For a HTN Now webinar discussion on scaling health technologies we welcomed Clair Scaife, nurse/AHP clinical lead with the service improvement team at Sheffield Children’s NHS Foundation Trust; Annmarie Grogan, clinical and palliative lead nurse with the children’s community nursing team at The Rotherham NHS Foundation Trust; and Riccardo Arduini, head of clinical effectiveness at Livi.
Our panel shared their insights and experiences with scaling health technologies, with Clair and Annmarie taking us through their journey to date in the virtual wards space, and Riccardo offering his perspective as both a former paramedic and from his current role working to implement Livi’s solutions across the NHS.
“Livi is part of the wider Kry group, covering four European countries,” Riccardo told us, “and in the healthcare space we work with insurance providers, with the NHS providing consultations, and we also offer pay-as-you-go services for the public.” As head of clinical effectiveness, his remit extends across performance from both business and clinical functions.
Annmarie talked about her role as clinical lead nurse for the children’s community nursing team, recently being involved in a pilot delivering a virtual ward providing hospital-level care to children and young people in Rotherham. “We do that through remote monitoring, with digital platforms and clinical oversight,” she stated, “our pilot is run alongside the pilot at Sheffield Children’s, where ours uses a step-up approach with remote monitoring for GP referrals to a virtual ward rather than to a hospital.”
As a paediatric nurse working as a clinical lead in the service improvement team, Clair’s role is delivering projects with clinical staff around improvements, mainly on patient flow, and currently virtual wards. “We’re part of a pilot that has been funded for a year, and since we provide both acute and specialist services, our model is slightly different to Rotherham’s, but we’re working together in key areas. Ours is haematology and oncology for our paediatric children and young people, for febrile neutropenia and some other pathways about to launch.”
Digital and legacy systems, data sharing
A key challenge has been around the interface of digital with the old systems, requiring work on integration, Clair shared, so making it easier for colleagues has been a focus. “There are also challenges with different systems at different times, but if we stay focused on our children and families, keeping children out of hospital and at home surrounded by their families, siblings, and so on, it’s about what is best for them.”
Annmarie discussed digital variation and how often, GP practices don’t have the right interface to be able to work with the team on the pilot. Data sharing is another big challenge, she went on, “and we’ve found it fairly challenging initially building up those relationships, especially with the GPs, and getting them to have trust in a different process, rather than sending to hospital straight away”. Informing them of the clinical oversight and emphasising that those cared for on the virtual ward do actually come under the care of acute paediatricians, has helped.
From Livi’s perspective on integration, Ricardo shared how one of the main things Livi has been working on over the last 12 months has been the development of an electronic medical record (EMR), that allows the sharing of patient details with the NHS or insurance partners. “That should improve our services, so when patients see a different clinician or come through a different pathway to us, everything is in one place, but from a tech point of view, integrating with other EMRs is not always easy.”
Having “excellent clinical assurance and a quality assurance team” that audit all of that work goes a long way toward resolving these challenges, according to Riccardo. “That has meant we can do the auditing and then see about adoption and gaining access from there.”
Measuring progress and success
Clair’s team is working with the region’s acute federation, a research study with an interim report expected at the end of October. “That is qualitative and quantitative data, asking questions to our workforce and our families about what it means to them,” she said. “That will help inform our business case going forward, and what approach we will take. Some of those challenges with clinician involvement, from a cost saving as well as benefit, it’s really important to try and get that down, which can be difficult with tariffs and funding, etcetera, but it’s not something that can’t be achieved.”
Scaling up would potentially add more value, but doing that would require consideration of the workforce and who will be involved, Clair considered. “Currently, we’re working with more specialist services, so when we look at when and how we scale up, it’s about who will be looking after the patients and what skills they have, as well as whether it can be funded.”
The number one measure of success should always be patient satisfaction, Riccardo said, followed closely by clinician experience. “If clinicians aren’t able to deliver a good service, that then impacts the patient, as well, so it’s making sure they have the tools they need. Measuring success through different partners can be difficult, because in our own EMR service we set targets internally on things like turnaround times, we have external targets with the NHS, and then our insurers tend to set the most stringent targets.”
Availability is key across all areas, making sure appointments are available when needed, “and that’s something we strive to get better at all the time”, Riccardo added.
“We had to make progress really quickly, because in hindsight, we might have introduced virtual wards at the wrong time,” Annmarie explained. “In paediatrics, we have a spike in winter admissions, and we went out with the respiratory pathway when we first launched in March, only to learn that referrals were in decline. We quickly introduced new pathways, went into gastroenterology, and then to general paediatrics, so the launch of the three pathways has been very successful.” Similarly, GP onboarding started slowly, but the team now has six GPs with a plan to have another ten by the end of October.
