Acute Care, News, Population Health September 12, 2022

Virtual wards are failing patients and clinicians: we must bridge the gaps before winter

By Elliott Engers; Tom Whicher; Elina Naydenova

With virtual wards vital to the NHS’s ability to function this winter, three experts assess what is needed to bridge the gaps in provision ahead of increased demand.

In early August, NHS England unveiled its new plan to increase the NHS’s capacity and resilience ahead of winter’s inevitable pressures. An increased use of virtual wards featured prominently in this plan, in line with their national target of 25,000 virtual beds to be operational by 2023.

With hospitals overwhelmed like never before, it’s not hard to understand why transferring patient care into the home – in a safe and controlled way – is an extremely beneficial proposition. But existing solutions are missing the mark. Despite much innovation, delays in adoption mean that the full transformative potential of the tech-enabled hospital at home has not yet been realised. We are now at a tipping point: on the heels of a global pandemic and one of the busiest summers yet, a tough winter is looming. It is time to get virtual wards right; for patients, for healthcare professionals and for the NHS.

Existing solutions don’t go far enough

‘Virtual wards’ are not new and versions of the concept – including ‘Hospital at Home’ – are already being used to support unwell and deteriorating patients to stay at home, as well as to discharge patients from hospital sooner.

What is generally considered to be a virtual ward often extends to little more than remote monitoring at home. While this does free up hospital beds, the impact on both clinical time saving and patient outcomes falls well short of potential.

This is because, overwhelmingly, staff must use old, inappropriate tools to manage remote patients – tools that weren’t built for this new paradigm. Many approaches are manual, slow, admin-intensive, and not advanced enough to scale.

New ways of working need new solutions

Remote care requires an entirely different way of working, and needs new technologies to manage it and make it scalable. Right now, communication and the flow of critical information is blocked. Electronic task lists and care coordination features are not flexible enough to fulfil the unique needs of virtual wards, where patients are not co-located with healthcare staff. Integration is near non-existent, and workflows are not built for mobile access, nor do they allow tasks to be allocated and tracked in real-time.

We must go further for patients or clinicians. A true virtual ward solution can do more – should do more – to protect patients and make clinicians’ jobs more manageable.

Creating a true virtual ward

If virtual wards are to be done correctly, and their potential fully realised, innovation and action must focus on six areas:

1. The right information at the right time

For virtual wards to save valuable clinical time and ensure high quality care, data generated in patients’ homes must be of equivalent quality to that captured in hospital. It should also be distilled into actionable insights to save clinicians from filtering large amounts of data. And here lies the problem.

The 2019 Topol Review emphasised that large volumes of unfiltered data can be immensely overwhelming for an already overworked workforce. We know that conventional remote monitoring generates noisy data that wastes clinical time and can mislead clinical assessments, introducing risk.

To overcome this, advanced tools are needed, such as those utilising AI, to take on the time-consuming task of reviewing millions of data points to ensure quality and translate data into insights.

2. Seamless patient engagement

Patient engagement tools must be a core component of virtual wards, ensuring patients have a positive experience and feel confident that they can contact the clinical team if they need.

Good patient engagement provides a seamless experience whether a patient is co-located with clinicians in an acute hospital setting, or in the community.

Patients should receive ad hoc or scheduled contact via a method that suits them. This could be a digital assessment form sent to the patient, providing a low cost but highly effective method that complements data gathered from remote monitoring devices.

Patients should also be able to easily request a phone, video, or in-person appointment at a time that suits them.

In combination with care coordination and remote monitoring tools, effective patient communications are a powerful way to keep patients safe and them and their families reassured.

3. Proactive rather than reactive management of health

Moving from reactive to proactive management of patients’ health means two things for virtual wards:

Firstly, care must be targeted to patients pre-admission to hospital instead of post-discharge. This means initiating virtual care in the community to minimise the risk of admission, especially for ambulatory care sensitive conditions. More importantly, when it comes to avoidable admissions to hospital and frail patients, this could prevent a deterioration in their condition, which could happen off the back of a hospitalisation and could cost them their independence.

