The lockdown narrative unravels: what future for integrated care?

By Professor Terry Young, BSc, PhD, FBCS

As the Deputy Prime Minister announces ‘a package of measures to ensure the public receives the best possible care this winter and next’ (DH website), it’s worth asking what happened last winter and the one before.

In the wake of the government’s announcements, and as integrated care systems (ICSs) inherit the delivery mantle, we have missed an opportunity to find better solutions. We were too reactionary, we relied on too narrow an expertise base, and we lost sight of the wider picture.

So, what happened? The initial narrative was that we played a poor hand rather well. Some politicians complained about groupthink and then economists questioned the benefits of lockdown. Recently Lord Sumption went further: “Ministers and scientists responsible for a policy that has inflicted untold misery on an entire population naturally find it hard to admit they may have been mistaken… The official narrative is beginning to unravel.”

While attention has focused on the politics, what of the guidance? In three articles written under the fog of crisis, I made observations that matter less for placing blame (we’ll blame whom we want to, anyway) and more for the future. The fears and guesses that drove lockdown will skew our chances of making ICSs work unless we can look away from politics and generate better guidance.

In Coronavirus and the model (Mar 19, 2020), I hoped that advice might be based on models that optimised the mix of testing, tracking and even vaccination and that priced the options. I noted that UK policymakers had a poor track record with this type of model, and so it turned out. We have some of the best modellers in the world across our campuses, yet only a minute fraction of this resource was funnelled into the logistics of outpacing the virus nationally or building a balanced strategy. Today, the ICS challenge of care for all at unprecedented scale and responsiveness will require new mixes of behaviour, drugs and technology.

In Coronavirus: what’s up with our experts? (ICJ, Aug 2020), I noted the dangers of appealing to but a single type of expert and called for wider pools of expertise before we threw our supply chains overboard and trashed our schools to keep the ship of state afloat. It didn’t seem like rocket science at the time, so it is surprising that it has taken nearly two years to challenge openly the full devastation connected with such a policy. In a similar way, ICSs can only work by building wide collaborations if people are to thrive after episodes of care or avoid such episodes altogether.

In Algorithms of destruction? (ICJ, Nov 2020), I contrasted two worlds driven by algorithms: home shopping that grew vibrantly and education and health that struggled. Simple examples explored how the findings of models require interpretation before we act. The comparison with today’s ICSs is obvious: we’ll need great algorithms wisely applied to deliver.

Data quality was a continual bugbear: the NHS is an excellent emergency service and is developing as a promoter and supporter of lifelong health. However, it is ill-equipped to provide real-time data in a worldwide crisis against a constantly evolving adversary. So, where does good data come from?

Modelling options is our only choice when the future is unutterably new and unbearably complicated. Even an all-embracing programme of research could never have worked. It needed a more agile and creative approach. One strategy lay in creative gaming between teams of modellers generating solutions with their predictions while others countered or triangulated evidence from measurements. Instead, a lot of local data was wasted.

The pandemic was an opportunity to put simulation to hugely effective use. Never before had we possessed such tools or so diverse a set of skills. Balancing epidemiological predictions against employment needs and the economic good of the nation – not to mention treatment against prevention – while designing new mechanisms for care delivery, was never going to be easy but it was possible at last and at scale.

Early evidence that models repay us handsomely started to emerge under lockdown (see this HSJ article or this academic paper). The problems facing ICSs bear similarities to those that drove lockdown – urgency, risk of meltdown, complexity – while the increased backlogs and blockages still put the poorest and oldest most at risk. Worse still, we are broke.

Very, very recently, in a university near, near at hand, someone has modelled what you need to square the circle with effective blends of expertise and predictive models for a better service that won’t unravel this winter or next.

MIRACL announces new partnership with Birmingham Women’s and Children’s NHS Foundation Trust

By Integrated Care Journal

MIRACL – the world’s only single-step multi-factor authentication provider – announces their new partnership with Birmingham Women’s and Children’s NHS Foundation Trust.

With a new directive from NHS Digital to ensure multi-factor authentication (MFA) across IT services within the NHS, MIRACL was perfectly placed to deploy their single-step MFA system in these world- renowned hospitals.

Time is of the essence for all those working in the NHS, so finding a MFA solution that was efficient yet provided the additional layer of security that was now required and, at a cost that met the tight NHS budget, was a challenge. Medical records are highly sought by cyber criminals so any data held by the hospital is always incredibly vulnerable and must be well protected on every level.

MIRACL was able to integrate their single-step MFA codelessly, in just fifteen minutes – minimising disruption to services during the implementation phase, yet providing an added layer of IT security across the organisation. With thousands of users within the Trust accessing IT services on a daily basis, the transfer happened seamlessly and without any unwanted hiccups.

