Insight

Overcoming the barriers to developing future-ready community diagnostic services

Even before the pandemic began, demand for diagnostic services of all types were rising and, in some cases, outstripping capacity. Covid-19 has exacerbated this problem, deepening the diagnostic backlog with knock-on effects for cancer and elective care.

However, it has also demonstrated what is possible. Seemingly complex changes were implemented at a pace not seen before, transforming services within a matter of weeks to ensure they continued during lockdowns, whilst incorporating Covid-minimisation measures.

Although the challenge of catching up with the diagnostic backlog is a steep one, it presents similar opportunities to deliver much-needed long-term change in diagnostic services.

Reshaping diagnostics for the new normal

The challenges created by Covid-19 are ongoing and require new and sustainable solutions. Standard diagnostic pathways have remained the same for many years, despite the fact they are often inefficient both for the NHS and its patients.

But the drive to develop a system that harnesses new ways of working and new technology has already begun. This includes more than 40 new community diagnostic centres that are currently being rolled out by NHS England and set to provide around 2.8m scans in their first full year of operation. Situated in a range of settings from local shopping centres to football stadiums, they are designed to give patients more direct access to the full range of diagnostic tests closer to home.

Crucial to the success of many of these initiatives, will be the relationship between the community and acute services. The transition to integrated care systems (ICS) will help to create this, but a truly interconnected system will still require wider change.

An independent review of diagnostics services for NHS England recently outlined the key components of a new service delivery model. This article explores some of its recommendations and the barriers Trusts need to overcome to achieve them.

What could the future of community diagnostic services look like?

There are three key models to transforming community diagnostic services.

Optimal care pathways

Building on established pathways through existing community support, such as pharmacists, opticians, and phlebotomy services, is one model of delivery that realises the benefits of a greater separation of acute and elective diagnostics.

This provides patients with quicker and more convenient access to care closer to home or work, whilst relieving pressure on acute sites. Telephone and virtual consultations are also expected to play a much larger role in diagnostic services in the near future.

Optimising these established pathways brings a range of challenges which Trusts need to consider, including:

  • Financial arrangements – Ensuring the commercial arrangements are cost-effective and attractive for the commissioner and the service provider, is important in order for services to run smoothly. A comprehensive activity forecast and tested commercial model is critical.
  • Care boundaries – Optimising care pathways should involve eliminating the boundaries that still exist in the care system. The transition to an ICS model will play a key role here. As will an effective commercial arrangement that gives the patient true flexibility and choice on where they receive their care in the community.
  • Collaborative working – Integrated care requires collaboration on all fronts. Often parity of esteem or an assumption of vested interest builds barriers between professionals. Ensuring clinical professionals are engaged and introduced at an early stage will help alleviate this.
  • Public perception – With the introduction of any new service model, comes the requirement for change management. Fear of a patient backlash often deters Trusts from doing this, but regular patient engagement and feedback is vital.
  • Social value – An area of increasing priority, the service provider should demonstrate how they will aid recovery of the local community and economy through employment and training, as well as community support.

Community diagnostic hubs

There is an opportunity to develop new diagnostic service models outside the existing Healthcare landscape that are more responsive and innovative, such as community (or remote) diagnostic hubs (CDHs).

They provide a one-stop shop for patients requiring potentially life-saving diagnostic tests closer to home. As noted earlier, centres that deliver this kind of service are already being rolled out and have begun combatting the impacts of Covid-19.

Their numbers and the services they offer are set to grow over the next five years in a bid to reduce the pressure on acute care. In the near term, non-invasive diagnostics are the most viable, but with developments in technology and practice, there will be an increase in more time-consuming, invasive diagnostics in the community.

As part of this initiative, Akeso supported leading specialist Trusts to implement CDHs. There are several key challenges to consider during this process to ensure a successful implementation:

  • Strategic vision and scope – Fully define the strategic objectives for the hub before implementation. This will inform the scope and operating model as well as support timely decision making and evaluation.
  • Patient need – Identify who the hub’s patients will be and what their needs are. Every aspect of the service model and patient pathway must be built around this.
  • Project management office (PMO) – Robust planning from the outset is critical to the success of the project implementation. With involvement from multiple stakeholders, capturing dependencies at each stage will not only ensure the Project is delivered on budget, but also prevent surprises further down the line.
  • Resourcing – Identify and engage with the right people early on. Collaborating with clinical and operational people across the organisation, who have the right expertise and experience to implement a new service model will avoid potential setbacks.
  • Capacity modelling – Model patient activity across the whole patient pathway. Capacity within the CDH must align with the Trust’s internal capacity. This may be dependent on the capacity to book patients’ assessments and follow-up consultations.
  • Service resilience – In light of Covid-19 ensure the safety of patients and service resilience by reviewing patient flow and infection control.

New diagnostic technologies

Innovation is advancing rapidly in areas such as genomic testing, point-of-care testing and the use of artificial intelligence for imaging, endoscopy, and wearable devices. These have the potential to transform the service diagnostic hubs can offer.

