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Innovation Collaborative for digital health podcast series
Conversations to share insights and learning on delivering digitally enabled services in the NHS and social care.
The Innovation Collaborative for digital health podcast series highlights how innovative technologies are being used to provide safe, personalised and more convenient care.
Episodes are hosted by former chief digital nurse Anne Cooper and former BBC TV and radio correspondent Nigel Thompson, where they invite guests to share their experiences with listeners.
During the series, we hear from a range of guest speakers about how they are scaling new technologies to support people at home to manage their health conditions and find out what motivates them to drive forward digital transformation across health and social care, whilst taking an honest look at how lessons have been learned and barriers overcome. Speakers roles and partner organisations were correct at the time of recording.
You will find each episode on this page or listen through Apple Podcasts, Google Podcasts or Spotify. Alternatively search 'NHS Innovation Collaborative' in your podcast platform.
Episode 1: South West’s ambition to become the most digitally advanced region in England
Dr Michael Marsh is NHS England's Medical Director and Chief Clinical Information Officer for the South West Regional team. Alongside his colleague, Dr Stephen Trowell, they have set themselves an ambition of becoming England’s most digitally advanced NHS region.
Michael and Stephen join us for this, our first episode, to delve a little deeper into that ambition, exploring why it’s important and what it means for patients.
Episode 1 transcript
Non-verbatim: Text adapted for improved readability
Anne Cooper: I don’t know about you, but I’m always inspired by great stories, about how people have done great work especially if it centres on empowering people to look after themselves at home well, supported by clinical teams. If you are like me you are in the right place. My name is Anne Cooper and I’m a nurse with a passion for how we use digital technology to help us to care for people. In this NHSX podcast series I will be chatting to people who have done just that. Come together and worked out how to use technology in new and innovative ways to improve care, all against the backdrop of a global pandemic. These are stories of clinical transformation with technology and they form part of the NHSX National Innovation Collaborative. If you want to know more about the collaborative please join the conversations on the National Innovation Collaborative workspace. You can find more information and a link in the show notes. So get your ears tuned in and get ready to be inspired.
Hello there. This is the first Innovation Collaborative podcast and I'm delighted that with me today are Dr Michael Marsh and Dr Stephen Trowell, who are both from NHS England and NHS Improvement Southwest. I'd like to start by asking them to tell us a little bit about themselves, Michael.
Dr Michael Marsh: Well, I'm a paediatrician by training. I specialised in children's intensive care. So in my clinical work, I used a lot of fancy equipment and certainly was engaged with seeing new developments come into care and see how they could transform what you do for your patients. I'm now the regional medical director for the south west of England and along with Steve, we have responsibility for the digital transformation of the NHS in the region.
Anne Cooper: Steve, what about you?
Dr Stephen Trowell: As Michael said Anne, I'm the director for digital transformation in the region, working very closely with Michael in the medical directorate, but by training, I was a physicist. So if you go back far enough in time, I started out building spacecraft and then moved on to designing, building MRI scans and then finally into working in the hospital environment and academia as well. So I've moved around a little bit, on a meandering path that's put me into NHS England now. But always in technology, so I got a deep interest in technology, particularly pushing the boundaries on what's possible. So it's actually interesting now to be in a slightly different world where the technology isn't necessarily cutting edge all the time. But there are other challenges in terms of deploying it and delivering that transformation that Michael described.
Anne Cooper: This is interesting. So in the south west, you're obviously part of the Innovation Collaborative and you've got high ambitions, haven't you, is my understanding. So why is it that you believe that innovation, digital innovation is something that you need and want to do?
Dr Michael Marsh: Our ambition is to be the most digitally-enabled region within the NHS in England. And I think our reason for that is with the combination of our background. So for me, close to critically ill children and I remember when I started my career - the monitors, the syringe drivers, the equipment we used - none of it connected to each other. And anything you wanted to know about what was doing, you had to record manually. And that included only the basic observations. And when children used to be referred to me from different hospitals, the only digital thing we had was the telephone to talk to each other. You couldn't share information, images, pictures, etc. And over the course of time, various innovations have changed that. So first of all I remember when we could transfer images of x-rays between hospitals - what a huge advance that brought. Then I remember when you could start to record from the monitor automatically onto a system that stopped you having to document with pen and paper what was going on. Of course, what you can see is that the logical development of technology is that all of those things that slowly can come together can be brought together. You can have more information available more easily, you can remotely look at patients who can improve their health care. So I think it's through healthcare that I was personally driven, as you could see how transformational technology can help you and that it doesn't have to be limited to people who are critically ill. I remember years ago my children, when they were teenagers, saying to me: “why do we have to go to a GP to talk to them about what's wrong when we can just have a conversation and then they produce a prescription?”. Now, that's a slightly narrow view of healthcare. But at certain times, that's all you need, a consultation and that of course can all be done electronically. Now, prescriptions can be done electronically. Healthcare could be, or even if they need medication, this can now be delivered to them remotely without getting in a car, spending hours waiting or minutes waiting. All these sorts of things can change. And so I think almost any aspect of healthcare from the highest technology and to the simplest interaction could be done differently, more effectively, efficiently and conveniently for the public.
Anne Cooper: So remote monitoring is a key part, isn't it? If the ambition that you have in the south west. Steve, can you tell us a little bit about what you've been doing?