Furthermore, as a passwordless solution, staff weren’t tasked with having to remember yet another password or have to share biometric data. A simple four-digit PIN is all that is required – the patented tech does the rest.

David Marshall, Head of ICT at Birmingham Women’s and Children’s NHS Foundation Trust, added, “numerous staff throughout our sites are having to access NHS IT on a daily basis, but time is always of the essence and it is essential that not only is all data kept safe and private, but staff who need to access information can do so instantly and securely. It was no surprise when we were required to add multi-factor authentication to our systems but finding a solution that would fit our needs was a challenge. MIRACL has provided a single-step MFA that does not require a password and has integrated into our systems seamlessly.”

Rob Griffin, CEO at MIRACL commented, “when we were advised that NHS Digital were directing hospitals to install MFA, we knew our solution was perfect. MIRACL provides MFA, yet requiring just a single-step to use, means that staff can access the IT services as they were before and without the need to remember another password or have a second device at hand to authenticate by SMS. We all know that staff are often working at a high pace across the NHS, so sourcing a solution that did not waste precious time authenticating was really important.”

Since deployment of the service in mid-April, there have been a total of 150,000 authentications and only 283 failures or a failure rate of only 0.18%.

MIRACL is the world’s only single-step multi-factor authentication provider. It can easily be integrated into current company and NHS platforms and is a low cost verification option but with banking level security. It boasts clients such as Experian, Domino’s and Cashfac and has been licensed by big tech names such as Google and Microsoft.

For further press information, interviews or photography please contact the MIRACL press office: sarah.sawrey-cookson@miracl.com | 07765 110438

New report calls for changes to systems leadership in healthcare

By Dr Axel Kaehne; Dr Julie Feather

A team of researchers have produced a landmark rapid review of systems leadership in healthcare, concluding that the NHS must better define what it needs from its leaders to address emerging challenges and policy changes.

Systems leadership in the NHS in England focuses on leading beyond organisational and professional boundaries to implement policy changes and meet budget requirements. However, despite increased recognition, there is no commonly agreed definition of what NHS systems leadership entails.

The NHS Leadership Observatory commissioned a team of researchers led by Dr Axel Kaehne and Dr Julie Feather from Edge Hill University’s Evaluation and Policy Unit to undertake the review of systems leadership, with support from Professor Naomi Chambers and Professor Ann Mahon from the Alliance Manchester Business School at the University of Manchester.

Their report has identified that the NHS lacks a clear definition of what systems leadership means and what qualities NHS leaders need to fulfil their roles. It recommends carrying out further studies to close these gaps and write a clear definition for NHS leaders to adhere to.

Postdoctoral Research Fellow Dr Julie Feather, who is part of Edge Hill’s Evaluation and Policy Analysis Unit, said: “Systems leadership refers to leadership attributes, qualities, behaviours, mindsets and actions which have a system-wide impact.

“This complex set of skills is essential in the modern NHS, but our report identified that leaders in the NHS don’t fully understand their role or the importance of being systems leaders which must be urgently addressed.”

The review is set against a policy background of the formal establishment of 42 Integrated Care Systems (ICS) across the NHS in England in July 2022. These are partnerships between the organisations that meet health and care needs across an area, aiding in cooperation and planning.

The creation of ICS means that more than ever NHS system leaders are required to have the skills necessary to steer and manage dynamic transformations across organisations. Adding to this is the need to balance longer term system sustainability with the reality of limited resources, all while improving population health outcomes and tackling health inequalities.

Existing NHS policies and research do not offer any generic set of skills for this type of work.

Reader in Health Services Research and project leader Dr Axel Kaehne added: “Our report identifies the complexity of being a systems leader and calls for further analysis to determine what training and development will be needed to ensure NHS leaders are properly supported to be able to steer and manage change in an increasingly unpredictable external environment.”

Professor of Health Leadership Ann Mahon from Alliance Manchester Business School said: “One of the important findings of our review was an almost universal absence of research on equality, diversity and inclusion as a critical perspective on the development of effective system leadership either from the workforce or the community perspective. This is a serious gap in the research that needs to be addressed.”

Other recommendations in the report include examining the needs of systems leadership within the context of the newly developed Integrated Care Boards; exploring how Equality, Diversity and Inclusion (EDI) can be embedded into business as usual through the lens of systems leadership; and explore how leaders can embrace technological advances.

The full report can be accessed online.

Dr Axel Kaehne is Vice President of EHMA – European Health Management Association

Dr Julie Feather is a qualified and registered social worker and a Postdoctoral Research Fellow in the Evaluation and Policy Analysis Unit at Edge Hill University.