Historically Healthcare providers have been slow to adopt new technological innovations. That is why it is important to explore the most effective way to introduce them. Here are some considerations to bear in mind:

  • Clinician uptake – Clinicians need to be encouraged to trust the integrity of new technology and move away from established processes.
  • Patient awareness – Patients must be supported to understand and adopt new technology. Striking the right balance between a face-to-face and digital service is vital.
  • System interoperability – New systems and equipment will need to exchange information seamlessly. Clinical data comes in a variety of formats and terminology, which means standardised catalogues will need to be developed for complete interoperability.
  • Safety – Safeguards must be put in place to ensure data compliance, and Healthcare workers are given the time and knowledge to implement them.

Combining these elements will create community diagnostics services that can rise to the challenges created by the pandemic, while also improving patient care.

By considering the key factors mentioned here at the outset, Trusts will be able to successfully implement and operate each element successfully.

As experts in delivering high quality solutions to the Healthcare sector, Akeso has a track record of supporting Trusts to do this in a way that develops the effective diagnostic services of tomorrow. To find out what we offer, get in touch at enquiries@akeso.co.uk

Contact our experts

Chris Robson

Chris Robson

Managing Director
Insight

Financial Improvement Plans: From Quick Wins to Strategic Programmes

As we progress towards medium-term pandemic recovery, there is a renewed focus from central government and NHSE on delivering greater efficiencies, whilst continuing to improve quality of care and patient outcomes. 

Unsurprisingly, Financial Improvement Plans remain a standing priority for NHS organisations, particularly in light of the recent NHSE announcement of up to 6% savings targets in FY23/24[1]. There is also additional pressure on ICBs to achieve financial balance, including those still carrying huge pre-pandemic deficits. 

In light of this, the challenge is to address, achieve, and exceed previous performance, whilst sustainably offsetting inflation in the context of ever-increasing service demands, an over-burdened workforce, and ageing infrastructure. 

Opportunities for Financial Improvement: ICBs and Collaboration

NHS leaders acknowledge that no single organisation can tackle the systemic and efficiency challenges facing the health and care sector alone[2]. Trusts and their system partners have been developing collaborative ways of working for several years as national policy has shifted away from competition to collaboration. However, workforce, funding, and investment barriers have been challenging to overcome.  With the formalisation of ICBs, there is now a real opportunity to tackle the financial challenges with a collective effort, whilst acknowledging collaborative programmes can take longer to deliver to benefits and savings. Areas of focus for ICBs should include:

Akeso’s Approach:

Our series on financial improvement plans for the NHS will look at pragmatic and tangible opportunities over differing time horizons and objectives, whilst also achieving clinical, operational, and patient benefits.

Quick-win, short-term initiatives can realise benefits within a year, and tactical savings within as little as 3 to 6 months. Medium-term schemes are designed to deliver between one to two years, and longer-term opportunities look two years and beyond, with some strategic programmes (e.g., system-wide estates planning) spanning over five years.

While cost reduction has become byword for relentless programmes of marginal gains, in the current environment organisations should a) take a holistic approach – managing cost pressures (including inflation) is arguably as important as identifying savings; and b) recognise that delivering better outcomes with the same resource has significant value.

The next article in our Financial Improvement series will provide further detail on the proven methodologies to deliver savings in the short- and medium-term. We will then set out how Population Health Management can support ICBs in the long-term.
For more details, please get in touch with Scott Healy, who leads our Financial Improvement offering.

References

[1] HSJ. ICSs get significantly harder savings target of 6pc. 2023. [online] Available at: https://www.hsj.co.uk/finance-and-efficiency/icss-get-significantly-harder-savings-target-of-6pc/7034819.article

[2] NHS Providers. 2022. [online] Available at: Making the most of the money: Efficiency and the long-term plan (nhsproviders.org)

Contact our experts

Scott Healy

Scott Healy

Director
Insight

Integrated Care Strategies: Turning rhetoric into reality

Thirty-six draft Integrated Care System (ICS) strategies have now been released with the final 5-year forward plans due to be completed by the early summer.

So, what can we learn from the strategies?

As to be expected, they reflect different levels of maturity and development of systems, which are impacted by current operational pressures.

Common themes across all the strategies are the focus on improving population health using collective resources, reducing health inequalities, as well as the emphasis on longer-term prevention, integration, and personalised care.  The biggest gap in describing key priorities is around how the NHS can support wider social and economic development, perhaps because of the limited definition of what this entails.

Whilst there are nuances in how ICSs define Population Health Management (PHM) it is refreshing to see commonality in how the term is referenced. In general, it is described as using data to allocate resources optimally to population cohorts with the greatest need, and to interventions that add most value. There is also the emphasis on predicting the health and care needs of local people in the future.

Although the strategies tick the box of ‘what’ should be included in an integrated strategy the ‘how’ of implementation has still not been defined.

Akeso have outlined four key challenges that need to be overcome to turn rhetoric to reality.