Secondly, mechanisms must be in place for early detection of deterioration. Therefore, being able to identify early signs and intervene before complications and readmissions to hospital become inevitable.

4. Health equity by design

The pandemic has revealed the multi-layered inequities that impact healthcare access and healthcare outcomes. One way in which virtual wards must address these is by investing in scalable community workforce models – that include healthcare assistants – to support care delivery to patients who cannot self-administer.

A second way to promote equity is by ensuring that no one is digitally excluded due to, for example, poor WiFi connectivity or lack of digital confidence or capability. Equally important is to look beyond physical symptoms to integrate social determinants of health into the modelling, planning and delivery of virtual wards.

5. Effective skill-mixing and empowerment

Enabling a diverse network of multidisciplinary staff to participate in the delivery of virtual wards is critical to resourcing these new models of care without adding to doctors’ and nurses’ workloads.

From healthcare assistants, to patients, to their friends and family members, different stakeholders should be empowered to fuel a proactive model of care at home. This includes training, decision-support tools and streamlined workflow management – and requires tools to handover and assign the right tasks to the right healthcare professionals – to cover the effective identification and appropriate escalation of health issues.

6. Effective task management

The best outcomes from virtual wards will result from multidisciplinary staff having secure access to a shared list of patients and the tasks that need to be done for them. They should be able to review the list in virtual ward rounds or whenever required, add and allocate tasks, and mark them as accepted, in-progress, or completed for colleagues to see or track. The entire team ought to have visibility and be able to collaborate and coordinate care remotely, ensuring caseload management is efficient and safe.

Automated workflows can make it easy for staff to identify where readings from intelligent remote monitoring devices fall outside of set ranges, supporting safer and more effective clinical decision-making.

Enabling a new era of care delivery

At this moment, NHS organisations have a unique opportunity to begin the virtual wards roll out on the strongest possible footing, with the best solutions in place. A focus on the six pillars that encompass care coordination, patient communication and remote monitoring, will accelerate a successful transition to a new era for care delivery, and help establish virtual wards as a credible, scalable alternative to acute hospital admissions.

Elliott Engers is CEO at Infinity Health.

Tom Whicher is CEO at DrDoctor.

Elina Naydenova is CEO at Feebris.

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Post-pandemic decrease in prescriptions could be leading to avoidable deaths

By Rusheen Bansal

Medicines used to treat serious and long-term conditions are not being prescribed as often as they should be following the pandemic, raising fears that this could be causing avoidable deaths from heart disease and strokes.

New analysis by Analytics firm Lane Clark & Peacock (LCP) LLP, of almost 9 billion prescriptions dispensed by pharmacies in England between 2017 and 2022, has highlighted that blood thinners and hormone treatments for cancer are among the medicines that have seen a marked decrease in prescriptions since Covid hit.

Blood thinners reduce the risk of blood clots and can prevent strokes, but prescriptions are 5 per cent lower than expected, meaning more people could be having avoidable strokes.

Prescriptions for hormone treatments for certain types of breast and prostate cancer are also 4.4 per cent lower than expected, which could be the result of delays in diagnosing people with cancer and starting them on treatment.

Dr Ben Bray, Principal in the Health Analytics team, commented: “We know that heart disease and stroke deaths were the largest contributors to excess deaths in the community for men in 2020 and the changes that we are seeing in prescription patterns could explain why we may be seeing more people dying from these types of diseases. Trying to tackle the backlog is a mammoth task for policymakers, but data like this is crucial to making sure the right patients and issues are targeted.”

Some medicines have seen an increase in use such as treatments for coughs and respiratory diseases – potentially related to the treatment of the symptoms of Covid or Long Covid.

Industry expert, Dr Deborah Layton, PhD FRPharmS FISPE, Director PEPI Consultancy Limited, UK, said: “No-one can deny that the impact of the pandemic on provision of healthcare has been profound. In brief, the results demonstrate a surge in prescribing of medications for symptomatic relief of relatively minor (acute) respiratory conditions and health supplements, with a concurrent decline in prescribing of medications for chronic disease.

