Hello and welcome to Talking digital health, a podcast by law firm Mills & Reeve, hosted by health and tech lawyers Sophie Burton-Jones and Charlotte Lewis.
Our aim on this podcast is to discuss key topics of interest to those procuring tech in the NHS and also those selling tech to the NHS.
I'm Sophie Burton-Jones and your host for this episode. I'm delighted to be joined by Dr Vivian Yiu, Consultant Nephrologist at West Suffolk NHS Foundation Trust today.
Thank you very much for having me. It's a pleasure to be here.
Thank you. And in this episode of Talking digital health, we'll be talking about digital transformation in the NHS, specifically Vivian's experience of her trust and implementation of its first virtual wards for 13 care pathways dating back to 2022 now.
So, first of all, could you briefly explain for us what a virtual ward is, please?
Of course. So, a virtual ward is a way for us to provide hospital level care to patients at home.
We know that for really patients, being an inpatient in the main hospital isn't always a very pleasant experience and many patients would prefer, if they could, to recover in the comfort of their own homes. And patients often want to be with their families and their pets and their children. And we know that for some patients, of course, being in hospital is very important.
If you need an operation, for example, you need to be in the hospital. But actually, for some patients, and especially our frailer, older population, being in hospital also carries with it some risks. And some of those risks include an increased risk of getting acutely confused because of the new environment.
Sometimes patients pick up things like infections, COVID for example, or flu. And for some patients, because they're confused in a different set of surroundings, they're more likely to fall over. And sadly for patients who are also poorly, they spend a lot of time in bed in the hospital. And we know that for our frailer patients, it's a very quick way for muscles to become less strong and potentially to waste away. So actually, they may find they come home in a less strong state than when they came in. And of course, that can be very distressing for the patients, and rehabilitation takes a long time. So the premise of the virtual ward is looking at ways to provide that hospital-level care, but in the patients' homes. And we've set up a variety of ways to do that. We can, for example, provide intravenous medications direct to patients. Normally, you'd have to be in hospital, but we can do that at home. We can provide antibiotics to patients at home. And one of the other things we can do that really helps patients feel safe and secure is that we can remotely monitor their vital size at home through a remote monitoring digital platform.
Sounds brilliant.
So how did the Trust go about setting up the virtual ward? I know there's multiple different pathways, but perhaps for your pathway in particular. And how involved were the clinicians, nurses and other stakeholders in the process?
We started back in 2022 when NHS England were very keen in the pandemic to explore virtual wards and providing digital support to patients at home. And we know that in the NHS long-term plan, chapter five talks about the importance of digital technology and supporting patients, how it can potentially save clinicians time with regards to bureaucracy and also adopting a digital first, but not only option for many patients. So in the background of that, the trust and the ICB worked together to set up the virtual ward. So I was very fortunate in that I had the support of my ICB colleagues in that. And actually, we put a team together very quickly.
I was the lead clinician for the West Suffolk Foundation Trust, and then very quickly for Suffolk and North East Essex ICB. So I would say that I was very involved from the very beginning. And what's really important is that virtual wards are digitally enabled. They are also clinically led. So what was driving the process was us thinking, what kind of care could we provide for patients at home?
What groups of patients could be suitable? And of course, importantly, what groups of patients would not be safe to manage in this way? So NHS England initially put emphasis on us looking after patients with frailty at home, and also with respiratory conditions at home. I think what made the West Suffolk virtual ward and then the SNE virtual ward and different for others is that I've really quickly looked at other conditions that we could also manage at home.
I didn't feel that we should restrict virtual wards and the hospital level care home to just certain groups of patients. So I would say from the get-go that as a nephrologist, as you mentioned at the beginning, I was very keen that my patients with renal conditions could be managed at home and that's how I came to be involved. So patients with acute kidney injury, which is a condition where the kidneys become damaged or injured because of acute illness, could be managed at home. And that was one of the first pathways that we put on.
I will say that many other trusts and systems now have developed their own pathway, and I've shared our acute kidney injury pathway with many other systems in the country.
I also felt that heart failure where the heart doesn't work properly and doesn't pump well so patients get fluid in the wrong space in their lungs or in their legs.