  1. ICSs capacity to progress longer term objectives such as preventing ill health is at risk from shorter term pressures: There is a risk that ICSs will struggle to make progress on local or longer-term priorities such as increasing healthy life expectancy and reducing avoidable ill-health given the national focus on shorter-term challenges such as the elective care backlogs and A&E waiting times. The recent National Audit Office (NAO) report outlines while 77% of senior ICS staff consider their ICSs intend to invest in preventative measures, only 31% feel they currently have the capacity to.

ICSs need to have the capacity and headspace to focus on prevention, and a framework to develop well defined business cases or evaluations, which set out the timeframe to achieve benefits and the required investment. The DHSC also need publish to its response to its consultation; Advancing our health: prevention in the 2020s.

  1. The NHS and social care continue to maintain separate budgets despite the ambition of integrating services through these new reforms. Therefore, a key priority is to remove system, organisation and workforce barriers so the NHS can work more closely with local government and other partnersto tackle the wider social determinants of health, and the broader issue of health inequalities. It also needs to be clear which improvements ICSs will be specifically accountable for, which are the responsibility of NHS England, and which are wider government responsibilities. This should be helped by the DHSC’s guidance on the scope of pooled and aligned budgets, which is due be released imminently.
  2. Significant workforce challenges across health and care: It is well documented there are critical shortages across the NHS and social care workforce, for example the number of people working in social care fell in 2021/22 for the first time in the least 10 years. The NHS Long Term Plan committed to producing a Workforce Implementation plan by September 2020, this now needs be an urgent priority to set the blueprint for workforce planning at a local level. This should include integrating workforce across health and adult social care, developing new cross-system ways of working, as well as exploring opportunities for system-wide recruitment and deployment, informed by joined-up workforce planning and skills development.
  3. What will be measured is likely to drive ICS direction and focus: Key system metrics and KPIs have yet to be set for most Integrated Care Systems. A system wide balanced scorecard will need to be agreed by system partners, which is inclusive of domains such as health inequalities, quality, workforce, and finance. The balanced scorecard will need reflect the short, medium, and longer strategy of the ICS, and include carefully selected metrics so reporting is not too onerous. Success measures outlined in the strategies will also need to be turned into ‘SMART’ goals so integrated care partnerships can track and report progress to local people.

Contact our experts

Peter Marshall

Peter Marshall

Associate Director
Insight

Delivering improvements to discharge practices

At Akeso, we are extremely saddened by the current healthcare crisis caused by the unprecedented NHS capacity constraints which is threatening the lives of so many of us this winter.

According to the latest discussions at No10, the Government’s response to this challenge is an improved discharge to medically fit patients that is enabled by solutions such as virtual wards.

Although programmes such as discharge to assess (D2A) and virtual wards are not new, we welcome the recognition that doing the same but (slightly) better is not going to solve the problem this winter, or in fact any winter going forward.

According to the NHS, there are 12,809 patients fit for discharge who are occupying beds which could be available to save lives. In an analysis by HSJ, 7,000 virtual ward beds exist, but only half of them are occupied.

So, what is causing this disconnect and why aren’t virtual wards that are in place delivering results?

We believe that the system is struggling with uptake due to the lack of mechanisms that offer a partnership platform between healthcare professionals, who must continue to care for patients uninterruptedly, and specialist partners that can facilitate discharge programmes and implement functional virtual wards.

Akeso can offer such a mechanism and work with Trusts to deliver improvements to discharge practices and implement technology enable virtual wards. We can enable this by offering:

  • Demand and capacity analysis to enable care pathway remodelling.
  • Workforce optimisation and empowerment to support discharge and remote care.
  • Project management to ensure programmes and solutions offer evidenced results.
  • Comprehensive guide and methodology which takes a Trust ‘step-by-step’ through business case, implementation, effective management and scaling of virtual wards.

A medically graded virtual ward technology which offers proven discharge results by reducing length of stay of medically fit patients.

We are here to talk and help Trusts and ICSs with a free assessment and actionable plan that can offer results right now!

Together with HSJ and Masimo we’ll be hosting a roundtable which will focus on Virtual Wards and Discharge in March. Watch this space for updates!

Insight

Technology-enabled virtual wards the future of healthcare

With an elective care backlog in excess of 7 million [1], record high workforce shortages [2] and decaying estates, our healthcare system is close to breaking point. Numerous tools have been deployed to try and combat these problems, but they continue to fall short of the mark. Not all hope is lost though. Driven by the global Covid-19 pandemic, we have seen a flurry of new techniques and solutions enter the market, promising to solve our problems and redefine healthcare nationally. One of these tools, Virtual Wards, has established such a strong base of supporting evidence that they can no longer be ignored. But are they the answer to our prayers? When deployed in a technology-enabled manner, following a structured implementation plan, they just might be.

In response to rising demand and in preparation for winter, NHS England (NHSE), Health Education England (HEE) and NHS Digital (NHSD) are collaborating to support ICSs in adopting Virtual Wards. Outlined in a two-year funded transformation program, the ambition is to have 40-50 Virtual Ward beds available in each Trust across the UK (24,000 beds in total). This is to be delivered in a tight time frame, with all Trusts required to meet the capacity target by December 2023.