Dr Stephen Trowell: You're right, remote monitoring is part of that landscape that Michael was describing in terms of the range of digital technologies that we're looking to develop and implement across the southwest, part of ambition of being the most digitally enabled region. Remote monitoring's part of it and I think we define that in its broadest sense. So that includes, for us, self-management of patients, as well as the active remote monitoring of vital signs from a distance. And in that sense, it covers the broad spectrum of the sort of low acuity people at home monitoring their own condition and folding that data flow into clinical processes is better than we have to date. Right through to a critical care example where you have someone who's clearly extremely ill but may be supported by a clinician who's remote from the bedside. So right across that whole spectrum and the sort of phases in between there, that's one of the areas we've been focusing on are the areas which are most critical to us in the south west from the point of view of most vulnerable patients. So during the COVID-19 outbreak, we were focused on the most vulnerable members of our society, and that included those with learning disabilities and some of the most elderly residents in care home environments in particular, not exclusively, but in particular focused on those cohorts of patients and individuals. So for us, we were then looking at how we can define packages of support for those folks in the most appropriate way. And that's not just monitoring their vital signs on a point by point basis that says, okay, we're going to measure your signs today and store that in a database somewhere. Obviously, that kind of remote monitoring technology is part of it. But more important to us was, as important, was the wider pathway redesign that goes alongside that data flow. So one of the examples that we've been looking at in the care home sector, to support the folks in home care, care home residents, is first we would put a reader on accessing clinical records in the care home environment. Which does a number of things, first of all, it can start that transformation process around interacting with that resident in a different way, whether that's visiting a GP, district nurse or geriatrician from an acute environment, whoever may be interacting with that resident. As well adding that layer on top of that, the remote monitoring aspects of what we're doing. So then that's some of the data to go into that reads the right clinical record. And that gives us the ability then to look at a holistic pathway redesign across the support that's in there for that patient. So it's not just about the technology to monitor the vital signs, it's around looking at the pathway redesign from an end to end perspective, and not just for the resident in the care home, but also factoring in their relatives, their other carers, people who know them best and understand them best, because actually some of that insight that they have into what that individual needs can be far more insightful than a visiting physician, for example. So we've been looking at how we can best support people in that environment through a range of technologies.
Anne Cooper: Michael's outlined his vision and why he has a vision to use technology in that way. And you've outlined some of the things that you're doing. But in order to make that happen, it's clear to me that you need to be able to bring people along with you. And you've already started talking, Steve, about who some of those people are. How have you been doing that? How have you been bringing people along the journey with you?
Dr Stephen Trowell: You're right, that is critical. So, as always, with digital technology, it's less about the technology invariably and more about the people. It's the people that make the change, it's the people that implement it. It's people that then behave differently on the back of it. In a work setting the technology often is not the limiting factor in terms of what we can achieve. So in order to bring people along at a regional scale, that is a real challenge, as you say Anne, and and part of the way we've done that is building on something we've been doing over a number of years, which is recognising that our colleagues in the digital space across all of integrated care systems (ICSs) in the south west effectively are part of an extended team. It's not just us in the region doing it. Clearly a lot of the delivery is done by them out there and them being defined as individuals within a clinical commissioning group (CCG) or an acute trust in the care home sector. People on the ground doing the doing, that's where the actual change happens. Doesn't happen in my office or Michael's, it happens down on the ground by those folks working differently.
Anne Cooper: I think in both of those examples, it's interesting because you've got people with a learning disability who traditionally are quite often not cared for in the health setting. And you've got residents in care homes who are equally cared for in a different setting. So that must have been a challenge working across organisational boundaries.
Dr Stephen Trowell: Exactly right. And often the answers are often found, in part, not in the NHS. So reaching out to social care colleagues, charities, the voluntary sector, often these are key agents of change and can work alongside us and are already doing a lot of work in this space anyway. So part of our role as we see it is to coordinate that activity of both the NHS and non NHS people working in this sector around a common goal. And part of the work is defining that and being really clear what it is we're trying to achieve and when and aligning the resources appropriately.
Dr Michael Marsh: One of the real things that digital technology enables us to do is to integrate what effectively is fragmentation of services. So the NHS national health system, well, the health and care of people doesn't suddenly have a care need instead of a health need. And traditionally, as you probably know from your background, a resident in a care home or a nursing home that appears to become less well or not their normal self might trigger a call to a GP or even a call of an ambulance and transfer to a hospital. And as Steve's sort of alluded to, things are different, but it's not clear what. The worry is they're deteriorating and they need some health care intervention and if possible if that could be done whilst they stay in their place of care, their home I think for that vulnerable group who are often near the end of life, that's got to be better than finding themselves in a new, strange, confusing environment. And lots of evidence suggests their outcomes would be better if they were able to stay in their own environment and involve the right people. And I think it's even though it's digital, it ironically enables much more human care to be delivered.
Dr Stephen Trowell: Just on that human factor I'll add Michael, that, you know one of the things we've been doing over the last couple of years in the south west is really focusing on the behavioural change piece around digital transformation. So what are the barriers to change in transforming? Recognising it's rarely the technology by itself that's a barrier. So working with teams, whether in a GP practice or teams in a ward or whoever it may be that's operating as a clinical team, understanding what are their barriers to change, what are they worried about? What are their personal fears? What are the insecurities around that change? Trying to address those because we recognise that it may be the best technology in the world, but if people are concerned about using it on the ground, it's unlikely to succeed. So as human factors extend into the change process and implementation, and that's something we've been doing a lot of work on in the south west and got good learning coming out of previous projects and programmes that we then fold into the remote monitoring programme that we're talking about today.
Dr Michael Marsh: And of course, we need the public to change as well. I tell the story that in the last year with the COVID-19 epidemic, there has been a great engagement with technology, particularly amongst some people who may have been averse to it. My mother is 85, used Zoom for the first time in the pandemic, having flatly refused to have anything to do with a mobile phone, never mind a digital platform where you could see people. But you know, through that she was able to meet and talk not just to her grandchild, but her newly arrived great grandchildren, my first grandchild who was born in this. And having got over that barrier she sees the advantage and is quite happy to have Zoom calls now, she even has an iPad, which I never, ever imagined happening. So I think we need the professionals, but also the public to sort of embrace the change and not be frightened by it, because when you've done things a certain way you know how to drive to the GP practice and have a consultation, but you might feel oh how do I log on to a call to engage with them and will it work? And will I do it properly?
Anne Cooper: To link right back round then to where we started your part of the conversation, where you talked about your vision when you were a practising paediatrician and to your view now about the future, where are we? What can remote monitoring do for us in the future? What transformations can it achieve, do you think?
Dr Michael Marsh: Well, I think it can remove lots of the episodes of care as we might have them. So lots of outpatients activity where you go to hospital and you have a discussion and you look at either some blood tests or things like that, that can disappear or be transferred. Some things clearly will need to have direct contact still. Likewise, I think we can hopefully get a shift from health care moving from treatment to prevention, because if you take more responsibility for your own health and monitor things, you know, there is an opportunity to intervene earlier or to not even become ill. So I think those are some of the key ones. And the other thing is that I think at the other end of the complex care is getting access to care more evenly across the population. In a rural setting, sometimes it's more difficult to access health care than in a city setting. Likewise, in a city or a rural setting, if you're in a more deprived part of the community, you may not have such easy access. And there are worries about people being digitally excluded. I think you can recognise that at the beginning and do things to enhance access for disadvantaged or hard to reach groups but I can see it helping with that agenda as well.