I also felt that that was a cohort of we should be managing on a virtual ward. And it's very gratifying to see now NHS England have said heart failure is a priority pathway for the virtual ward, but we started back in 2022 with that. And the final one was the delivery of intravenous antibiotics. I felt that for some patients, for example, with cellulitis, an acute infection of the skin, or the patient with urinary tract infections, they didn't always need to spend a week or 10 days sitting in the hospital just having daily antibiotics. I was able to see that because of my experience as a consultant on a regular medical ward. And so I felt very strongly that we should adopt these patients into the virtual ward. So we started with five pathways.
The two are dated by NHS England, and then the other pathways as well. So I was able to develop and design all of those pathways with my colleagues.
We had metering involved, of course, to oversee from a nursing perspective. And then we also had the engagement of all the specialist clinicians from all of those pathways involved.
Obviously, that took a lot of discussion and a lot of meetings. But I think it was really important that we have specialist expertise, as well as generalists in the virtual ward, because I felt that the patients should be getting the same quality of care on a virtual ward as they would do in a hospital and potentially better care, because there's a new way of working, we have to prove that it works and that it's safe in order that we can grow to other patients.
Yeah, so quite a lot of time and planning involved before you get anywhere near to the actual virtual. And was there much new technology that people needed to familiarise themselves with, or was it a case of adapting what you already had for an at-home setting?
That's a really interesting question, because at the beginning, we were given a very short time frame by NHS England to get this programme started. So in the very beginning, we knew we were going to have a remote monitoring solution. And I think at that point, I felt, well, we needed to have a system that our colleagues needed to get familiar with very quickly, but we also needed to set up the virtual ward very quickly. So we decided to go with a remote monitoring platform we had trialed within our ICB already. And that was mainly because lots of staff were already familiar and comfortable, but there were other considerations and I think we had to think about that because we needed to enable many patients with frailty, who are often older, to be able to use the virtual ward.
A lot of the technologies out there involved downloading apps onto people's mobile phones. I felt that a lot of our patients may not be so comfortable doing that. I also felt that asking patients to manually input their own vital signs into an app every day may be very difficult for them.
It may also lead to some inaccuracies in those vital signs. And of course, as a clinician, I need to have accurate data to work with. And so it's really important to me when choosing a remote monitoring platform, we make it easy for patients to use. And also, it's really important that we don't overburden those who might be looking after them, their families or their carers. And if we're asking their family member to come in four times a day to help them input data, that's asking a lot from someone to come in who may also have jobs and their own other families to look after. So the one we chose meant that we could have patients have minimal input into the platform. They didn't need to do very much. They could just wear a device. And so for patients who may have learning difficulties, for example, or patients who might have mild confusion, for example, they could still come to the virtual ward. And it's very important that we didn't digitally exclude patients or group the patients from coming.
We could also video call our patients. That was very important to us. And we also had asynchronous text messaging, which meant that patients and their families could communicate with us and our staff throughout the day and night, should they be concerned. And that provided a lot of reassurance for them.
I think for us, it was also important that we could have a system where we could provide internet access to patients who may otherwise not have that as Suffolk and Northeast Essex is a very rural locality. Some patients don't have access to the internet, and so we wanted to be able to provide them with modern and instant internet access because for some patients who couldn't afford internet otherwise, for example, we didn't want to exclude those patients.
And was this your first experience of procuring technology? And how did you find it?
Indeed, I was a regular hospital consultant before this. It was a very new experience for me. So, it was a great, but very steep learning curve. I think for me, there was a lot of thinking about not only or was clinically appropriate but having to work through the information governance aspect thinking about the interoperability with our own electronic healthcare record. And also thinking about cost and thinking about having a long-term partner who would be prepared to learn and grow with our virtual ward was also really important.
Great. And I guess we've talked so far about the kind of setting it up and getting it going, but once the virtual ward was up and running, were there any issues or changes required, and how did you approach that?
I would say that during those first few months, and even now two years on, it's our two-year anniversary in November, there's been a loss of learning. And I think one of the key things to think about with a virtual ward is that it's a very new way of caring for patients. So if you or your trust haven't done this before, you need to be prepared that there'll be a lot of things that you'll need to learn and change. And I don't think there's one step formula that works for everyone. Each of our healthcare systems is different.