With NHSE putting their faith in Virtual Wards, so too should we. But what is a Virtual Ward? What kind of benefits can they deliver and how can we ensure that our Virtual Ward is actually successful?

About Virtual Wards

Virtual Wards aren’t new, with the first examples deployed over 15 years ago [3]. At their core, they aim to move patients out of hospitals and into homes, whilst still delivering an acute level of care. Despite being used across the UK (and globally), their model of care remains largely unchanged, with little innovation or improvement seen in the space. That is, until now.

Many Virtual Wards currently in use are ‘traditional’ in their approach, with the care delivery model underpinned by telehealth services and routine home visits. This approach requires significant clinical time investment, proliferating systemic workforce problems and, in some cases, functioning to hinder the service rather than help it.

There is, however, a ‘non-traditional’ Virtual Ward model, one that uses state of the art remote monitoring technology to deliver acute level care to patients [cite]. These models are defined as ‘Technology-enabled Virtual Wards’, delivering quality care without the same workforce demand as traditional models.

Technology-enabled Virtual Wards

The NHS defines a technology-enabled Virtual Ward (TEVW) as ‘the management of patients via a digital platform’. A broad definition which could be used to describe any number of solutions currently on the market. It is also, a misleading one, as beyond the shared use of technology, there is very few similarities between the different solutions. App only, monitoring + app and telehealth platforms can all be considered as technology enabled Virtual Wards, but each has a unique set of benefits and delivers care in a novel way.

Although telehealth and app only solutions have their place, providers should be focused on deploying Virtual Wards that utilise hospital grade remote monitoring technology. These Virtual Wards are the new frontier of digital health, delivering a broader suite of benefits, to a greater patient cohort, than any other solution [4].

For the remainder of the article, when we refer to a TEVW, we refer specifically to one that is using hospital grade, remote monitoring technology.

Benefits of Technology-Enabled Virtual Wards

Not all TEVWs are built the same, with maximum (in terms of both breadth and depth) benefits only observed in those that integrate remote monitoring in patient care pathways. But what are these benefits? Where, how and by who will they be felt? To understand the potential impact of TEVW, we have conducted benefits modelling using leading technology within the Virtual ward space, Masimo SafetyNet as an example, to explore the following areas:

  • Average Length of Stay
  • Workforce efficiency
  • Readmission rate & admission avoidance
  • Backlog reduction
  • Release of acute bed capacity

Our analysis models the potential positive impacts that an average sized Trust (778 beds) could achieve by adopting a TEVW. This is not the only potential application though. With appropriate tailoring, TEVWs can be applied to any use case, with the technology being used globally to support the care of patients suffering from any number of conditions from cancer to heart failure.

In the context of the acute emergency and orthopaedics cases, we understand there to be two main applications for a TEVW respectively: avoiding admission and expediting discharge. The benefits of TEVWs will be discussed in the context of these primary applications.

1) Avoiding admission

TEVWs offer providers a way to avoid unnecessary admissions and re-admissions to the acute setting, instead delivering care to patients in the home environment. Acute patients, such as emergency department attendees, can be admitted to the Virtual Ward, rather than the physical ward, preventing the occupation of an acute bed.

Our benefits modelling indicates that for an average sized Trust of c.760 beds, up to 7,000 bed days could be released through readmission avoidance of acute emergency patients [5,6,7,8]. This would save an estimated £3 million in avoidable readmission costs [7,9] and release 63 hours of clinical resource back to patient facing activities [10]. In addition to financial and capacity benefits, research has shown that patients have a greater perceived quality of care and sense of empowerment when treated through a TEVW model [11].

In the context of acute emergency cases:

Patients per year graph

2) Early discharge

TEVWs enable postprocedural remote monitoring and encourage early discharge, releasing both clinical and bed capacity [12,13].

Wearable sensors alert clinicians to changes in a patient’s condition, in real-time, helping the remote management team to intervene sooner and ensuring patients receive the same quality of care within the Virtual Ward [12,13]. This functionality brings the home environment in line with the acute environment and provides clinicians with the confidence they need in order to discharge more acutely unwell individuals, earlier. 1/3 patients stay in hospital beyond the necessary point of care, the ability of TEVWs to reduce length of stay will be critical in reducing this number and expediting discharge. You can read more about this in our D2A technology article here.

Reducing length of stay will release clinical and bed capacity, allowing critically ill patients to be treated with fewer delays and removing a key bottleneck in care delivery. In the case of primary hip and knee procedures, the ambition is that technology enabled Virtual Wards will reduce length of stay by up to 3 days. This could release an estimated 900 bed days which could be utilised to addressing the current backlog for orthopaedic procedures.