Anne Cooper: What have been some of the most difficult parts of all of this?
Dr Michael Marsh: Some of it is getting people to change. Sometimes I think it's not the clinical teams, but the leadership teams. Sometimes it's been a case of identifying the funding that's necessary to initiate a change and also changing the delivery of health care where you're paid to do an outpatient episode, to deliver health care in a different way. People are uncertain about how to make an organisation work financially? But those again are all solvable issues and then I suppose the other really challenging thing is because the possibilities are infinite, the health service is big, the number of people involved, there is a complexity element of putting it all together and I think it comes down to, do you think or how do I solve it all? It can be overwhelming and we need to sort of break it down into bite size bits and slowly get the bits connected that you need to, get the pathways changed, get the cultures changed, you can get the adoption. Asd I reflect back, I couldn't imagine 25 years ago when you were excited about travelling. You'd have a ticket that had 17 illegible copies in red ink for your plane ticket and you'd turn up and book into the system. We now login, do it online and have a little QR code with a ticket on your phone and you check yourself. We should see similar changes in healthcare so it's so different, you look back and go, you did what?!
Anne Cooper: I think your ideas and your vision for what the future looks like are compelling really and I wonder if the Innovation Collaborative is about sharing and trying to make sure that we spread our ideas as far and wide as we can. What are you doing in the south west to share what you're doing in the collaborative?
Dr Stephen Trowell: We have a little mantra in the south west, as well as others do, but we pinch with pride. So although we talk about being the most digitally enabled region, our mission to achieve that is actually helped when other regions are doing digital things that we're not doing. Meaning that they can do some of that heavy lifting, the difficult work that is the early implementation, early sorting out of all the issues that Michael's described there, whether it's the sourcing, the funding or the commissioning and contracting arrangements and all of the things that need to go alongside digital transformation. If we can fast follow those teams elsewhere in the country. That's fantastic for us. So that's one thing in terms of benefiting from the collaborative space that the Innovation Collaboration has set up. Equally in terms of showing what we're doing, we're very open in publishing all of our information as and when we're discovering and working through it and very happy to facilitate ongoing conversations with other parts of the country around what we're doing. So one example of that is we are very interested in the ECG work up on Teesside. And I know the clinical leader's coming down to one of our workshops soon to discuss what they've done first hand, we can then learn very quickly, take advantage of their expertise and rapidly follow suit with what they've done, so that's a two way street. So it works both ways. So that's the power of the Innovation Collaborative for us is the ability to share detailed information, because as always, with these sorts of projects, the difficulty is the grit, it's the details that trip people up and act as barriers. And if we can uncover where that grit is and what the actual bear traps are and the details that can cause problems in the deployment or adoption of the technology, that can speed things up immensely.
Dr Michael Marsh: And one of the other things Anne is that if you're going to do anything in healthcare and you want to do it to the highest standards, you need to know what you're doing. And that doesn't matter whether it's delivering basic care to a patient in a bed. But you need to know what you're doing so we have to measure what we're doing. You then need to compare it to others, if others are doing it and see how you compare and look to improve it. So one of the other things is constantly looking to record what you're doing, document what you've done, look for the evidence of benefits and disbenefits or challenges, as Steve's just described, and then try to improve it, but also share that with others so people can go ohh maybe we can do that or can we can we copy that, because besides the sort of the things that we've already talked about, I think a lot of criticism of the health service before is, well, you couldn't even say how many operations you've done. Well, digital technology, the recording system, that's going to be a thing of the past. We will be able to document pretty well everything we're doing, have it recorded automatically fed into systems which will change that data into information to inform us what's going on, what you're doing and how well you're doing it. So that's another element where the digital transformation can help us really improve health care and deliver greater value for the public.
Anne Cooper: If you were to offer advice to the people who are following in your footsteps, what key pieces of advice would you offer? You go first Steve.
Dr Stephen Trowell: Key piece of advice, I think, would be to be really clear on the objectives, because as Michael described earlier, it's a huge potential landscape. Remote monitoring itself is a big subject across the entire health system and you could, you could actively work in that space for a lifetime. So I think being really clear, what's the priority? What are we trying to achieve now today, this quarter, this year? What are those outputs likely to be? What's the clinical impact of those? And also being really open about the disbenefits. You know, remote monitoring in particular we're very mindful of issues around loneliness, for example, where that clinical contact face-to-face might be the only contact the individual has. So being very open minded around this isn't a panacea for everything, but it has a role to play. And if we are clear in defining the potential outputs, describing the clinical impacts and understanding how that links into the wider health system performance and the impacts on the practitioners on the ground, health and performance financially and outcomes for patients fundamentally, then you stand a good chance of success. I think there's a danger in trying to change everything all at once because we're all very ambitious and we're all clearly impatient. We want to make these transitions and transformations as quickly as we can, but that is not possible to do it well. So it's being very precise and prioritising effectively based on clinical need rather than being led by the technology.
Anne Cooper: Thank you. Michael?
Dr Michael Marsh: Yeah, my advice would be, one, be bold. Don't don't limit your ambition to what you can think because your thinking is likely to limit what you can achieve. So be bold. I got some great advice from my son years ago when I said, "Oh I'm not sure I'm ready to do that big challenge". And he said to me, "What do you mean? You know, Alexander the Great was 32 by the time he conquered the world and died". So don't limit yourself to thinking you're not ready to do it. And then the third thing I would say is also look for the opportunities you don't get to choose when is necessarily the right time. So sometimes planets align, people are ready, and you've got to look for when it's the right time to do something, when the door's ajar push it open and also recognise when it's not worth putting all your effort pushing against that firmly locked, closed door because you lose loads of energy. So put your energy and your focus when you can on the opportunity that's going to work.
Anne Cooper: Thank you, both of you. That's a really inspiring story to hear. I'd like to wish you well with your projects. I know that you're working on the care home work actively and on the learning disability work, which I'm sure people can read about on the website, on the Innovation Collaborative website. So thank you very much for your time this afternoon.
Episode 2: How technology enabled remote monitoring has helped NHS teams across Leicester, Leicestershire and Rutland respond to the COVID-19 pandemic
Last year, Barry James spent a month in hospital. Keen to get home, he agreed to use Leicestershire Partnership NHS Trust’s technology-enabled remote monitoring service which meant that he could be cared for safely at home.