Your patient population will be different. And I think your trust's appetite for risk and innovation may also be different. And I think all of those things are important to bear in mind. With myself in my trust, we hadn't had a virtual ward before. Some trusts had through COVID and so it was not a new experience for them. And they were able to scale up much quicker. For the West Suffolk, it was a very new experience. And so trying to get clinical colleagues on board with this new way of working was a long process.
It takes time to convince colleagues that it's safe to manage patients at home. It also takes time to convince patients and their families that this is a safe way to care for them at home as well.
There were difficulties, I think, with the remote monitoring platform, with workforce and staff, and there were also some difficulties scaling up. So I'd like to just address each of those difficulties. So in terms of staffing, we started off with ACP (advanced clinical practitioners). They are usually nurses by background. They can also be therapists or pharmacists, and they develop advanced clinical assessment skills. And we had a group of those starting with us at the beginning. But certainly at the beginning, they found it very different to what they were used to because they were not looking after the patients directly face to face. And so although they were wonderful and very helpful to us at the beginning, we quickly realised we needed to employ our very own group of ACPs only for the virtual ward rather than having them based in different other wards so we could train them from the very beginning about how we worked, about how our referral and assessment processes worked. And although it's taken a lot of time and investment in their education, we now have a core team who are able and very willing to support us and who share that common goal of delivering virtual wards. For our nurses in the beginning as well, some did follow it with a tricky transition from their previous roles.
We need nurses who are comfortable managing acutely unwell patients, but also in the community, very different from having hospital nurses and community nurses. And finding a niche group of nurses who are comfortable working in both areas has been a challenge and continues to be. But those nurses who have come to us and stayed with us really enjoy those dual aspects of their role. But it has taken time to build our staffing over time. And I think with the remote monitoring platform, some things we found were not every patient could still have access despite the hub.
If you live in the middle of a field, not near to any masts, and sometimes not always having electricity, it's a real challenge to deliver virtual healthcare.
Sometimes for our patients, they haven't always enjoyed using the wearable device. And for some people, they still haven't found the video calling works every time. And so when we're looking for longer-term partners with that, we do think about having a more stable platform, perhaps with greater connectivity. And our current platform still doesn't have full interoperability with our own electronic health care record.
We have found workarounds, but actually for our next phase, we very much want a partner who can actually deliver vital signs and potentially look straight into our records. And we'd also want to have better viewage of medications that patients take at home, electronic drug charts to be developed, for example.
I think you mentioned it a little bit there, but there's been some great feedback in terms of patient satisfaction, what you've taken them on that journey and they've seen how it can benefit them.
Has there been any feedback from the clinicians, the advanced practitioners, the nurses that you've talked about in terms of how they've found it in terms of, I don't know, time saving, ease of use, anything like that for them?
So I just want to touch back a little bit on the patients and family feedback, because initially we weren't quite sure how patients and their families would respond to the virtual ward. But what we've consistently found throughout the two years is that patients really, really enjoyed being on the virtual ward.
Almost every day, we have feedback from patients about how they love being cared for in their own home.
When we did patient satisfaction scores and we do them regularly, usually 98 or 99, sometimes 99.8% of patients say they found the staff helpful, friendly, and they would love for them to be back on the virtual ward if they ever needed hospital care in the future. And we similarly have a lot of positive feedback from patients' families or their carers saying it's much better for mom, dad, partner to be cared for at home. They felt really safe. The staff were really encouraging and friendly. And also they get to see a doctor every day. They get to have their questions answered every day. And that's something perhaps they don't always have in a very busy acute hospital ward. So they always feel that they're well informed.
They're able to have shared decision making. And we're also able to offer advanced care planning for our frailer patients who may be towards the end of life and we're able to put in a package around them and also fully hand over to our community colleagues and our GPs so that when they leave us they have a comprehensive follow-up planning. So when we, for example, extended the virtual wards to our care home colleagues, the feedback was similarly very positive. We didn't want patients having to be conveyed to hospital. They were very happy and keen to look after the patients who they knew so well in their own hides. But the feedback from patients and families had been really positive.