In the context of orthopaedics patients:

Reduce length of stay

Implementing technology-enabled Virtual Wards 

The potential benefit of technology enabled Virtual Wards is clear and as a result NHSE calling for their rapid adoption [14,15]. However, without firm guidance on how to implement these solutions effectively, they may fail to deliver expected benefits and jeopardise patient care [16].

Learnings from previous Virtual Ward implementations have been distilled into a set of critical success factors which must be considered if the TEVW is to be delivered effectively. Sourcing the right solution, defining a clear objective, mapping the commercials and understanding the use case are all pivotal in achieving success. Steps to address these factors are outlined as part of our comprehensive Virtual Ward implementation guide.

Akeso’s methodology is based on Masimo SafetyNet which you can find here.

Sourcing the right solution, and partnering with the right provider, are essential in ensuring the Virtual ward is both clinically compliant and highly effective. Several providers claim to meet these criteria, but with only a few functioning examples of TEVWs locally, it is difficult to assess the validity of these statements. route of sourcing an effective, complaint TEVW is utilise the Sparks Dynamic Purchasing System (DPS) framework. Spark DPS categorises leading technology providers across a variety of sectors based on their capabilities and offerings. We have summarised these providers, and what they offer (based on the DPS framework), below.

Figure 1 – Summary of key technology-enabled Virtual Ward providers
Figure 1 – Summary of key technology-enabled Virtual Ward providers on the Spark DPS framework.

When considering which TEVW supplier to use, it is important to consider future TEVW applications, beyond the current target. Many providers have Virtual Wards up and running, supplied by different organisations. This can lead to problems with integration, consistency and quality for both patients and clinicians. The aim should be to procure a single solution that is scalable and adaptable to all areas of your service. Masimo SafetyNet is a robust example of a TEVW solution that holds this capability.

The Future

We currently have a discharge problem in the NHS, with patients waiting up to 9 months to be sent home [cite]. Virtual Wards will support expedited discharge, reducing Length of Stay back toward national targets. Read more about it in our Discharge to Assess (D2A) technology enablement article ‘Turning homes into hospitals’.

Although current benefits are obvious, we should begin to think about what role TEVWs might play in the future of healthcare. Using the clinical information TEVWs provide, we could look to begin moving the discharge threshold, allowing higher acuity patients to be treated in an at home environment. Doing so would extend the benefits of Virtual Wards, beyond what current models (including our own) predict.

The vision for technology
Figure 2 – The vision for technology enabled Virtual Wards

But the future of Virtual Wards doesn’t just lie in moving the discharge threshold. Traditionally, Virtual Wards were deployed to prevent patient admission- the opposite end of the care pathway to the current discharge focus. We believe technology-enabled Virtual Wards could eventually be deployed across every stage of the patient care journey, not just the bookends, supporting a movement toward personalised medicine and redefining care pathways completely. There is evidence of this globally already, with Virtual Wards across Australasia supporting entire cancer care pathways [17].

Future applications of technology-enabled Virtual Wards
Figure 3 – Potential future applications of technology-enabled Virtual Wards, across the entire patient care pathway.

It is important to keep these opportunities top of mind as we deal with our current issues, continuing to innovate and adapt during a time of immense pressure. Doing so will ensure that solutions implemented can flex and change as our needs do, remaining relevant long into the future.

References

  1. The British Medical Association. NHS backlog data analysis. 2022. [online] Available here.
  2. House of Commons Committee. Workforce: recruitment, training and retention in health and social care. 2022. [online] Available here.
  3. KingsFund, 2006. Case study: Virtual wards at Croydon Primary Care Trust. [ebook] Available here.
  4. NHSX. A guide to setting up technology-enabled virtual wards. 2022. [online] Available here.
  5. 15.5% avg national re-admission rate, as reported by Nuffield Trust in https://www.nuffieldtrust.org.uk/resource/emergency-readmissions
  6. 20% patient eligibility for MSN-enabled virtual ward, as an Akeso&Co assumption
  7. 6.6 days of avg length of stay for re-admission acute patients, as reported by the Internal and Emergency Medicine inhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354916/
  8. 90% avg bed occupancy for General and Acute beds, as reported by NHSE onhttps://www.england.nhs.uk/statistics/statistical-work-areas/bed-availability-and-occupancy/bed-data-overnight/
  9. £400 per bed per day, 2022-23 national tariff payment system, as reported by NHSE on <https://www.england.nhs.uk/wp-content/uploads/2020/11/22-23-National-tariff-payment-system.pdf
  10. 1.6 WTE/bed based on avg staff required to service a 40-bedded ward in hospital published on the VW Bed Benefit Tool from NHSEI available at https://www.future.nhs.uk
  11. Nunan, J., Clarke, D., Malakouti, A., Tannetta, D., Calthrop, A., Hanson Xu, X., Berin Chan, N., Khalil, R., Li, W. and Walden, A., 2020. Triage Into the Community for COVID-19 (TICC-19) Patients Pathway – Service evaluation of the virtual monitoring of patients with COVID pneumonia. Acute Medicine Journal, 19(4), pp.183-191.
  12. Masimo. Masimo SafetyNet Telesurveillance Solution. Presentation; 2020.
  13. Masimo.co.uk. Masimo – About. [online] Available at: https://www.masimo.co.uk/company/masimo/about
  14. England.nhs.uk, 2022. Delivery Plan for Tackling the backlog of elective care. [ebook] NHS. Available at: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2022/02/C1466-delivery-plan-for-tackling-the-covid-19-backlog-of-elective-care.pdf
  15. NHS England, 2022. 2022/23 priorities and operational planning guidance. [ebook] Available at: https://www.england.nhs.uk/wp-content/uploads/2022/02/20211223-B1160-2022-23-priorities-and-operational-planning-guidance-v3.2.pdf
  16. James Illman (2022). ‘Patients at risk’ from ‘hastily rolled out virtual wards’. Health Service Journalhttps://www.hsj.co.uk/quality-and-performance/patients-at-risk-from-hastily-rolled-out-virtual-wards/7031648.article
  17. https://theclinician.com/
Insight