What change is needed to support the scaling of digital projects?
Getting buy-in from everyone is something that needs to happen to help drive digital projects forward, Riccardo considered, “and we’ve all had to adapt to a lot of changes since COVID, it’s now become more of a part of the day-to-day”. Securing that buy-in from a government level all the way to the higher levels of NHSE, and being able to adopt different ideas, will be key to a change moving forward.
“I think what I’ve learned over the past two years with virtual wards is that it’s often the people that don’t know enough about it that you need to get on board,” Clair noted. “Our families are keen, on the whole, it can often be the clinicians, but I find once they’re using the systems and can see the value in it, that makes it easier.” It’s also about value in monetary terms and the difference it’s going to make, and integration is key to make it easier and better for all involved, she added, “and that isn’t an overnight success, it needs hard work, but if it was easier to integrate we’d all be doing it”.
Annmarie highlighted the importance of changing the culture away from hospitals being a building, and getting the acceptance that the care can be given in a different place, or a different way. “For GPs, when it came to the initial buy-in, we presented at the GP forums, and we analysed the data of children’s assessment unit referrals and the highest GP practice from Rotherham referring in to the unit, then targeted them. With the funding we got, we asked them to be involved in the pilot, and let them know there would be a sum of money available for them to do that.”
Adapting to suit different patient needs
Clair talked us through adapting to different patient needs, and the role of culture and data in helping to tailor services to suit patients. “I did an audit with our bed managers last winter, with six weeks’ worth of data for our children from a general paediatrics point of view, with a length of stay of three days or more. I thought we would be doing something similar to Annmarie, but what we ended up doing because of nurse-led discharge and other flow projects, was to focus on specialties.”
That approach then scaled-up an idea, Clair continued, “because that team were really happy, and what we did changed based on the result of our data”. It’s important to have support from clinicians, nurses, and AHPs, but patient experience needs to be looked at more, in terms of what opportunities there are out there. “Having a goal is really important, and regionally we would love to scale this up.”
For Livi, different approaches are required when it comes to working with NHS organisations versus insurance partners, Riccardo told us. “With our NHS partners, we provide a hard booked appointment list for clinicians, which works well. For our insurance partners, we found the best way for our clinicians to be working there was a bookable drop-in flex model, with a pool of all of our GPs, and when an appointment is due to start it falls into the bucket of the next available GP.” That makes sure appointments start on time, and that that availability is always in place.
To run this model also depends upon Livi’s “fantastic analytics team”, Riccardo went on, “who work on forecasting for all of our different service lines”. At the beginning of the day, the team can look at inflow from the previous day, or what has come in already, and move some things about to better manage demand. “From a GP’s perspective, very little changes, they might just be seeing NHS patients rather than private patients,” he added.
Lessons learned and looking ahead
For Riccardo, the biggest lesson learned has been around working collaboratively, “bringing different teams together, taking those ideas that one person might have had, and giving people the opportunity before we start to move forward with anything, to talk about potential blockers, commercial viability, operational constraints, and so on”.
Livi’s tech teams have built an AI system which helps clinicians focus on patients, Riccardo shared, it’s in a “very small” pilot phase at the moment. “The next step for us is looking at triage tools, trying to find the right person for the right patient. We’re now taking on ACPs that are working really well within our different service lines, and we have physios, and we’re looking to adopt secondary care providers as well. The idea is that there’s a continuation of care and we can work with the best providers to offer that care.”
“I agree with Riccardo, but also, it’s keeping your workforce engaged, the nursing teams, the people on the floor delivering the pilot,” Annmarie commented. “It can be difficult to keep the momentum going – we had a gap with few referrals, and staff were left wondering how to get more of them, but it comes back to regular engagement and regular teaching.”
In Rotherham, the team would like to focus on offering a more equitable service and getting that out to all children and families in the area, rather than just selected GPs, Annmarie said. “We’d also like to increase beds, because we started with five, and to have that larger capacity would be great – feedback from families has been really positive, and I was skeptical about putting digital monitoring into homes, but the reassurance that it gives to families has been one of the greatest bits of feedback. It’s giving them more control and empowering them to monitor their own children, and they’ve also got it 24 hours per day.”
The immediate future for Clair’s team is the go-live of the next pathway in haematology oncology, which is due to launch early in October. “As Annmarie said, it’s then about having more beds, more resource. The pilot is showing some really positive things, but we want to be able to increase our beds for the right patient cohorts. Adults are generally ahead of us, some paediatric services are ahead of us, but we are doing well. I’ve just proposed a three-year plan with key stakeholders together, and it’s having that buy-in and support from the locality and the region in the current climate, but it’s an exciting prospect.”
We’d like to thank our panellists for taking the time to share these insights with us.