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.

GHM Care messaging app integrates with digital care management platform Nourish Care

By Integrated Care Journal

Advancements in nurse call technology unearths a wealth of valuable data for care homes when surfaced alongside daily care records.

GHM Care has announced their flagship nurse call messaging and reporting tool Nexus will now integrate with Nourish Care’s digital care management platform. The ability to integrate personal care records with a nurse call system is a huge step towards a joined-up care environment.

Nexus is a messaging platform that delivers nurse call alerts directly to the smartphones of carers, improving staff efficiencies and response times.

The integration with Nourish will allow Nexus users to link nurse call activity against a resident’s personal care records, driving a greater resident experience through interoperability. Care teams will have complete transparency of the time of the day calls are being made, time of acceptance, reason for the call and the resolution times. This information surfaced alongside daily care records offers contextual oversight, further promoting better care decisions and outcomes. In addition, the integration will enable care teams to run detailed reports and populate care plans within Nourish.

Care homes will benefit from a more comprehensive picture of the personal care provided through more powerful data.

Neil McManus, Managing Director of GHM Care stated: “It’s been great working with Nourish on this project and now we can deliver exactly what our joint customers have asked for. The new functionality has been launched in response to the needs of care homes who previously would not have the time or capacity to record every nurse call alert in a resident’s personal care records. As a result, there is often a disconnect between care records and nurse call activity. The new integration overcomes this by automatically updating Nourish personal care records with any associated nurse call activity.”

Steve Lawrence, Head of Proposition and Partnerships from Nourish Care added: “We are thrilled to be partnering with GHM Care, their leading nurse call solution will open the door to new and exciting data insights when surfaced alongside daily care records housed in Nourish. I look forward to seeing the positive impact this delivers for care teams and those they support.”

Training & Development Lead, Luke Annetts, from Blackadder Corporation said: “I think the integration between Nexus and Nourish has worked well, the information transfers quickly from the Nexus cloud onto Nourish. I think that this information will be really helpful for reporting purposes, especially when we look at accidents/incidents and response times”.

Nourish Care is an app-based care management platform that allows care services to record at the point of care, streamline administrative processes and equip teams with the tools to provide more person-centred care and improve outcomes for the people they support. Nourish works with more than 2,500 care services in the UK and overseas within residential homes, nursing homes, learning disability services, mental health services, and other care settings. Nourish was one of the first recognised as a NHS Transformation Directorate Assured Supplier for the Digital Social Care Records (DSCR) DPS at launch and were also the first accredited by the PRSB as a Quality Partner, working to promote best practice standards for care.

To find out more about how Nourish can help your care service, visit their website www.nourishcare.co.uk to book your free demo today.

To find out more about Nexus by GHM Care, visit www.ghmcare.co.uk.

Health worker sexual abuse reporting site launched

By Integrated Care Journal

Women in Global Health launch #HealthToo Project today, a platform to compile reporting of sexual abuse of health workers.

Sexual Exploitation, Abuse and Harrasment (SEAH) is a considerably under-reported form of violence healthcare workers face, according to Women in Global Health, an organization that campaigns for the protection of women workers in healthcare settings.

“There is a huge gap in data and research related SEAH in the health and care sector from all regions, with the most serious absence of data is in low- and middle-income countries, where women are reportedly the most affected, ” said Dr Magda Robalo, Global Managing Director, Women in Global Health.

A majority 62 percent of 330,000 health workers across a range of countries reported exposure to work related violence and harassment (WRVH) in a single year, according to the Journal for Occupational and Environmental Medicine. But this data is not disaggregated to separate the SEAH component.

In response, Women in Global Health launch today a new platform and research project entitled “#HealthToo”, to seek, compile and document stories from women health workers who have experienced work-related SEAH. The platform is open for individual story contributions from September 5 to November 30, 2022. By submitting their stories anonymously, women will be able to share their experiences freely without risking job security or personal repercussions in their place of work.

Rarely discussed, under-reported

Currently, a large percentage of women in the global health workforce face discrimination, bias and sexual harassment in their work. In some countries, women also experience WRVH either on the way to work or when engaged in community outreach.

The causes vary: many women face unprotected exposure to sexual and violent acts because perpetrators remain unaccountable in work settings owing to a lack of legal and policy frameworks, poor or no follow up, under reporting due to fear of retribution or issues around standard of proof. Other factors have also contributed to the abuse, including women’s segregation into lower status roles, systemic bias and discrimination in the health care sector.

In several contexts, particularly low- and middle-income countries, there is no legislative framework in place to support gender equality at work and no laws to prohibit and punish sexual discrimination and sexual harassment at work.