Discharge to Assess: Where the rubber hits the road

There are seven key steps to generating traction and improving the discharge-to-assess pathways. These are a mix of technical development in respect of discharge-to-assess (such as the establishment of agreed patient strata) and the generic challenges of change management (such as engagement, communication, and skills building). The first 3 phases (which are the planning phases) will be broadly sequential but the delivery phases can be run in parallel, as the figure below indicates:

  1. Establish a core guiding coalition: build a small group with representation from the acute, community, and social care teams who will act as the core accountable team.  This team will guide the program to ensure time and resources are well spent.
  2. Understand where you are and why, in order to build the local case for change, including:
    1. Maturity model completion:  complete the self-assessment complete the self-assessment of the Akeso discharge-to-assess maturity model to show where the current system is already fit-for-purpose and where changes need to be made
    2. Internal analysis on “no right to reside” and other key metrics (such as risk adjected length of stay, and elective and cancer waitlist variation) to give additional local relevance
  3. Define the overall model of discharge-to-assess which best suits your location, given the NHS England guidance, known exemplar case studies, and the results from the maturity assessment, including:
    1. Patient stratification: be clear on which patients fall under the category of relevant for discharge-to-assess and how/when they are highlighted
    2. Workforce models: with community and social care partners, develop a sustainable workforce model which meets local population health needs and is achievable with local resources
    3. High-level process: agree what the high-level discharge-to-assess process is which balances discharge efficacy with clinical risk
    4. Technology aspirations: be clear on where technology will help (with both current and potential future systems)
  4. Launch the program of change: take the time to engage with a broad range of stakeholders to lay out the overall aims of the discharge-to-assess program and how it contributes to the aims of the organisation, including:
    1. Vision expected outcomes, and expected timelines: establish what success looks like from an outcome perspective (for example, number of patients remaining in the acute setting with no right to reside; 7-day re-admission rate
    2. Leadership team & resource: ensure that there is sufficient resource ring-fenced to deliver and manage the work, and that senior leaders are actively supportive
    3. Govern and track effectively: embed discharge-to-assess governance within the existing board and directorate mechanisms to ensure its visibility
    4. Communicate plans and progress
      Healthcare team working
    5. Establish portfolio of work: the maturity matrix and case study examples will suggest a wide range of work to be done. It’s important that any portfolio and phasing is chosen which reflects the need and resources available, including:
      1. Pilot and refine: choose 1-2 specific patient groups or services on which to pilot the design where there is both a clear need and support for discharge-to-assess; learn from these pilots and moderate the initial designs as necessary and remember that “getting it right first time” doesn’t apply in this situation! Learning and adapting is part of the process. To aid this, you may want to instigate regular learning cycles (such as Plan-Do-Study-Act) and daily management meetings
      2. Embed and roll-out: broaden the scope of patients and services for whom discharge-to-assess is available, building on the learnings from the pilots (in 1 or 2 further phases)
      3. Business case development: when investment is necessary, put together a robust business case (using recognised approaches such as the HM Treasury 5-case model)N.B. when engaging in technology-driven change, it is very important to ensure that practices are “digital-ready” before they become digitised so take the time to improve ways of working before the technology is available. It is value destroying to embed poor current practice within a new system. Many organisations, therefore, go through two phases of transformation: pre-tech and post-tech availability
    6. Train, support and reward those involved in delivering this new way of working. The pilots will establish local standard methods and learnings. These should be documented and shared with groups involved in subsequent phases of roll-out. The pioneers who drive the change should be given the reward and profile that it deserves.
    7. Communication progress, learnings, and successes, including regular broad updates and particular highlights. Appreciation of the efforts of everyone involved could be included within monthly and annual recognition systems. 

Keeping people healthy and returning them to their usual home after a hospital spell is a key ambition for all those involved in health and social care. There is an even greater imperative to do so given the pressures on the system now (be they workforce, elective backlog or capacity constraints). Discharge-to-assess, enabled by technology is one of the ways in which we can work together to ease this problem. Many organisations are already making this work. We hope that these four articles can encourage more progress for the benefit of citizens and health and social care workers alike.