“The authors also report that these changes have not returned to pre-pandemic levels. Whilst this elegant study illuminates changes in health service provision arising during the pandemic, it does not necessarily imply a causal relationship. Nevertheless, studies like this inform us further of changes in services, particularly in primary care that we are now just getting to understand.”

Innovation uptake in West Midlands reduces A&E visits from care home residents by 30%

By David Duffy

The West Midlands Academic Health Science Network (WMAHSN) has released its 2021-22 Impact Report, highlighting the innovative solutions that have contributed to improving health and generating income growth across the West Midlands, and nationally.

Key achievements outlined in the report include a 30 per cent decrease in A&E visits from care home residents, across the West Midlands, as a result of the spread and adoption of deterioration management tools such as ‘Stop and Watch’.

Over 1,255 West Midlands care homes engaging in the test and adoption of deterioration management tools to improve safety for care home residents. More than 1,365 patients in the region are also benefiting from the prescription of PCSK9i inhibitors, a revolutionary medicine that helps lower cholesterol.

About the West Midlands Academic Health Science Network

The WMAHSN is one of 15 Academic Health Science Networks (AHSNs) across England and plays a pivotal role in ensuring innovations are shared faster regionally, nationally and internationally. Its goal is to make the West Midlands healthier, more productive and deliver the best possible clinical outcomes for patients.

AHSNs connect the NHS and academic organisations with local authorities, the third sector and industry, and create the conditions to facilitate change across health and social care economies.

Over the last two years, the organisation has grown to support the efforts around delivering its strategic programme themes, which includes cardiovascular disease prevention, mental health resilience, and workforce innovation and transformation.

The new report highlights the WMAHSN’s ability to adapt and pivot its services to address the region’s shifting needs and priorities, including supporting the region’s response to the pandemic. This not only demonstrates its ability to remain agile, but also how the organisation is uniquely placed to support the needs of its partners and future proof the region’s healthcare sector, for years to come.

Tony Davis, Director of Innovation and Commercial at the WMAHSN, said: “It is our mission to transform health and social care through innovation. Therefore, it is inspiring and positive to see organisations across the region adopting these innovations to respond to our complex health, and social care system.

“In collaboration with partners, and organizations around the West Midlands, we intend to keep strengthening our ability to work nationally, regionally, and locally, and maintain the environment we have helped create to improve the overall health and wellbeing of our communities.”

As the WMAHSN approaches its tenth birthday in 2023, the organisation continues to aid local health and care systems, looking at how its workforce supports NHS England and NHS Improvement, and the Office for Life Sciences priorities, ensuring that patients in the West Midlands have access to the best health and care services.

Other key highlights from the WMAHSN Impact Report includes:

Four providers in the West Midlands have adopted HeartFlow, a non-invasive, cardiac test for stable symptomatic patients with coronary heart disease. Over 5,000 scans were performed nationally during last year led nationally by the WMAHSN.
A 30 per cent decrease in A&E visits from care home residents, across the West Midlands, as a result of the spread and adoption of deterioration management tools such as ‘Stop and Watch’. Over half of care homes (63 per cent) in Staffordshire and Stoke-On-Trent have fully adopted the deterioration management tools.
The creation of the QI Notify-Emlap application and a pilot scheme in partnership with The Dudley Group NHS Foundation Trust. The app supports clinicians to use their National Emergency Laparotomy Audit data more efficiently to drive their emergency laparotomy quality improvement work. Early results from the pilot suggests regular usage could reduce ‘Door to Theatre’ time.
Promoting alternative forms of treatment to those from an ethnic minority background, living with a learning disability or autism with the STOMP project. The project aims to reduce the over prescription of antipsychotics, often oversubscribed to these groups, by increasing medication reviews.

To read the full impact report, visit the WMAHSN website.

Experts urge NHS to leverage position as England’s largest employer to help fight health inequalities

By Integrated Care Journal

Public Policy Project’s ICS Network has urged the NHS to leverage its position as England’s largest employer and to realise its potential for social and economic rejuvenation.

The calls came at a recent webinar, where PPP and ICJ released the latest findings from the ICS Futures roundtable series. The series saw ICS leaders from across the country convened for three Chatham House debates to identify challenges and opportunities in integrated care, to scale best practice and provide ongoing practical advice for system leaders and care providers. The series ended with an open webinar discussing the Next steps for integrated care.