“Work-related SEAH in the health workforce is an extension of the gender-based violence against women and girls that we witness every day, and in the vast majority of cases, it is perpetrated by male colleagues, male patients/clients and male members of the community,” said Dr. Robalo.

“The presence of women at all levels…makes an immediate difference.”

Dr Magda Robalo, Global Managing Director, Women in Global Health

If not acted upon urgently and consistently, such acts create unsafe and toxic work environments that affect retention of women staff, reduce their physical and mental health leading to increased healthcare costs and a reduction in the quality of care provided.

By addressing the root causes of gender inequity in the health and care workforce and challenging the power and privilege afforded to men, Women in Global Health aims to contribute to the overall reduction of workplace SEAH in global health and therefore strengthen health systems.

This should be backed with concrete action by decision makers to put appropriate laws and policies in place, including ratification and implementation of the International Labour Organization Convention 190 (cILO 190).

“There is no single pathway to solve sexual exploitation and abuse but the presence of women at all levels from leadership down, coupled with adequate laws and policies makes an immediate difference by creating a conducive, motivating and empowering work environment free of such abuse and discrimination,“ said Dr Robalo.

Social care: a sector now in perpetual crisis

By Rusheen Bansal

Association of Directors of Adult Social Services reports dramatic rise in numbers of those seeking review or start of social care provision.

The number of people awaiting review of current provisions, start of a service or direct payment for social care, has increased by 37 per cent from November 2021 to April 2022, according to a count carried out by The Association of Directors of Adult Social Services (ADASS) in 83 councils.

Almost 300,000 people are waiting for an assessment of their needs by social workers, an increase of 90,000 (44 per cent) in five months. One in four has been waiting longer than six months. At this rate, the number waiting can hit 400,000 by November 2022, a two-fold increase from last year.

While demand for care is expected to increase in line with winter pressures, peaking around January and dropping in the spring, the findings from ADASS suggest that the typical ‘cycle’ of system pressure is changing, being replaced by a state of perpetual crisis.

To the outside observer, those stating that social care is in crisis may sound like a broken record. For years now, however, stakeholder groups and think tanks have been warning that crippling staff shortages, precarious pay, working conditions and insufficient funding had left a system on its knees, even before the Covid-19 pandemic hit.

A shrinking (paid) workforce

The crux of the issue is relatively simple, if not profound in scale – as Cathie Williams, ADASS Chief Executive put it: “the big reason why almost 40,000 people are waiting for the care and support they need to actually start is that care providers simply do not have the pairs of hands they need to sustain services.”

A recent PPP report, The Social Care Workforce: Averting a Crisis, quotes a 2021 survey of 2,000 social care services undertaken by the National Care Forum (NCF) that reveals how 74 per cent of providers have experienced an increase in the number of staff leaving since April 2021. Indeed, the vacancy rate for care home providers has nearly doubled in the last year, from 5.9 per cent (in March 2021) to 10.3 per cent (in May 2022).

The NCF survey also states that 50 per cent of those leaving highlighted stress as the main reason for their departure, with 44 per cent citing poor pay. Due to poor retention of the social care workforce, existing employees are experiencing an increase in workload that has not been accompanied by an increase in pay thus far.

Care workers are paid a median hourly rate of £9.50, in line with the National Living Wage. However, a high proportion of these workers are employed on zero hours contracts – 41 per cent of social care workers in London are on such contracts. To that end, social care professionals often leave the sector for less demanding and/or better paid jobs such as retail roles or jobs in the NHS, where similar skills are often more appreciated and rewarded.

ADASS has discovered a similar pattern – almost seven in ten ADASS members surveyed said that care providers in their area had closed or handed back contracts. Many more said they could not meet all needs for care and support because of providers’ inability to recruit and retain staff. The implications of this are significant. When people’s needs are unmet (or unknown), this can place a sizeable burden on their lives and on the lives of unpaid carers who may feel obliged to step in. Indeed, over the last ten years, the number of young people aged 16-25 in England and Wales providing unpaid care to family and loved ones has risen to approximately 350,000.

“The picture is deteriorating rapidly”

Councils are simply overwhelmed. The ADASS Spring Survey found that most councils were facing an increase in numbers of people seeking support: 87 per cent said more were coming forward for help with mental health issues, 67 per cent reported more approaches because of domestic abuse or safeguarding, and 73 per cent reported seeing more cases of breakdowns of unpaid carer arrangements. In addition, 82 per cent of councils were dealing with increased numbers of referrals of people from hospitals and 74 per cent were reporting more referrals or requests for support from the community. To that end, the Health Foundation has estimated that an additional £7.6 billion will be needed to meet demand in 2022/2023.

