Health Navigator’s managing director, Mark England explores the idea of an NHS at Home model – the barriers, the pitfalls, and how it could be implemented.
Feeling confessional, originally a software engineer, with a thirst for healthcare improvement and a deep vein of NHS passion–I’ve probably thrown away more self-monitoring kitchen I have ever regularly used. Fortunately, I don’t have serious underlying health needs but unlike many patients, I have the knowledge, skills and motivation to monitor my health. I do, however, get defeated often: configuring all the connections, keeping something charged with yet another cable, finding my glasses, synchronising with another app and what was that password? This can often be the very definition of a palaver. The cold harsh digital reality is often at the bottom of that draw of mixed, tangled and under-used cables, somewhere in most people’s homes.
The idea that devices and technology alone can impact care models is seductive to many in the current crisis. The goal of people receiving connected, supported and personalised care in their own homes is laudable but if we don’t stand back and take stock of the evidence base and the digital reality in our draw of cables, we could be filling the junk markets of future years and miss the opportunity to create desperately needed capacity. Below I reflect on some ideas to improve the chance of success of an NHS at Home.
Ten years ago, a few into my NHS career, as soon as we had digitised nursing observations in the acute setting, the potential for delivering enhanced virtual observation rounds at home became clear. We quickly asked if we could use this technology to create earlier but safer discharge pathways and prevent future exacerbation and readmission. The barriers at that time were mostly managerial or technical no acute internal financial case to invest, the sub-optimal ergonomics of monitoring technology, the poor data network access in many homes and the lack of software workarounds to gracefully handle intermittent connectivity.
Much has changed in these areas as we can all observe, even through the fog of digital health hype. However, the key to successfully developing an effective NHS at Home clinical model is, as ever, the patients themselves. People need to be coached, coaxed and proactively supported to engage and become active in their care. Adherence to medication is often poor so expecting ‘out the box’ adherence to tech is naive. However, if we use the right blend of human and digital capabilities, NHS at Home could be a critical element in creating the capacity to support and navigate through the operational challenges that living with Covid 19 is presenting, particularly as another winter approaches.
Obviously, there is a prerequisite for robust digital tools that are ergonomic, cyber-secure, safe accredited, cost-effective and efficiently supported and managed remotely in a wide range of different environments. However, there are other, often missed, critical success factors required for an effective virtual ward in an NHS that is living with Covid 19. These apply equally whether managing Covid 19 patients themselves or those with chronic long term multimorbidity and increased vulnerability:
I. Patients are activated d, i.e. they have the knowledge, skills and confidence to adhere to key elements of the largely self administered virtual ward care plan. This doesn’t just happen without listening carefully to patients, educating and motivating them to engage in their own care. This is proven to reduce their anxiety and isolation which alone can lead to the virtual ward not being enough for their care needs. Building this confidence and literacy is the role of an effective clinical health coach.
II. An effective virtual ward approach to patient flow must include effective and active caseload metrics for prioritising attention that is based on the patient’s personalised care plan with rapid escalation to step up to physical care in the community and an effective discharge pathway to maintain flow. Clear system wide clinical and operational understanding and design of the care model and pathways can deliver this.
III. An effective cross-team communication platform for the wider team visibility and where appropriate involvement in supporting ergonomic board rounds, appropriate alerts remote outpatient support, asynchronous messages and broader case conferences.
And where remote monitoring is clinically prescribed and can practically be established:
IV. Non-clinical digital care assistants to ensure scarce clinical resources aren’t diverted onto wasteful activities–fixing ‘Bluetooth-Ache’ rather than ‘inhaler technique.’
V. Sophisticated data-science approaches to monitoring feeds to ensure that the virtual ward buzzers and bleeps don’t falsely alert and consume scarce clinical resource as evidence shows can be the case.
VI. As close integration as possible with existing clinical systems, within the reality of existing interoperability.
With these factors in place, NHS at Home can be a practical approach to rapidly creating additional capacity and assist a significant number of patients with Covid-19and high-risk, long-term conditions. In mobilising this at scale, resources need to be allocated to put the success factors in place and not be consumed by ‘digital tools’ alone. For the NHS to be able to cope living with Covid-19, virtual wards are too important to fail in a supplier led NPFiTlike product-fest.
I have managed to track my activity regularly for the last couple of years.A health check gave me a blood pressure nudge, cardio-vascular events in those close to me made me alert to my health and the ergonomics improved; the battery lasts a week, its connection setting sticks and the app has enough interesting features to sustain a password. With the right engagement to build people’s motivation and the right solution and support, we can deliver so much care via an effective NHS at Home model. It forms a welcome and critical part of emergency preparedness for future peaks and winter but this model also brings forward the personalised care at home envisioned in the Long Term Plan.