For a free Discharge-to-assess consultation, please contact us for an initial conversation with our consultants.

Insight

Transforming homes into hospitals

D2A pathways and associated practices are key tools in expediting patient discharge, relieving pressure on the acute environment and improving patient flow [1,2]. Although effective on their own, by applying technology in new and innovative ways, these pathways can be further enhanced to generate further benefits.  

Supporting technology is best viewed as ‘catalysts’ for D2A pathways. When implemented effectively, they can amplify the benefits of discharge to assess such as: improved patient experience, faster discharge, and the release of capacity for other clinical need.

The role of technology enablement in D2A

The number of D2A enabling technologies is increasing continually, catalysed by the global Covid-19 pandemic. Solutions such as “Virtual Wards” and various health apps provide cost-effective ways of delivering care to more patients in a resource efficient manner [3,4].  With so many technologies, solutions, and providers now on the market, the space has become confusing. An understanding of what the technologies do, what benefits they may generate, and how they support more efficient discharge is not easily come by.

In order to help, we have clustered the current propositions into three main types: ‘alternative models of care’, ‘care management tools’ and ‘service augmenters’ which are explained below. Each of these enhances one or more of the D2A pathways as defined in our previous articles.

Extended models of care to include a patients’ home

Technology solutions labelled as ‘alternative models of care’ seek to fundamentally redefine the patient care pathway. Key solutions in this space include Virtual Wards and Telehealth Services, effectively turning our homes into hospitals.

Technology-enabled Virtual Wards are pioneering, demonstrating the ability to move patients out of the acute environment whilst maintaining the same quality of care [5]. In Masimo’s SafetyNet solution, for example, this is enabled by remote monitoring, allowing real-time assessment of patient “vital signs” and automated alerts when patients conditions begin to deteriorate [6]. When implemented effectively, these solutions can reduce length of stay and release clinical capacity.

Homes into hospitals

Care management and enhanced communication between professionals

The second suite of D2A enabling technologies aim to consolidate the care management process, presenting a complete view of the end-to-end process. Patient discharge is managed by multidisciplinary teams, each uniquely involved in the movement of the patient out of the acute environment and their continued care in the community. Historically, communication between these groups has been limited, delaying discharge, and causing continuity issues in care delivery.

Innovative technology platforms such as ‘Hospital to Home’ [7] provide consolidated views of both the discharge process and the overall patient care pathway, in a way that fosters collaboration between clinical stakeholders. In the context of D2A, these platforms can enable faster, more consistent discharge practices, supporting clinicians to understand discharge stages, who needs to be involved and what needs to happen when.

Accessing national capacity as and when it is needed

Driven by the growing workforce shortage across the NHSE, several 3rd party clinical service providers have been established over the past few years. These providers offer access to clinicians, via telehealth platforms, to support with rate-limiting tasks such as triage. diagnostic and outpatient assessments. In doing so they expand a provider’s workforce, reducing bottlenecks and delays.

These services can diffuse pressure, such as during Winter, to mitigate against seasonal variation for the period when it’s needed. Virtual Lucy [8] and Medefer [9] are industry leading providers of these services, not only demonstrating the ability to reduce discharge delays but also preventing patients from unnecessary admission to acute services in the first place.

Ensuring the solution is successful

The implementation and management of digital transformations is rarely done well, but there are steps that can be taken to improve the chance of success. Each technology implementation is different, with unique challenges and success metrics. There are, however, key success factors, common to all implementations regardless of technology type or use. The programme objective, intended use case and commercial viability are all essential to consider if the technology implementation is to achieve success.

Programme objective

A single objective should be defined to drive progress and foster alignment across the delivery team. 

Often, we see large programmes of work undertaken as a knee jerk reaction to changing pressures across our health landscape, resulting in ‘solutions’ that are naïve of the problem they attempt to solve [10].

Providers must be proactive in defining their programme objective, setting a clear goal before work commences. It should be easily understood and clearly linked to actions that support its realisation. Having a single, clearly defined objective (for example, enhanced patient experience) will align stakeholders, keep the project on course and ensure positive outcomes are achieved.

The clarity of this objective will then lead to Key Performance Indicators (KPIs – such as a relevant PROM, percentage of patients in an acute site beyond their point of need, and patients supported at home) which can be used to assess the success of the solution.

Intended use case

Technology should be aligned to where it is needed most. 

Discharge processes differ significantly, not just between providers but between clinical pathways. It is unlikely, therefore, that there will be a ‘one size fits all’ technology solution across providers; adaptation is always required to tailor the needs of each unique situation. Many providers fail to consider this, deploying generalised rather than tailored solutions. Providers should focus on strategic deployment models, delivering technology solutions to highest need or highest-pressure pathways first, and then expanding these solutions across lower priority / lower risk pathways over time.