Sarah McClinton, ADASS President, commented: “These new findings confirm our worst fears for adult social care. The picture is deteriorating rapidly and people in need of care and support to enable them to live full and independent lives are being left in uncertainty, dependency and pain.”

In September 2021, the government announced a new ‘Health and Social Care Levy’, effective April 2023 onwards – a 1.25 per cent increase in National Insurance contributions from employed people as well as pensioners. Yet, now more than ever, policy experts recommend that financial planning and smart allocation, elements that have been lacking in the past, are required to reap the maximum benefits from this additional funding. The Levy, which will aggregate to £5.4 billion over three years, has been reported to fund necessary reforms in the social care sector such as improving staff training and recruitment practices, initiatives for mental health well-being and new avenues for career progression. Yet, many regard this amount as insufficient – according to The Health Foundation, a further £7 billion will be required every year to tackle demographic and inflationary pressures and to increase staff pay.

While it is true that the COVID-19 pandemic significantly worsened the social care crisis, it is only one of the many crises that have exposed and underscored the foundational instability of this system. Since the 2016 Brexit vote, for instance, the vacancy rate of social care workers has increased year-on-year. Prior to this, 1 in 20 social care workers were EEA migrants, and since more than 90 per cent did not have British citizenship, many had to leave England. To mitigate concurrent widespread resignations, the government announced a Health and Care Visa that would help fast-track visa applications for those in the healthcare sector. However, care workers are not categorised in the list of eligible jobs.

More than 600 people are joining waiting lists to be assessed for care and support in England each day. Resolving issues other than funding are key for the successful integration of social care into effective healthcare. Greater efforts should be made for recruiting and retaining social care staff, especially younger people, by improving the pay, workload and working conditions in the sector. Otherwise, broken record or not, the system is in danger of collapse.

New research finds recruitment crisis threatens to undermine virtual ward revolution

By Integrated Care Journal

Nearly half of NHS Trusts need to recruit new roles amid sector-wide staffing crisis to enable the effective operation of Virtual Wards.

Freedom of Information Act data obtained by digital health technology provider, Spirit Health, has revealed the scale of the recruitment crisis that threatens to undermine the delivery of NHS England’s virtual ward ambition.

Spirit Health collected data from 107 NHS Trusts across England and found that 40 per cent need to recruit additional staff to support the delivery of virtual wards. The NHS is increasingly pivoting to virtual wards, which are intended to allow people to receive care outside of hospital settings, whether at home or in domiciliary care facilities. The Covid-19 pandemic saw the NHS establish COVID Virtual Wards, and their success has prompted a renewed ambition for their widespread use outside of treating Covid-19.

The acceleration of digital expansion plans is in response to NHS England’s recent mandate for all NHS Trusts to offer 40 to 50 virtual beds per 100,000 population. This ‘comprehensive development of virtual wards’ comes at a time when hospital waiting lists are exceeding 6.6 million, with the Health and Social Care secretary demanding radical action to avoid a winter crisis.

Of Trusts needing to recruit, a third (32.6 per cent) anticipate making appointments across up to three roles, while some Trusts have stated that they expect to recruit new staff in as many as seven different roles before launching a virtual ward.

Of the 31 Trusts that subsequently provided a breakdown of the roles they intend to hire, 84 per cent anticipate hiring Secondary Care Practitioners (such as consultants, therapists, advanced clinical practitioners, and nurses), with a further 29 per cent seeking primary care practitioners (such as GPs and pharmacists). The projected influx of specialised staff underscores the scale of this initiative – and the recruitment challenge that threatens to undermine the successful rollout of virtual wards.

The impact of workforce challenges on the expansion of virtual wards has been felt directly by Spirit Health’s clinical monitoring team. In recent months, its in-house team has experienced an uplift in the number of requests for flexible clinical support to Trusts to deliver digital programmes and help them onboard staff. This latest research comes after a recent report by the Health and Social Care Select Committee which suggested more than 475,000 NHS staff will be needed by early 2030 to deliver vital care, throwing into question how NHS Trusts plan to recruit and retain key staff.¹

Healthcare authorities hope that the deployment of virtual wards will significantly reduce these pressures by combatting staff shortages and minimising lengthy discharge times. Initial pilots of the programme have offered promising results already: virtual wards have been proven to deliver a 40.3 per cent reduction in the average length of hospital stay and a 50 per cent reduction in re-admission rates.²³ Likewise, Spirit Health’s CliniTouch Vie platform has seen a 67.5 per cent reduction in unscheduled emergency admissions.⁴

The NHS’s adoption of digital healthcare services is also likely to be motivated by the economic benefits of these proven efficiencies. Virtual wards are expected to save the NHS up to £4,000 per patient stay, whilst CliniTouch Vie alone is predicted to save the health service more than £500,000, by building on the successful virtual ward pilot operation it ran to support Leicestershire Partnership NHS Trust.⁵

These significant savings will go a long way in supporting the NHS workforce of the future – with funding being freed up to be reinvested in both the upskilling of the current workforce and enlistment of new staff to further ease the current strains on the health system.