In this episode, Zoe Harris, Leicestershire Partnership’s cardio-respiratory service lead, joins Barry to discuss his experience of being cared for remotely using a technology platform and how the COVID-19 pandemic is driving forward the rapid expansion of remote monitoring schemes.
Take a look at the Remote monitoring for patients with chronic conditions in the Midlands case study to find out more about this project.
Episode 2 transcript
Non-verbatim: Text adapted for improved readability
Anne Cooper: I don’t know about you, but I’m always inspired by great stories, about how people have done great work, especially if it centres on empowering people to look after themselves at home well supported by clinical teams. If you are like me, you are in the right place. My name is Anne Cooper and I’m a nurse with a passion for how we use digital technology to help us to care for people. In this NHSX podcast series I will be chatting to people who have done just that. Come together and work out how to use technology in new and innovative ways to improve care, all against the backdrop of a global pandemic. These are stories of clinical transformation with technology, and they form part of the NHSX national Innovation Collaborative. If you want to know more about the collaborative, please join the conversations on the national Innovation Collaborative workspace. You can find more information and a link in the show notes. So, get your ears tuned in and get ready to be inspired.
Anne Cooper: Hello, everybody, how lovely to be here with you. We're here to talk about your experiences of using technology to improve clinical services. And I wondered if we could start with you, Zoe, and if you could tell us a little bit about yourself, but also what type of services you deliver.
Zoe Harris: My name's Zoe Harris. I am a nurse by professional background, and I've been working and providing care to patients with cardio-respiratory disease for the last 25 years. I'm now in the fortunate position to be the cardio-respiratory clinical service lead, and I lead three clinical services. So that's the heart failure specialist community nurses, the respiratory specialist service, caring for people with COPD and the heart failure and respiratory community rehabilitation teams.
Anne Cooper: And Barry, I understand that you are one of Zoe's patients. Would you like to tell us a little bit about you and your health experience?
Barry James: I'm an engineering lecturer. I work for a college. Two years ago, I had what the doctor said to me was a little fluid on the lungs. He sent me for an X-ray to The Glenfield Hospital in Leicester. They said to me, yes, you've got some fluid on your lungs, we might keep you overnight to do some tests on you, and that overnight extended to a month in hospital. Which was very traumatic for me, my wife and family, although they came to see me every day, it still was a worrying time for me as well as. I came out of hospital and then, it was amazing to smell all the different smells, the grass being cut, the flowers, everything, the blossom. So, then I was assigned a community heart nurse and she came to see me and she was very, very good. Her, and at the weekends I had another one, Emma. If I had any queries or instances where I was anxious about my condition, they put me at ease, put my family at ease which was very, very good. Then a couple of months after that, I got asked if I would go on the telehealth programme, so I agreed to do that. And that, again, has been very, very useful for me. Very, very useful.
Anne Cooper: Can I come back to you Zoe? Obviously, last year, the way that you delivered your services up to then suddenly became less possible, I guess. Is that right?
Zoe Harris: Yeah, it basically just changed overnight in the sense that none of us in living memory had delivered clinical services during a pandemic. And we care for people who are vulnerable, who have long term conditions, but also can also be older people and frail. We were fortunate in that Ageing Well provided some funding for us to be able to look at digital pathways so that we could deliver our care in an entirely new and innovative way, but also make that change really quickly, taking both the clinical team and our patients with us so that we could still absolutely care and support our patients with long term conditions, but reduce some of the face-to-face contact. So, in turn reducing the risk of cross infection between people.
Anne Cooper: That sounds like it was exciting but daunting at the same time. How did the team respond to that?
Zoe Harris: I think generally the team in Leicestershire and the community are just absolutely fantastic. They are senior clinicians, and they are from a multi-disciplinary background. So, it's a mixture of nurses and therapists. And I think that despite the fact that everybody was kind of worried about their own lives and their families, from a leadership perspective there, that really shone through for me. So, we kind of articulated that we would take a product off the shelf, but the clinicians would be able to input into shaping, making it right for our patients as the project continued, because having worked in the NHS for 25 years, clinical governance is tricky and usually takes us a long time to work through getting new innovations off the ground. However, what I would say in the pandemic was that clinical governance became far quicker, so we were able to do our checks and balances and deliver safe care far quicker than we'd ever been able to before. Because that's what we had to do to keep our patients safe in their place of preferred care with the hope that we would recognise they were exacerbating sooner and then hospital admissions would only be needed if absolutely necessary. So that was the whole kind of rationale behind the plan of what we were trying to do.
Anne Cooper: So how did you decide which patients might be able to work with you on this new project, a new way of working using technology?
Zoe Harris: So we basically cleansed the patient caseloads back in March and April when we knew that we would be using digital technology. So, anybody who was clinically optimised at that time, with their consent, was discharged with the caveat they could come back onto caseload. So, we focused very much on the patients that had a need at that time. So, Barry, being a patient in point, in that his care was being delivered by his heart failure nurse and he was offered the tech in July of 2020. So, as I say, we focused on patients with heart failure and COPD in terms of the first two clinical pathways to use technology with. And that was part of our core long term condition service.
Anne Cooper: So Barry, when they approached you, what happened? What did you think about what they were wanting to do?
Barry James: I thought it was a brilliant idea because it was safer because you're not going into the hospital. I could put my data into the computer every day as I was at the beginning. There was no infection that I could get because I was just sitting in front of my computer inputting the data. And I knew that the nurses were checking that daily, which was fantastic. And I've had calls on a Saturday afternoon from a heart nurse to say that one of your readings is quite low or quite high. And so, it's fantastic.
Anne Cooper: Tell me a little bit more about what you actually have to do, Barry. What recordings do you have to put into the system? How does it work?
Barry James: I do my blood pressure, my pulse, weight, and the oximeter.
Anne Cooper: Do you key those into the computer?
Barry James: I put those into a tablet daily and it asks you questions and then once a month you have some questions to answer. And with technology anything is only as good as the people using it. And one day I pressed the wrong key. And they rang me up and said, “are you okay”? And I said “I'm fine thank you. I just pressed the wrong key.” So yeah, it works. It works for me, which is fantastic.
Anne Cooper: And as you said earlier, you were at much reduced risk of getting covid infection because you were at home and safe. And I guess that that was a positive thing for you.