The webinar was held to coincide with ICSs taking statutory footing on July 1st, and was chaired by Matthew Swindells, Joint Chair of West London’s four Acute NHS Trusts & former Deputy Chief Executive of NHS England. Mr Swindells was joined by Dr Penny Dash, Chair, NW London Integrated Care System, Paul Maubach, NHS Midlands’ Strategic Advisor on ICS Collaboration and Laura Stamboulieh, Partner, Strategic Advisory for Montagu Evans.

The role of the NHS

There was a particular focus was on the role of the NHS itself in tackling the wider determinants of health. One lesson from the pandemic that was learnt across the country was the impact of low trust – particularly among more deprived areas of the country. As is well documented, vaccination rates were significantly lower in parts of the country relatively high on the deprivation index, and these sectors of the population tend to have poorer health outcomes more generally.

“Part of the problem is not employing people from those areas”, suggested Paul Maubach, contending that a lack of representation from these areas has contributed to low trust of authorities and public services, healthcare included. It was agreed that choosing to adopt more proactive and inclusive recruitment strategies would align with the wider agenda to address and reverse health inequalities.

The need to differentiate between health inequalities and healthcare inequalities was also a central topic of the session, particularly in view of what the NHS and ICSs can feasibly impact upon. Many drivers of poor health are deeply rooted in socioeconomic trends far outside the purview of health and care professionals, but there is much that can be addressed in the short term with the right focus and the right policies.

For example, one of the greatest drivers of poor health in later life are educational outcomes. In turn, a crucial indicator of lower educational outcomes in the future is poor oral health at the age of two, so ensuring better access to NHS dentistry among more deprived cohorts would allow those more at risk to be identified, engaged, and supported by their local health and care systems, as well as improving access to dental services themselves.

This area of discussion highlighted one crucial, but often overlooked point; that all health and care services are interconnected, and ultimately, are trying to achieve the same outcomes. Part of the role of ICSs, therefore, is to create a culture where all stakeholders collaborate to achieve this shared goal (improving population health).

To this end, Dr Penny Dash argued the importance of those on integrated care boards (ICBs) having clearly delineated areas of responsibility and accountability, to create clarity over how different parts of the system fit together and to ensure that decision making does not become bogged down in bureaucratic hierarchies. “If you can’t answer the question related to your remit, you shouldn’t be at the table.”

The importance of data was emphasised throughout the session – both from a population health management perspective, as well as the effective planning and monitoring of estates and facilities.

It was posited by Laura Stamboulieh that “the role of the estate as an enabler is often overlooked. The ultimate delivery of ICSs will rely on a well-developed health and care estate.” On this point, it was noted that NHS estate planning has evolved little since the introduction of digital healthcare and the increase in remote working. As such, an updated, modernised approach to estate planning will be essential to delivering effective, integrated care, at scale.

Community Diagnostic Centres: A critical response to regional inequalities

By Niamh Macdonald

The latest report from Vanguard, Assessing the current state of play of CDC delivery across England, 2021, provides much needed clarity on the current status of CDC rollout and identifies where more support is required to achieve regional equality in healthcare provision.

The backlog in patient care is affecting every region across England, with waiting lists at an all-time high and services struggling to keep up with demand. Community diagnostic centres (CDCs) were earmarked by Sir Mike Richards as a necessity across communities to support quicker and safer access to both elective and diagnostic procedures in 2019.

A few years and a global pandemic later and the need for streamlined diagnostic service provision is now greater than ever.

An additional layer to the elective care crisis is the disproportionate impacts being felt across England; while no region of the country has been left untouched by the crisis, some are clearly being affected more severely than others. The approach to delivering CDCs is also disjointed across regions and their respective integrated care systems (ICS).

To deliver high-quality diagnostic care in the face of the backlog, a joint up and co-ordinated approach is vital. The latest report from Vanguard, Assessing the current state of play of CDC delivery across England, 2021, outlines the findings of a Freedom of Information (FOI) research project, undertaken in 2021. The findings of the report not only provide a bigger picture on the current status of CDC rollout but also identifies where more support is needed in order to achieve regional equality in healthcare provision.