Speaking about the recruitment crisis that is threatening the implementation of virtual wards, Dr Noel O’Kelly, Clinical Director at Spirit Health, said: “Virtual Wards offer a lifeline to enable the continued delivery of first-rate care and be a strong addition to face-to-face services, which have struggled to keep pace with the current workforce challenges and lengthy patient waiting lists across the health sector.

NHS staffing shortages threaten to undermine the exciting opportunity that virtual wards bring: digital healthcare technology cannot support patients without the necessary specialists to operate it. These findings echo the frustrations that we hear from our partner trusts, who are reporting that workforce challenges are hindering efforts to scale this technology achieve its full potential. We must urgently demonstrate the capacity of this technology to ease pressures for the stretched workforce, and thus attract fresh talent to support its delivery.”

^{1 https://committees.parliament.uk/publications/23246/documents/169640/default/}

^{2 Swift, J. et al, 2022. An evaluation of a virtual COVID-19 ward to accelerate the supported discharge of patients from an acute hospital setting. British Journal of Healthcare Management, 28(1), pp.7-15.}

^{3 NHSX. 2022. Remote monitoring for patients with chronic conditions in the Midlands [online] Available at: <https://www.nhsx.nhs.uk/covid-19-response/technology-nhs/remote-monitoring-for-patients-with-chronic-conditions-in-the-midlands/> [Accessed 25 January 2022]}

^{4 Ghosh S, O’Kelly N, Roberts EJ et al. Combined interventions for COPD admissions within an urban setting. BJHCM: 2016;3:122–131.}

^{5 A successful pilot of virtual wards for COPD, Heart Failure, and Covid-19 across LPT produced savings of £529,719 for the health system.}

Health Inequality, Thought Leadership August 22, 2022

A case study in effective integration: the Staten Island PPS

By Joe Conte

Collaboration, trust and community engagement will be central to successful long term reform of health and care. This is no different in the USA.

The pandemic provided many lessons, not least of which was that the health system could quickly pivot to less costly telehealth, digital and virtual care. For over two decades, these services were available but adopted reluctantly and not well capitalised upon.

One reason is that healthcare is faced with the inherent conflict between investment in bricks and mortar, and a model of care that is more patient-centred and community-based. The US model of care is heavily invested in expensive infrastructure and its healthcare bill is nearing $4 trillion, almost double the per capita cost of other industrialised nations. Despite this extraordinary expense, quality outcomes lag global norms, as does US life expectancy.

Delivery System Reform Incentive Payment programme

According to Forbes, US expenditure on healthcare is expected to be nearly $6 trillion by 2027. The redesign of healthcare is a matter of national importance, not just because of cost but the health disparities resulting from it. One strategy is the focus on moving from volume to value, as Michael Porter advocates in his book, Redefining Health Care.

The Delivery System Reform Incentive Payment (DSRIP) was designed to improve clinical quality while reducing costs and promoting the transition from volume to value. In April 2014, the Center for Medicaid/Medicare Services (CMS) approved New York State’s (NYS) Medicaid redesign waiver, known as DSRIP, in the amount of $8 billion over five years. To earn the maximum $8 billion valuation, performance on specific, pre-set quality and utilisation targets needed to be achieved with a focus on incentivising value. The waiver permits states to use Medicaid funding in ways not specifically authorised in Federal rules so that innovative strategies may be deployed to test new models of care using non-traditional services.

“Community engagement, trust and collaboration were keys to the success of the PPS programme.”

Joe Conte, Executive Director, Staten Island Performing Provider System

To achieve rapid change and capitalise on innovative strategies to affect nearly six million Medicaid recipients, NYS approved 25 provider networks, spread throughout the state. Known as performing provider systems (PPS), they were geographically disparate, with vastly differing population health needs and provider capacities. Their potential individual earnings over the five-year programme ranged from $45 million to $1.2 billion. Staten Island PPS (SI PPS) charted its own unique course improving population health outcomes while creating significant changes in the health care dynamic of the community.

Staten Island PPS background and programme description

Staten Island, with a population of about 500,000 is one of the five boroughs of NYC, with more than 30 per cent of the community covered by Medicaid. The SI PPS is a network of 70 medical, behavioural and social service providers, nursing homes, federally qualified health centres, primary care practices, and faith-based and community-based organisations. When the 1115 Waiver opportunity (which typically reflect priorities identified by the states and the federal Centers for Medicare and Medicaid Services) was presented to the community, great interest was demonstrated. The two major hospital systems were the anchor organisations.