Barry James: Very much so. I mean, I got letters from the government saying that I was clinically extremely vulnerable. That initially makes you very, very you know, you don't want to go out of the house and things like that. But I knew that this way my data was being looked at and in fact, I spoke to the nurses more about my condition than the doctor which was reassuring.
Anne Cooper: And Zoe, the nurses had to adapt then to quite a different way of working.
Zoe Harris: They did. But I think that they were really adaptable and flexible in terms of their patient management. And I think it's really important to know that the technology, we describe that [the technology] as an adjunct to providing care. It's not. So that actually if a patient required a face-to-face physical assessment, that would happen. But we were trying to cut down some of the routine of clinical visiting that had happened before the pandemic in the way of home visits and clinic appointments. So, it became another armory in our clinical equipment of how we could deliver care whilst reducing some of the risk.
Anne Cooper: Barry, you seem to be quite tech savvy. Have I got that right?
Barry James: Yeah. I was until I pressed the wrong key on that.
Anne Cooper: We all do that.
Barry James: Yeah. Because I've been using a similar platform with my students. I used to have students come to the college from all over England, so it was digital, the e-portfolio. I've been using a similar platform for a number of years.
Anne Cooper: So did you have people who were less tech savvy than Barry and how did you deal with that?
Zoe Harris: To be honest we tried to make no assumptions about somebody's age or frailty in terms of their ability to use tech. What we did was in every single case, we went back to our patients and said this is something we can do, you can make an informed decision about whether you want to participate in your care being delivered in this way. And then we would set an individual management plan with the person which would then take into account any disability or special needs they had. So, for example, there was one gentleman, who I remember really clearly. He was ninety-five. He was visually impaired and basically he didn't have a smartphone. So, we provided him with a smartphone so that he could access the technology and then we would call into his home at a specified time on a daily basis so that his carers could give us the information. So, I think what we did with the cohort of patients that have gone through our care pathways, which is totaling a thousand now, is look at individual patient needs and plan the care around them. I feel incredibly proud of the clinical team that I represent because I just really feel like they really stepped up to meet the needs of our patients in a really tricky time.
Anne Cooper: I'm guessing that some of them may equally not be quite so tech savvy, so they'll have had to step up and learn too.
Zoe Harris: Definitely. And I think that we work with a particular tech company, and they've been really supportive. So, I would say that we've had a very sort of hand in glove operational relationship with them. And I think throughout the projects we’ve engaged with the tech company, our staff, and our patients to constantly reflect on what we were doing, what we were learning, what was the feedback, how can we enhance it in real time. So, it wasn't just we took a product off the shelf and that was it. We ran with it. We've developed it with patients throughout the year. So, I think that is part of, I don't know, I think it's been a successful project and why it's been successful to date, because we had that way of managing it.
Anne Cooper: So as you both know; the Innovation Collaborative seeks to share learning across different projects. What advice would you give other people who were looking at wanting to start a project like this? Start with Zoe and then come on to Barry.
Zoe Harris: I think that the digital agenda in healthcare was always coming. I think the pandemic has escalated the use of tech in the delivery of health care. And I think for me kind of now, nothing is off the table. So, yes, we started using tech with our patients with long term conditions, but we quickly extended that to developing a digital rehab programme for patients. So, despite the fact, as Barry said earlier, he was shielding in his own home, actually, we could provide exercise and education through a structured, clinically led programme in the safety of somebody's home. It's really important that people haven't become deconditioned while they've been shielding. And then we also delivered a Covid virtual ward to support patients on hospital discharge that were Covid positive, again, because that's what the system required and that's been really successful. So, I think I really feel like we were given a seed of an idea in a clinical team a year ago and we've kind of grown a garden centre, that is how I feel. We constantly thought about what our patients need, what can we do to work in a different way? So basically, now the ideas keep coming and we're starting to share that now as a system so that other care pathways can learn by what we've done and think about how that is possibly applicable to the care that they provide.
Anne Cooper: I love the garden centre analogy and I also love the fact that you're starting with what people need and then exploring how anything really can help you to better deliver care in that context. Barry, what about you? What would you say to people who were looking at doing something like this?
Barry James: For me, it's been fantastic. I live very close to Glenfield Hospital in Leicester so I'm able to get there. It's probably a mile away from me. But there were patients in the same ward as me who were from 30, 40, 50 miles away. So, this kind of platform is ideal for them. And I think moving forward, as Zoe said, some of the patients are older, so they're not used to technology. So, when you move in a couple of years’ time, people will be using technology, which is just part and parcel of the daily routine. So, I think it will get easier. But for me, it's, it's been fantastic, a real godsend.
Anne Cooper: As you know, the Innovation Collaborative is all about sharing, and that's what the podcast is about. Would it be possible for you both to share what your vision of the future using technology to deliver clinical services might be? What might it look like?
Zoe Harris: Yes, we're looking at having a virtual ward. I described that we'd had a virtual ward to support patients with Covid. However, what we're looking at in cardio-respiratory is that we have a virtual ward all of the time and we will flex the beds depending on what the needs of our patients are at that time. So, in autumn, winter times, that'll be a proportion of Covid patients on hospital discharge. But also, there is a place to either step up or step down from same day emergency care pathways and post hospital discharge. So, I think what we have learnt is that and it's a little bit obvious, probably, but if we provide support for patients on discharge, you have a real chance of them not going back into hospital from an emergency position because they feel safe and supported and they've got access to clinical teams. So, we're trying to bridge the gap for individualised patient support on discharge.
Anne Cooper: That sounds like a great initiative. People don't really want to be cycling back through into admission in hospital and would often much prefer to stay at home. So, I think that's really important work Zoe. So, Barry, can I just ask you, what do you think are the ongoing benefits of this type of delivering care to you?
Barry James: Long term for me, I realise that I can diagnose the signs or what I have to do with my medication. For instance, if my swelling in my ankles or my legs gets worse, I can take more diuretic tablets. If my blood pressure is high, I know that something is not normal. So, I can then contact my heart nurse and sort that out. So yeah, it's invaluable for me really.
Anne Cooper: It sounds to me very much like technology is empowering you to be able to look after yourself. Is that right?
Barry James: Yes, certainly is, yes. It's a brilliant innovation for me. Instead of pestering the doctors or the heart nurses all the while, it just gives me and my family peace of mind really.