Going back to your question with regards to staff, a lot of our staff, again, enjoy the privilege that we all have of caring for patients in their own hopes. It's a real joy to see patients so happy to be looked after there at home, to be able to rehabilitate quicker. We have therapists and pharmacists, for example, who are able to go out and ensure that patients have a much better understanding of their drugs.
The infant five patients go high from hospital with a large bag, and they're able to deal with their drugs. why they're taking those drugs. And sometimes, they therefore don't take those drugs. But actually having a pharmacist who's able to go sort out their medications, spend time explaining why they should do those things have been really rewarding. And also, we find that staff really enjoy having more contact with patients compared to an acute ward where they're not running around and looking after many, many patients.
It wouldn't be fair for me to say that everything is rosy because it's not always that way. We have staff who have to travel a lot to be able to get to our patients. And travel tight has definitely been one of the downsides of the rule. In a hospital, your patients are exactly next to each other, so it doesn't take long to move from one bed to another. But obviously patients' homes are all over our locality, so our staff do find it a struggle to get around. Sometimes transporting medications and samples back to the hospital takes longer to do. And of course, our staff do work very long hours.
Bigger than virtual ward, it's operational 24 hours a day, so we’re finding that we have less staff than a regular ward. We do have fewer staff and it's a little bit trickier. So although there are efficiencies, I think like much of the NHS, we would always like to have more staff to enable us to do more for our patients.
Yeah, of course, we hear that one loud and clear.
And I guess the final question, if you were to go through the process again in terms of setting up and implementing a virtual ward, is there anything you think obvious that you would do differently or recommend others consider when they're looking at doing this?
No, absolutely good.
I think when I was setting off, there were a lot of unknowns. And I think now that virtual wards are more established, I would say, don't be afraid to go and ask others what they've done first.
When I meet other teams or support other systems at the start of their virtual ward journey, I often jokingly tell them, I've made lots of mistakes.
I'm going to tell you them all. So even if you make your own, I make mine. And I think having a really open approach to learning from all the things that might not go so well initially. I always think, when we are going live with a new pathway or a new technology, that actually we should all understand that we're here to learn.
We're all here to iterate and make our pathway and our care better. And having a no blame, but actually learning approach to our mistakes is really important. And patients and families understand that not everything goes well every single time, but actually we learn from each of those episodes so that we can do better.
With regards to remote monitoring technology, I would say that the key thing is we don't need to have continuous monitoring for all of our patients all the time.
It's important to have the flexibility to have spot monitoring and continuous monitoring. And it's also important to find a partner who can add additional technologies, such as the measuring of ECGs, such as urine dipsticks, blood sugar monitoring, etc. Make sure you don't just have the essentials, but to look and to future proof your platform.
Having a partner who can interoperate with your current system is very important. And also for our clinical pathways, it's important not to be over ambitious when you start. It's much better, and we're doing this with our new pathways now, to start with a small number of patients, a small number of admission criteria. So you build confidence and safety, and then you can expand and scale up more rapidly.
Trying to do too much at the very beginning often leads to a rather large fall, which then takes time to recover from later on. But I will say that don't limit yourself to thinking about only the priority pathways.
Looking ahead, we're looking to expand admission avoidance and step-up pathways. We're looking to provide palliative care for our patients. We're looking to expand criteria for our respiratory pathways, for our renal pathways. And we also recently have taken on board children and young people, so I think always look at the art of the possible. Don't be constrained in your thinking.
Think actually what kind of virtual ward could I put in so that all patients who are clinically appropriate could have access to this really great model of care.
That's brilliant. And thank you so much for your time today, Vivian.
If you'd like to read more about the Virtual Award Programme at West Suffolk, we're going to be publishing some linked content alongside this episode, which you can look at. At Mills & Reeve, we're very happy to discuss any legal queries you might have about NHS digital transformation generally, including on procurement, implementation, or contract management. And my (Sophie) individual contact details are available on our website at mills-reeve.com.
Thank you for joining us on this episode of Talking digital health by law firm Mills & Reeve.