According to New York State Department of Health, SI PPS funding was set at a valuation of roughly $208 million based on projects selected and clinical performance variables. Partner organisations attended facilitated workshops to analyse population health data to select 11 programmes (see table below) from among 50 offered. Over the course of a year, the process contributed to a sense of inclusion by the stakeholders and ownership of the implementation strategy devised for each of the programmes.

Table 1: Initial SI PPS Projects: 94,505 patients actively engaged (click to enlarge)

Table 1 illustrates the projects selected by SI PPS and the number of lives that needed to be “actively engaged” to achieve improvement goals. Each year, performance requirements and the number of lives increased and performance targets were reset based on prior year achievements. Certain indicators identified as critical to a programme’s success were associated with high-performance funds (HPF) that rewarded organisations for performance when a gap-to-goal of greater than 20 per cent was achieved. Depending on how many organisations achieved those metrics, the HPF could mean millions in additional revenue. In the Outcomes section, you will see that this resulted in a significant bonus payment to SI PPS.

System of care

To achieve performance goals, SI PPS used a standardised approach that focused on a system of care methodology. Systemic identification of gaps in services, skills, and community resources led to the design, implementation, evaluation, refinement, and sustainability of programmes. These addressed gaps identified from quantitative and qualitative assessments and have been implemented with SI PPS oversight, funding, and other resource support. Two use cases of the model are described below.

Major reorganisation of the community-based care model was at the core of DSRIP transformation, including the integration of medical providers in behavioural health clinics to provide physical health services to improve health outcomes and use of data to drive changes in the model. Staten Island PPS’ analytic platform showed that more than 50 per cent or preventable ER care was driven by five per cent of patients. The vast majority with behavioural health needs of non-emergent nature. Delivery of integrated behavioural health and primary care services to individuals diagnosed behavioural health issues ensures co-ordination of care for both types of services and reduced ER visits.

In nursing homes, SI PPS analytics demonstrated that sepsis hospitalisations were driving significant admission and re-admission rates. A quality initiative was created to focus on early identification and standardised treatment across all 10 skilled nursing facilities in Staten Island. Additional training, equipment standardisation and clinical protocols were developed. After 12 months, sepsis hospitalisations were reduced by 23 per cent and the gains continue.

The SI PPS programme relied on the use of business intelligence enabled by data exchange among partners, transforming traditional outcome strategies that produced excellent utilisation and population health improvement.

Technology platform: business intelligence

To create a data-driven culture and use business intelligence to guide programme design, innovative initiatives and performance measurement, SI PPS created an advanced population health management (PHM) ecosystem that monitors outcomes of care at an individual, practice and population level.

The PHM platform illustrated in Diagram 1 (below) integrated health data from multiple sources, including claims, clinical data, emergency management systems (911), law enforcement data, payor data and clinical event notifications (CEN) from the local health information exchange (HIE). The platform contained harmonised individual patient records and analytic tools to facilitate care delivery across Staten Island. The platform’s geo-mapping and hot-spotting capability made it possible to see geographic areas with service, health outcome and social determinant of health gaps. The tool enabled SI PPS and partner organisations to track progress toward outcome targets and provided a clear, comprehensive and population-based understanding of care quality and cost outcomes. SI PPS created its own social determinants of health system called WeSource to assess and refer clients to needed social services while linking to their clinical profile.

Highlights of PPS outcomes

2020, final performance metrics for the five-year programme were released. SI PPS was recognised as the top performer in NY and awarded $62 million in bonus payments.

Key outcomes of the programme include:

A 400 per cent expansion of access to medication assisted treatment for people with opioid use disorder (Hospital Times, 2019)
Reductions in ER use by more than 25 per cent for high-risk clients engaged in a comprehensive care co-ordination programme called HEALTHi, which provided critical time intervention to people with multiple complex conditions
Avoidable hospital readmissions reduced by 25 per cent via intensive care co-ordination model
Sepsis intervention programme reduced hospital transfers from nursing homes by 23 per cent and saved more than $3 million annually (Journal of Long-Term Care, LSE)
Shelter to permanent housing program with NYC Department of Social Services (DSS) saved on average $25,000 per family
Creation of training programme to educate and place certified recovery peer advocates (CRPA) and community health workers (CHW) in the ER and other high-impact settings
Development of an asthma home visit programme for adolescent super utilisers
Creation of SDOH network to assess and meet needs such as food insecurity, employment, training and housing for more than 28,000 families
A safe prescriber programme educated prescribers about opioid alternatives and evidence-based prescribing algorithms reduced unnecessary prescriptions for opioids by 31 per cent
Comprehensive cultural competency and health literacy training programmes for partner organisations delivered 70,000 hours of training to partner staff

Collaboration is key

Community engagement, trust and collaboration were the keys to success of the PPS programme. Although significant strides were made to begin to transform the delivery of care on Staten Island, much work is to be done locally and nationally to improve quality and reduce costs for the sickest and most vulnerable patients. Governments, payers and regulatory agencies must work rapidly to develop innovative payment systems that incentive value over volume, and to address significant health disparities among historically marginalised communities in an effort to reduce rising costs and poor health outcomes.