Anne Cooper: That's fantastic. And Zoe, how does that make you feel as a nurse?
Zoe Harris: I think that's absolutely fabulous. I think a side effect of what we've done is that patients like Barry become much more aware of what's normal for them in terms of the slight nuances that their condition is exacerbating. And actually, at that point, if they seek help and treatment, then that has a real impact on getting better sooner. So, I think this is fabulous. And, of course, what clinical teams should be doing, because we just want to empower people to be able to self-manage after they are optimised and discharged from our caseloads. I mean that's a perfect scenario in my view.
Anne Cooper: That's fantastic. Thank you so much for sharing and also telling your story about how technology enabled care is an important part of the future. And as you know, we'll be sharing that on the Innovation Collaborative workplace. Thank you.
Anne Cooper: Thanks so much for listening. I hope you enjoyed the conversation. And remember to follow the podcast series and sign into the Innovation Collaborative on the Future NHS platform.
Episode 3: How University Hospital Southampton is using technology to empower patients through self-management using a patient portal platform across Hampshire and Isle of White ICS
Ashwin Pinto is Consultant Neurologist and Chief Clinical Information Officer at University Hospitals Southampton NHS FT. Supported by the NHSX Innovation Collaborative, the Trust is accelerating tech enabled self-management for patients, giving over 25,000 patients use of a platform, enabling shared decision making and reducing unnecessary outpatient appointments by 20%.
In this episode, cancer patient Roger Burns joins Ashwin to chat about his experience of using the patient portal, specifically about how it has put his mind at ease regarding test results and sped up his communication with his clinical team.
Episode 3 transcript
Non-verbatim: Text adapted for improved readability
Anne Cooper: I don’t know about you, but I’m always inspired by great stories, about how people have done great work, especially if it centres on empowering people to look after themselves at home, well supported by clinical teams. If you are like me, you are in the right place. My name is Anne Cooper and I’m a nurse with a passion for how we use digital technology to help us to care for people. In this NHSX podcast series I will be chatting to people who have done just that. Come together and work out how to use technology in new and innovative ways to improve care, all against the backdrop of a global pandemic. These are stories of clinical transformation with technology, and they form part of the NHSX National Innovation Collaborative. If you want to know more about the collaborative, please join the conversations on the National Innovation Collaborative workspace. You can find more information and a link in the show notes. So, get your ears tuned in and get ready to be inspired.
Anne Cooper: Hello, everybody. It's really nice to be with you today. I'm going to, first of all, invite you both to introduce yourselves and tell us a little bit about the project, starting with Ashwin. Do you want to tell us who you are and a little bit about My Medical Record?
Ashwin Pinto: My name is Ashwin Pinto. I am a consultant neurologist and the joint chief clinical information officer for the University Hospital Southampton trust. And we've been involved as a trust in personal health records for probably about seven years now, but really picking up the pace of development in the last 18 months or so.
Anne Cooper: Roger, how have you got involved in this work?
Roger Burns: I'm a cancer patient, prostate cancer patient. I'm retired. And in 2012, I was diagnosed with both rheumatic rheumatism and prostate cancer. And eventually in 2015, I was invited to join My Medical Record, which I did very quickly.
Anne Cooper: Do you want to tell me about what that has provided for you, Roger?
Roger Burns: Well, I suppose the important thing for me was the lack of having to chase results from either the GP or from the hospital, because what I can do now very simply, is I can get my PSA blood test results in about four hours, five hours after I've actually had the blood test. And this has been going on for five years now. And what you can see on the website is your history of results, there's a graphical output and it puts one's mind at ease because you don't have to chase the GP to find out what the result was. And they usually say it's OK, satisfactory, but not tell you the actual result. And I'm the kind of person who likes to know the result. But it proved beneficial to me in 2016 when my PSA, which I got the results for online, was creeping up slightly and then it passed the magic marker point of five. And so, the same day as I got the result, I used the internal messaging service within the app and sent a message to the oncology department and said, “What about this”? And I was pleasantly surprised to have a reply the same day and an appointment with the oncologist two weeks thereafter. And so, there was no delay. Now if I hadn't had that service, I'm sure it would have taken a few weeks before I was seen or even talked to.
Anne Cooper: It must give you great peace of mind knowing that you can see things quite promptly and that you can communicate with the hospital when you can see that things are not as you think they should be.
Roger Burns: Yes and I also have blood tests for my rheumatology and they're the full blood count and so forth. Ashwin can probably explain more what they are, but I get them all online as well and they are generally OK. There's one or two which sometimes are at the top of the range or at the bottom of the range. And occasionally I send a message asking, am I ok, and the reply comes back within 24 hours, yes. So, what's important here to me is I've not had to involve my GP at all for five years. It's all done directly online, and I get six monthly checkups. The policy at the hospital is to have quarterly PSA blood tests simply because I underwent chemo. And that's a policy decision which is fine by me. But it's peace of mind fundamentally.
Anne Cooper: And also, I guess it helps you to feel more in control.
Roger Burns: Oh, yes. I mean, it means I don't have to faff around and chase people and find out what's happening and wonder if it's OK. I can see the results in the raw and complete peace of mind.
Anne Cooper: Ashwin, this must have been really useful over the last year when we've been discouraging patients to visit us in hospital in person. So how have you been using that system in the last year or so?
Ashwin Pinto: So I think Roger's clinical team really highlights how the transformation work has been going on for some time, but was accelerated by, sadly, the changes in the pandemic. So, Roger will tell us and I'll ask him again about the messaging function as that's so important to know about - that you can directly access a member of your team that knows your case and can give you a personalised reply, particularly at a time when. We call that team Patient Pathway Coordinators or secretaries and they’re not at their desks necessarily where the phone may ring and certainly not be answered because we're desperately trying to man all the resources we can to get to patients' queries. But it's impossible to answer every phone call on time so people have the frustration of leaving a voicemail and not knowing when they'll get that voicemail listened to or indeed a reply. It’s far better to have a system that links Roger to his team, not just to an unnamed person, but to a member of his team. We can ask Roger, do you know the people who reply to you, Roger, when you send a message in?