Compounding inequalities

Health inequalities have been widening across England in recent years and these societal fault lines were underscored by the impact of Covid-19. There is currently a gap of almost 19 years in healthy life expectancy between the most and least deprived areas of the country. Further still, during the pandemic average life expectancy fell for the first time since 2000.

Higher rates of Covid-19 were concentrated in the most deprived areas of England, intensifying pressure on the hospitals and care services within these regions. This has caused patients living in these areas to suffer the greatest disruptions to elective care services.

According to evidence submitted by the Health Foundation to the House of Commons Health and Social Care Committee, patient treatment completion in the most deprived areas of England has fallen by 31 per cent, while completion fell to 26 per cent in the least deprived areas. Regional inequalities are only set to widen as the effects of the pandemic continue to impact patient waiting times.

“A joint up and co-ordinated approach across England is vital to minimise the disruption to services and reduce the patient care backlog.”

Targeting inequalities with CDCs

The Vanguard report, Assessing the current state of play of CDC delivery across England, 2021, provides an overview of current CDC delivery across England. The region with ICS, STP and Clinical Commissioning Groups (CCGs) that are farthest along in their delivery strategy is the Southeast. A high proportion of respondents reported to have a strategy in place and expect their CDC to be fully operational in the next three years. The Southeast also had the highest proportion of respondents that identified CDCs as a high spend priority.

Contrastingly, just one-third of respondents in the West Midlands identified CDCs as a high spend priority. Furthermore, the West Midlands region has the highest waiting lists for all procedures in England, accounting for 20.5 per cent of all national waiting lists as of July 2021. It is evident from the current picture of CDC roll out that more regionally tailored support is needed to level out delivery across the country, ensuring that the impact of CDCs is maximised.

Central to the CDC ‘mission’ is to minimise regional inequalities by supporting the delivery of integrated care, helping to join up disconnected patient pathways and bring services closer to the communities that use them. It is hoped this will expand capacity and improve access to care. By increasing the capacity to tackle waiting lists, the successful implementation of CDCs could help to reduce healthcare inequalities and disparities in patient outcomes.

Lindsay Dransfield, Chief Commercial Officer at flexible Healthcare Spaces provider, Vanguard said: “CDCs are an essential component to reducing patient care backlogs, creating more accessible healthcare for individuals in more deprived areas.

“Following the recent government announcement that £2.3 billion is to be spent on increasing diagnostic activity across the UK, it is now more important than ever to reduce regional health inequalities through the introduction of more CDCs.”

Fair access to funding

While the Health and Care Levy, introduced in September 2021, provides significant funding for tackling waiting lists and elective care backlogs, there remains significant challenges in ensuring equitable distribution of funding. For CDCs to be rolled out with more consistency across England, the government must ensure that regions are able to fairly access funding and support. There is currently a lack of clarity across ICS/STP/CCGs around how decisions are made to allocate funding, this lack of guidance is detrimental to regions already being impacted by higher waiting lists and capacity issues.

The Vanguard report recommends that the government and NHS “remove bureaucracy in the national procurement process to ensure CDC delivery is accessible for all bodies involved with the ICS”. Unnecessary bureaucracy in the procurement process has cost and time implications for healthcare providers, in some cases making it impossible for them to undertake the application process.

On top of reducing bureaucracy around funding, the report recommends putting in place regionally ringfenced budgets for CDCs that are calculated based on a number of indicators, such as waiting lists, current budgets, staffing requirements and available land. This will ultimately help to provide a more consistent approach in the roll out of CDCs and subsequently generate fairer patient outcomes.

A co-ordinated approach

Central to the NHS Long Term Plan is the goal of delivering fully integrated community-based healthcare. To achieve this, the Vanguard report demonstrates the need for a clear framework for CDC delivery to provide clarity across ICSs. A joint up and co-ordinated approach across England is vital to minimise the disruption to services and reduce the patient care backlog, but the benefits must be felt equally. With the most deprived areas of England facing some of the harshest consequences of the pandemic, the roll out of CDCs is an important step in ensuring accessible and equal healthcare.