In defining the use case for the D2A enabling technology, an understanding of the underlying population should be developed. Demographic factors such as ethnicity, gender and comorbidity are known to influence the efficacy of healthcare interventions. Understanding these factors will support delivery of tailored, technology-enabled, discharge solutions.

Commercial viability

The commercial viability of the technology should be defined early in the project lifecycle. 

The balance between costs and benefits (as captured in KPIs) underpins the commercial viability of a technology solution. Through defining a clear objective and understanding the intended use case, the benefits of a technology solution can be easily understood. The financial implications (both ongoing and upfront) of the technology should be modelled to support an equal understanding of associated costs.

Aside from Virtual Wards, which have £450 million in backing, there is no ring-fenced funding available for D2A enabling technologies. A formal business case will be required to secure funding for initial set up and continued use of these technologies. To complete the NHSE business case in full, clear definition of costs, benefits, and ROI time horizons will be required. Importantly, financial benefits must be shown to outweigh costs, with a robust evidence base established to support this conclusion.

What’s next

Having understood the D2A enabling technology landscape, and how to ensure these tools work to support you, the task of delivery comes next.  This is where all the value is generated. The final article in our series will focus on setting up delivery programmes to succeed, demystifying the process by establishing the key elements for success.

References

[1] Rojas-García, A., Turner, S., Pizzo, E., Hudson, E., Thomas, J., & Raine, R. (2018). Impact and experiences of delayed discharge: A mixed-studies systematic review. Health expectations: an international journal of public participation in health care and health policy, 21(1), 41–56. https://doi.org/10.1111/hex.12619 

[2] NHS Confederation (2021). Discharge to assess: the case for permanent funding. NHS Confederation. https://www.nhsconfed.org/system/files/2021-07/Discharge-to-assess-funding-briefing-for-HMT.pdf  

[3] Independent Healthcare Providers Network (2020). Our Virtual Ward improves patient flow at Kettering General Hospital NHS Foundation Trust. Independent Healthcare Providers Network. https://www.ihpn.org.uk/wp-content/uploads/2021/05/HAH-discharge-case-study.pdf  

[4] Shah, S.S., Safa, A., Johal, K. et al. A prospective observational real world feasibility study assessing the role of app-based remote patient monitoring in reducing primary care clinician workload during the COVID pandemic. BMC Fam Pract22, 248 (2021). https://doi.org/10.1186/s12875-021-01594-7  

[5] Health Innovation Network South London (2021). Rapid evaluation of Croydon Virtual Ward. Health Innovation Network South London. https://healthinnovationnetwork.com/wp-content/uploads/2022/01/Croydon-VW-Evaluation-Report-to-NHSX-v10.pdf  

[6] Masimo SafetyNet.  https://www.masimo.co.uk/products/hospital-automation/masimo-safetynet/  

[7] Hospital-to-home. https://hospital-to-home.uk/  

[8] Virtual Lucy. https://www.virtuallucy.co.uk/  

[9] Medefer. https://medefer.com/  

[10] James Illman (2022). ‘Patients at risk’ from ‘hastily rolled out virtual wards’. Health Service Journal. https://www.hsj.co.uk/quality-and-performance/patients-at-risk-from-hastily-rolled-out-virtual-wards/7031648.article

Insight

Technology-enabled Virtual Wards

How hospital grade remote monitoring technology can enable the delivery of high-impact patient outcomes.

Technology-enabled Virtual Wards have arrived, are you ready?

The NHS must establish 24,000 Virtual Ward beds by December 2023 to support a targeted increase of 30% in elective care procedures by 2025. The delivery of effective ‘in-hospital’ patient care depends on reliable communication, monitoring, and alerts. Maintaining this level of care efficiently and effectively in a Virtual Ward, outside of the hospital, requires reliable, trusted, proven and privacy-compliant solutions for timely detection, prevention, and treatment. Masimo SafetyNet® is a Digital Health platform from Masimo, whose innovative monitoring products have been in use across the NHS for over 15 years, with a proven track record of success.

Masimo SafetyNet is an example of Virtual Ward enabling technology

Virtual ward chart

For Patients: Technology-enabled Virtual Wards help assure higher-acuity patients that they remain under the watchful eye of clinicians even following discharge to their own home.​

For Acute Care Providers: Masimo SafetyNet offers advanced automation features so institutions can more easily deploy home monitoring, track patient compliance, identify when intervention may be required, and prioritise patient needs whilst maintaining the ability to scale up to meet patient demand.​

For NHS Leaders: Masimo SafetyNet is an effective, easily deployed turnkey solution designed to address the challenge of rapidly establishing and operating Virtual Wards whilst optimising use of clinical resources.

​For an average sized2 NHS Trust, a robust technology-enabled Virtual Ward could…

Tech enabled ward example
The above figures are estimates, for further detail on inputs for the analysis, please see the references below 3, 4.​

Masimo offers an end-to-end approach to help NHS providers implement Virtual Wards with the Masimo SafetyNet app currently available at no charge for NHS Trusts. ​

Deployment launched across the NHS; contact Masimo to activate your site!

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