Roger Burns: Yes, I don't know their actual position, but I know their names because they always put their names on the message. But just picking up your point there, before I had my chemo, about two years before that, three years before that, I had radiotherapy and once or twice and I needed to ring whoever because of a missed appointment or a missed radiotherapy session or something like that. And it was very frustrating, even though I had the name and the phone number of the appointed specialist nurse to actually get in touch with anybody was quite difficult. But all that is completely resolved now because I do it online.
Ashwin Pinto: and Roger I’m going to ask you a little bit about the follow up. So, I know a little bit about urology, not much, it's been a long time since I left medical school now where we were taught about that. But in terms of questionnaires about, for example, how you're getting on, how you're feeling in yourself, you know, and so forth, do you have the opportunity using My Medical Records to tell us about about you’re feeling, normally measured by quality of life questionnaires, but we use different tools. Have you got any comments on that?
Roger Burns: There's a whole host of facilities on the app which the patient can choose to ignore or use. And one of them is, and I haven't used it for a while, I think it's called a health questionnaire. But every time you have a PSA test, you're meant to fill this in, which asks you all sorts of things about your health. How you feel, have you changed and so forth. And I must admit, because my results are fairly flat in as much as they don't change and I'm okay, I don't actually fill that in often even though I'm supposed to, but no one is particularly worried because I'm OK.
Ashwin Pinto: Yeah, but I think we would value the ability to look at you in the round. So not just your PSA, but actually you have the opportunity to tell us “actually my PSA may be just a tiny bit higher, but I'm not feeling well”. And as you know, blood tests are only one component of assessing your health, even including the PSA, which is quite a useful test. But as you well know, it's not a perfect test. But I think that’s a strength of the app, that we capture in real time how you feel you are doing.
Roger Burns: Well, that's a fair point. And perhaps I ought to respond and fill in the health questionnaire a bit more often.
Anne Cooper: I think it's really good to know that that functionality is there, though. It's really useful to know that if you want to communicate there’s an easy way to communicate with your clinical team.
Roger Burns: It is. And about six months ago I thought I had the blood forms which are given to me every year but for some reason I couldn't find them. So, I used the messaging service and said, can you send me some more blood forms? And they arrived within a couple of days in the post. So again, there's an example of not having to phone somebody up and give your details, make sure it's sent to the right person. It's all within the app.
Anne Cooper: Ashwin, I wondered if other patients have embraced the system in the same way that Roger clearly has.
Ashwin Pinto: Yeah. And again, I was going to ask Roger about it because it's very helpful to hear people's experiences about the shared letters and so forth. So obviously we now publish your letter to your GP or indeed if we write directly to you to a single repository within the app. I don't know if you make use of that. Roger, what do you feel about that?
Roger Burns: I certainly do. In fact, if I have an appointment, usually within about a month afterwards, I have a look in the app to see what's been said. And generally everything is ok. Except I have to admit, there was one occasion where there was a locum oncologist and it was a phone conversation because it was during the pandemic and what I said and what he wrote were the exact opposite. So, I dropped a message, again through the internal messaging system, just to point out what that the letter to the GP ought to have said and the reply came back, “Thanks for letting us know. We'll put it on your record”. So that was the end of it for me. But it's a facility where you like to know what people are saying about you from a health point of view.
Ashwin Pinto: I think that's the feedback we've had. So, answering your question Anne. We have other patient groups, we have patient groups in different areas, neurology is my specific area. Perhaps the difference from Roger's illness to the illness I manage is the blood tests aren't so important. More important are the patients’ symptoms, how they're doing. And we have quality of life surveys and surveys assessing patients’ activities of daily living. [They're] really important, how are they able to get on day to day? And we find that those questionnaires are so important when we cannot see people face to face in a clinic. We've always measured those things. But when we don't have the face to face assessment available so easily, or indeed patients sensibly are choosing not to attend clinic because they're concerned during the pandemic, then I think the ability to gain much more information, more much deeper information about how patients are getting on is really important. And that two way interaction between the team in the hospital and the patient is critical in getting patients to understand their condition better so they can, wherever possible, self-manage. And then alternatively, if things aren't going so well, ask us the right questions so that we can support them in making the best decision for them about change in treatment.
Anne Cooper: Ashwin in the last year, how important has this been for the trust?
Ashwin Pinto: We already had a model of looking at our services and seeing how we could improve the experience for patients. Most importantly, I think about that shared care, that shared decision making, when you have, as Roger has had it several times in his illness, I'm sure, difficult decisions to make.So we can present information to the patient, trusted information so that they don't have to scramble around and look online at sources of information that we may not believe to be particularly reliable. And then of course, they can share back and forth questions about it, about something they've seen on their record or something that's very specific to them, their particular blood test, how that influences their treatment options and so forth. So that ability to have this interaction, of course, we've had digital for years. We've been able to email to patients with their permission, obviously, because of the confidentiality side and so forth. But that is not the same as putting all of your healthcare needs into one place or your additional care record into one place. Again Roger, I'm not sure if you had experience of using email for any health-related things before, but I'm sure you'd agree that the messaging service, so that you can refer back to something you might have asked a year ago, is really useful.
Roger Burns: I don't recollect any use of email, it's all been through the app and I can't say more good about it. They're just brilliant in terms of putting your mind at ease and having responses.
Anne Cooper: What about skills? Did you find, Roger, that you had all the skills that you needed to use the technology? And Ashwin, how do patients respond in terms of the skills that they need?
Roger Burns: When I was invited, I was invited to join. I was asked if I wanted some help, but I'm fairly tech savvy. So, I found the actual app very easy to use. And what the trust did do, which they haven't done for about 18 months because of the pandemic, is they had a Saturday morning and early afternoon session where they invited any patient who wanted to come and they could actually talk about their experiences or the difficulties. And so, there was always help available to understand how to use the app. And the app is actually now very intuitive, it is easy to use.
Ashwin Pinto: I think there's been a couple of advances this year. And Roger, please interrupt as you see how important they've been. We've had a couple of things that we think have made it easier for patients. We're acutely aware of the digital divide. Of course, we mustn't always assume that because somebody is perhaps, in their 80s or 90s even, that they're not digitally literate. I'm always constantly surprised that when I start bringing it up, people say, well, I live my life on my smartphone and they're in their 80s or in their 90s. So, we never presume that. We always ask whether patients are interested and then if they're not, then that's fine. But if they have the technology and they do want to use it, then that's also fine. And we try to make life a bit easier for patients. So, the things that Roger might be aware of or might be one, is the notifications that we all now rely on using our apps. It's very important that you are notified that something new's happened rather than being reactive and having to log in and check whether a blood test has come through. So Roger will now know that, I don't know if you've had notifications through Roger?
