome-based development,” he noted. “What I would like to see is us collecting information about digital confidence or NHS App use in our demographic data – just by doing that, we’d be able to see who should receive electronic letters, who might benefit from the virtual ward like Fay’s doing, and who may need additional support.”
Reflecting on her experience of setting up the virtual ward, Fay told us that winning hearts and minds across the organisation was “the toughest challenge”. Getting clinical engagement and buy-in was helped along by the trust’s chief executive and medical director, who could push the idea from the top down, and two senior nurses. “We were literally going in there and going head-to-head sometimes with consultants, because the knee-jerk reaction was always to consider what happens if a patient dies,” she said. “It was trying to say, that outcome may not change, but it doesn’t mean that has to happen in hospital; it means we can provide the same level of care in the patient’s own home.”
Getting patients on board relies on a nurse-led model, Fay went on, “and if we were completely reliant on referrals we’d be sitting on about 12 patients, because it’s about our clinicians having the knowledge of what alternative services are out there”. Future plans include developing a referral form for alternative pathways. “I also was responsible for creating our acute frailty unit, so I knew that data was a massive thing for doctors, which inspired us to record key things like length of stay, but also how long it took for us to get a patient back if they deteriorated, so we could prove it was just as quick, if not quicker, in facilitating those patients that do deteriorate.”
Mayur considered the potential for the use of AI in automating patient assessment or first point of contact, noting the nationally outlined role of the NHS App as the digital front door to the health service, and the possibility for a solution to run through that to integrate and book appointments in the right place, or provide advice. Post-deployment monitoring and having a feedback loop in place will be essential for that, he said, “because otherwise how will we know if the AI is giving bad advice?”. A good example of this is the pilot of an AI triage tool in Sussex, which was integrated into the NHS App and reduced phone queue volumes by 29 percent, he pointed out.
Key takeaways
“I’d like to build on what Saleem has been saying about not doing enough co-design with people,” Mayur stated. “We’ve got a fragmented system, and everything that is set up is designed around an internal process, not to help people move through the system, so just by reaching out to people and finding out what is working for them, and what isn’t, using an iterative quality improvement methodology we could see where those little bits are we can change to make things better.” It’s also important to share that information collected back out to people, he considered, “because quite often we ask people questions, then never get back to them on how their information was used to make things better, and it’s that whole loop we don’t do very well”.
“I’m old enough to remember that this neighbourhood direction we’re going in is something we already had in the past,” Saleem reflected. “When I was younger, we had local clinics or centres we would go to, and we as a community used to be really familiar with what was available locally.” We need to focus on raising awareness of what is available, consulting with local authorities to see how they can be part of that development, he continued. “As Mayur’s already highlighted, the development of a co-production group and their collaboration would be a huge enabling part to that, as well.”
Relying on patients to complete questionnaires to get feedback on the virtual ward resulted in poor uptake, Fay told us, and building that into the discharge process worked a lot better. “The nurse will be there to ask patients for their feedback, any improvements they think we could make, and we take that away and see whether there’s anything we can home-in on,” she said.
“Everything that we do regarding patient feedback is mainly singular patient, periodic feedback,” Saleem shared. “What we can extend that to is peer-led conversation, and that will energise the topic much more. That should be developed as a continual exercise, so we get that continuity, we get more people involved, and we see the confidence grow within that group.”
We’d like to thank our panellists for taking the time to share these insights with us.