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What should integrated care partnerships be prioritising?

By Eliot Gillings

As the wheels of integrated care begin to turn, Eliot Gillings explores exactly what integrated care partnerships should be prioritising, and why.

An integrated care partnership (ICP) is ultimately responsible for the creation of an integration strategy that can inform the work of integrated care boards (ICBs) and partner organisations. Looking at short-, medium-, and long-term challenges to the delivery of health and care (which may impact certain regions disproportionately), the ICP has the opportunity to assess and address health inequalities through system-wide action.

Key to enacting system-wide action will be the development of collaborative networks between ICPs and partner organisations, including social care providers, charity and volunteer groups, primary care networks and others. Beyond enabling a more holistic and personalised provision of care, an institutional emphasis on collaboration will enable an ICP better understand the challenges faced by their systems and their populations.

In building that network, however, it will be key for ICPs to deliver short-term solutions to health inequalities within their systems, which will, in turn, necessitate the rapid establishment of institutional priorities. Accordingly, the following list highlights some key areas of consideration for ICPs as they continue to grow as statutory bodies.

1. Closing the gap on data inequality

One of the central purposes of ICSs is reducing health inequality through population health strategies. However, while ICSs and health organisations already engage and utilise several sources of information, the development of new information-sharing networks should be a key priority to expand the assessment of outcomes and improve the provision of care.

Accordingly, ICPs should seek to explore the variety of local partners and stakeholders engaged with communities whose health data does not currently feed into the system level. This is of particular consideration for systems where deprivation is unevenly distributed amongst certain demographics – but also those that experience high levels of digital exclusion.

2. Finding new solutions to inclusion health challenges

ICSs generally face challenges meeting the health and care needs of socially or economically excluded people. This is especially true of systems that already experience high rates of economic or social deprivation. Meeting the needs of people who are socially excluded and may experience multiple overlapping risk factors as a result, is particularly challenging from a population health perspective as they may be inconsistently accounted for in health databases.

To address these groups, ICSs must work to build information-sharing relationships with third-sector organisations and local groups who may offer services to socially excluded individuals and build relationships with the communities and individuals themselves. This work should also involve regular assessments of the impact of information sharing on health outcomes among these populations. Constant collaboration with partners and stakeholders to adjust the collection of information and the provision of care and outcomes should also be prioritised.

3. Developing novel approaches to information

Building out a network that includes partners and stakeholders engaged with underrepresented and/or excluded groups and individuals is one means to improve access to data. However, the utilisation of new forms and sources of data will also be a key consideration for ICPs. For instance, ICPs may consider exploring a ‘whole-family’ approach to care, where the knock-on impacts of health within family units are considered within a strategy.

Strategies for the use and integration of new information should also be developed in conjunction with partner organisations and designed to address the particular needs of a system. However, it is key that frameworks for information sharing remain consistent to improve collaboration between ICSs.

4. Utilising all levels of ICS functions

Often, individuals or organisations will be better served by engaging with an ICS at the neighbourhood or place level. This is particularly important when health inequalities are considered, as outcomes may drastically differ within a health system and a lack of engagement with health authorities may serve as a blocker to the delivery of improved outcomes to a vulnerable group. Accordingly, ICPs should ensure that well-developed strategies are in place to engage at these levels, and form insights that can inform work at the neighbourhood, place, and system level.

5. Provisioning for social care

The adult social care landscape contains a diverse range of providers. Many are small enterprises which may have competing priorities, but these organisations nonetheless have close ties to the communities and individuals they serve. They may also provide care to individuals whose needs are misunderstood or not met in traditional health care settings. As such, they are an incredibly valuable resource to ICPs, particularly those keenly engaged with finding solutions to the health inequalities faced by the socially excluded.

It will be crucial that ICPs do not come to speak for these providers, but rather serve to connect them to a broad network of information-sharing that can simultaneously improve their provision of care and deliver insights to improve health outcomes elsewhere. ICPs should, therefore, prioritise outreach to adult social care providers for the delivery of short-term solutions to health inequalities.