The Vanguard report recommendations include:

Put in place clear, accessible national funding streams in order to secure confidence in CDC delivery and enable the development of long-term, futureproofed plans.
Ringfence central Government funding for CDC delivery per region, assessed on a range of factors (such as number of patients, average time for delivery of care, number of ICSs in region) to ensure the roll out of CDCs is fair and serves to actively reduce regional inequalities.
Develop localised awareness and education programmes for ICSs to ensure all bodies involved with CDC delivery are aware of the opportunities available to them in terms of funding, partnership opportunities and have access to necessary additional support to ensure the success of CDC delivery.
Broaden the national awareness of regional health inequalities and provide additional support and resources, beyond funding alone, to regions suffering from covid-related backlogs to better prepare them for future incidences of heightened pressure and to prioritise patient outcomes.
Remove bureaucracy in the national procurement process to ensure CDC roll out is accessible for all bodies involved in the ICS.
The Government and NHS should actively identify appropriate infrastructure partners who can rapidly design, build and commission appropriate high quality, safe clinical infrastructure and develop a register of verified infrastructure delivery partners to ensure CDC delivery is consistent on a national scale.
Develop a sustainability guide for CDC delivery to help the NHS reach its goal of Net Zero carbon by 2045.
Promote Modern Methods of Construction (MMC) for CDC delivery to transform existing facilities and create purpose-built new estates that have the flexibility to be re-purposed and expanded upon, enabling a rapid response to changing demands and enabling ICSs to build out there CDC in a modular fashion to tackle patient waiting lists.

Clarifying the metrics: A true picture of system wide activity

By Maria Kane

Maria Kane, Chief Executive of North Bristol NHS Trust, addresses the need for defined and aligned metrics to provide one overall picture of system wide activity and reveal where improvements can be made.

Every acute trust is facing three challenges: the elective care debt, urgent care recovery and an exhausted and depleted workforce. With Integrated Care Systems (ICSs) on the horizon, we have an opportunity to step back and look at the bigger picture to see where we can make system improvements to meet these challenges and add value to the patient, public and taxpayer.

However, it is difficult to understand what is going on in any given health and care system. This is because the finance framework and metrics currently available are not defined or aligned enough to help determine the exact value (cost and outcome) of activity the funding is producing.

A clear picture of each health system

Each ICS will be responsible for allocation of funding at system level. The aim is to distribute resources according to population need and to help reduce health inequalities. However, all payment systems are complex and to ensure the right calculations for payment of care and enable health systems to provide the right care in the right places, it is vital to have access to the right sources of data. Where patient-level data is limited, this can impact on how system budgets are allocated.

Currently, trusts are operating with a mixed economy of block and activity contracts. Most of these are now block contracts since Covid-19 began, but there are also have large numbers of individual providers on specialist and general contracts, which makes it difficult to see the big picture. Specialist contracts, for example, can cover wide areas which makes it harder to pin down what is happening in each ICS. Operating with a variety of contracts like this can create significant challenges when trying to set out a whole system budget.

A greater understanding of each system

ICSs provide the health system with an opportunity to clarify and get on top of the metrics and to have a single interpretation within each system. This will allow the scope to broaden and incorporate areas such as mental health.

Giving full responsibility of finances to ICSs and enabling them to operate the whole budget will bring many benefits and allow good population health management. However, there needs to be a shared understanding of how local services are run to ensure all areas of the system are given adequate funding. All members of the ICS need to understand how each part of the system works and it is crucial that financial decisions are based on a sound knowledge of the challenges across the whole system.

Bringing together sources of data from across community, primary and acute care can help to provide one overall picture of how the system is performing. Data can highlight where funding needs to be focused to help create change, improvement and the best patient care, as well as being able to highlight areas where proactive care can start to make a difference, but the finance framework and metrics need to be tackled first.

Capita Healthcare Decisions have been at the forefront of tackling the challenges within healthcare systems for over 27 years. To find out more visit: https://capitahealthcaredecisions.com/