The government has pledged to move NHS care towards the community, digital and prevention. An HSJ webinar, in association with Doccla, looked at work some NHS organisations were already doing which could achieve all three.
The Labour government wasted no time laying out its three big shifts for the NHS – from hospital to community, from analogue to digital, and from sickness to prevention – but these proposed new ways of working will no doubt be a step change for those responsible for delivering care.
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However, an HSJ webinar, in association with Doccla, heard how the technology partner and its customers were already working towards all three shifts by implementing proactive virtual care to look after people in the community.
It sounds like an ambitious task, and viewers were likely wondering where to even begin with such a project. Doccla’s chief medical officer, Greg Edwards, said that among the first steps he would recommend when introducing proactive virtual care is identifying the patient cohort. This could be via a medical condition – some of the most common candidates being chronic obstructive pulmonary disease, heart failure and frailty. Then, by examining factors such as how regularly people were being admitted to hospital, patients could be placed into tiers to determine the intensity of monitoring they required.
However, Gurnak Singh Dosanjh, GP and deputy chief clinical information officer Leicester, Leicestershire and Rutland Integrated Care Board, explained his system adopted a different, “disease agnostic” approach when setting up virtual care. Instead, they used a tool to identify patients by need and then targeted the most challenging groups.
Another crucial step to successfully introducing virtual care is getting key stakeholders on board. Dr Edwards stressed the importance of integration and, assuming secondary care was leading the project, involving community and primary care partners.
“One of the key things that really has come out of any discussion about virtual care is ensuring that patients don’t fall through the gaps,” he said. “Hence that integration is really important. It’s clear that systems need to be sure what part of the patient’s care they’re looking after, and what part they’re responsible for, so that there are clear escalation routes.”
Pointing out that a well-designed model should “impact the whole system, so we should see benefits all the way through”, Dr Dosanjh said LLR ICB had worked “with all of our individual stakeholders to map out what the next appropriate route would be… we’re trying to make every contact count and also get the patient to the right place the first time rather than the patient bouncing around the system.”
Dr Dosanjh admitted that looking at proactive virtual care “from a purely system lens”, as opposed to how it would affect each individual service, had its challenges. However, he said it had helped to have “all the stakeholders in the room from the get-go”, adding: “When we were facing challenges… because we had that shared ownership, we work[ed] together to try and overcome those.”
Moving beyond ‘It’s 6pm on a Friday night. Who do I call?’
The panellists agreed virtual care should ideally be proactive. They contrasted the remote monitoring models that places like LLR had implemented with how many providers used virtual wards reactively, in that they only cared for patients who were already in acute need.
Maggie Westby, senior researcher, National Institute for Health and Care Research Applied Research Collaboration West (University of Bristol), has been researching frailty virtual wards “trying to find out what works, for whom, under what circumstances”. She warned virtual wards – even when aimed at proactive intervention – risked “being in a silo” and only being used for people already “in trouble”.
Dr Westby highlighted the importance of early intervention, particularly with frailty. “If somebody has a crisis, then they don’t recover from where they were before functionally, which is a vicious circle,” she said. “The way to stop that is stopping them hav[ing] a crisis in the first place.”
Dr Dosanjh added: “Traditionally, what we see is, if a patient is unwell or feels unwell, they have to reach into healthcare… which can be very challenging for clinicians and patients to try and navigate and understand, ‘Okay, it’s 6 pm on a Friday night. Who do I call? Do I call 111? Do I call a GP? Do I call 999?’
“But we really wanted to understand, how can we move that and shift the focus so that, when a patient does start to feel unwell or starts to feel like something is not quite right, the clinical team reaches into the patient at the earliest point.”
Doccla’s customers have several examples of promising outcomes from proactive care.
Hertfordshire Community Trust has been working with Doccla on its “Minus Nine” project, where they try to reach patients nine days before they would otherwise be admitted. One of their areas of focus has been proactive virtual care for those with heart failure. Tara Donnelly, founder of Digital Care and adviser to Doccla, explained the trust’s evaluation of the project had shown some “quite powerful changes”, including “highly improved patient self-confidence about managing their conditions”, financial savings and a 32 per cent reduction in emergency department admissions among the cohort.
Dr Dosanjh said that, along with positive patient feedback, his system was seeing promising clinical outcomes and “stories of patients who have started to deteriorate and have ended up in the appropriate place rather than having to navigate a very complex system”.
Meanwhile, Dr Edwards explained that, by providing remote monitoring, Doccla had helped the virtual wards in Hampshire and the Isle of Wight reduce the frequency of home visits “and therefore repurpose that resource”.
However, for viewers still not convinced by proactive virtual care, Ms Donnelly issued a powerful call to action: “We’ve got to be really honest. The NHS does not deal with long-term conditions well. Care is too often fragmented, slightly chaotic [with] lots of handoffs. People are asked to come for outpatient appointments when they might not need them, and then they find it hard to get a clinician when they do.
“So, we’re not getting it right… We’ve got to think completely differently about the way we deliver this kind of care to people.”
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