Roger Burns: Yes, it always happens. So, if something is posted to the app, an appointment or a blood test or a letter or whatever it comes to in my normal email, and it just says, please go to the app or words to that effect, there's no information in the email about the medical side. That is correctly done through the app.
Ashwin Pinto: And the other major advance we made this year was the ability to allow patients to use their NHS login to log into the My Medical Record platform. Now, as we've all heard, one of the things that has been widely promoted this year to reduce the demand on GP services was the NHS app, which is a universal app. Doesn't matter in England which GP practice you're registered at, it will link you to your own GP practice and allow you to access parts of your summary care record and also your medication record for secondary care. We've been able to leverage the huge adoption, I think there are four million people registered to use the NHS app. We've been able to use that to offer that as an even easier way for people who struggled to remember so many different usernames and passwords. So, they have one login into both their shared care record with their GP and their shared care record with the hospital, albeit different apps. But at least one login gets them to both places.
Anne Cooper: I'm reflecting on how much has changed really and in the last few years around some of these areas. I'm also wondering, Ashwin, how much you're participating in the National Innovation Collaborative and how are you sharing your work? How could people find out about what you're doing?
Ashwin Pinto: Certainly in the ICS, which is Hampshire and Isle of Wight. We have, I think, been tasked by NHSX to look at how we can deliver that at scale across a much broader population. So, to give you some figures, I think we are at about 70,000 registrations for My Medical Record in Southampton. That sounds like a very promising number. Until you realise the trust, probably see up to 500,000 patients one way or another per year. I can't remember the exact figures, but it's a large number. So, we've got some way to go. But across the ICS we hope it will join up care. But there are plenty of pathways in which patients start in one hospital and remain under the care of a physician or a surgeon at that hospital, but also attend a regional or as we call it a “tertiary care clinic”. And the ability to have one record across the multiple places that a patient attends would be fantastic and would reduce information overload for patients in terms of one place to go that gives them access to lots of information.
Roger Burns: Well, from a patient point of view, that is vital because there's nothing worse going to an appointment where the person you are seeing either hasn't read your notes or doesn't realise there is something else about your medical condition. But I've actually had a good experience at Southampton because one department, the rheumatology department, can read my oncology files and vice versa, which is great as far as I'm concerned.
Anne Cooper: I've got one final question for both of you. That time's gone very quickly, hasn't it. Roger, would you encourage other patients to use this technology? I think we're going to know the answer to this.
Roger Burns: One hundred percent. That's an easy question. It's so good. I'd have no problem whatsoever in recommending it.
Anne Cooper: And, Ashwin, how would you encourage other clinicians to embrace a different way of delivering care using this technology?
Ashwin Pinto: I think by showing them the examples of improvements in care and actually being able to record outcome data, something that we all are very passionate about in the NHS now. To find out that our patients are hopefully improving with the treatments that we recommend and by sharing that information with the patient so they can track their progress over time. And that shared record and therefore shared decision making, which is another, as you well know, a big theme in the NHS at the moment about sharing decision making. To do that, you need to have a common database. You need to be able to see the data that allows you as a patient to make decisions. So, knowledge is power. It always has been, always will be. And by making sure that's widely available to the clinicians across often several organisations, but most importantly to the patient, that will help us transform care and achieve better outcomes.
Anne Cooper: Thank you very much, both of you. Thank you for the conversation. It was really interesting.
Roger Burns: Yeah, thanks very much. Thank you for the opportunity.
Ashwin Pinto: Thank you very much. And thank you, actually.
Anne Cooper: Thanks so much for listening. I hope you enjoyed the conversation. And remember to follow the podcast series and sign up to the Innovation Collaborative on the Future NHS platform.
Episode 4: Can telemedicine provide different ways of providing care for children and young people with chronic conditions?
How in the North East and Yorkshire they are implementing a new device that enables clinicians to provide a range of physical examinations remotely for children and young people with chronic conditions remotely.
Paul Dimitri, a professor of child health and paediatric consultant at Sheffield Children’s NHS Foundation Trust and Megan Dale, clinical lead for the Tytocare project at Bradford Teaching Hospitals NHS Foundation Trust, discuss their progress in implementing a new device that enables clinicians to provide a range of physical examinations for children and young people remotely.
Supported by NHSX funding, the Tytocare telemedicine device allows clinical teams to provide a full virtual consultation over Zoom or MS Teams, with the technology enabling them to take remote observations such as listening to the child’s chest and heart, examining skin rashes and measuring their temperature and heart rate.
Episode 4 transcript
Non-verbatim: Text adapted for improved readability
Anne Cooper I don’t know about you, but I’m always inspired by great stories, about how people have done great work especially if it centres on empowering people to look after themselves at home well supported by clinical teams. If you are like me you are in the right place. My name is Anne Cooper and I’m a nurse with a passion for how we use digital technology to help us to care for people. In this NHSX podcast series I will be chatting to people who have done just that. Come together and worked out how to use technology in new and innovative ways to improve care, all against the backdrop of a global pandemic. These are stories of clinical transformation with technology and they form part of the NHSX National Innovation Collaborative. If you want to know more about the Collaborative please join the conversations on the National Innovation Collaborative Workspace. You can find more information and a link in the show notes. So get your ears tuned in and get ready to be inspired.
Anne Cooper: Hello, everybody. It's a delight to be here with Megan Dale and Paul Dimitri, as part of the Innovation Collaborative podcast. First of all, I'd like to ask you both a little bit about who you are and how you first got involved in this work. We'll start with Paul.
Paul Dimitri: I'm a professor of child health and a consultant in Paediatric Endocrinology at Sheffield Children's NHS Foundation Trust. And I'm also director of research and innovation at the trust. But how I got involved in this project was through my connections with the Yorkshire and Humber academic health science network. So I head up one of the 11 NIHR MedTech and in vitro diagnostic cooperatives, namely the NIHR children and young people's MedTech cooperatives. We focus on the development of child health technology. And I spoke with the Yorkshire and Humber academic health science network about the Tytocare project, Tytocare being the piece of equipment that we're looking at and assessing. And I spoke to them about evaluating the technology that they're rolling out over the Yorkshire and Humber network. So we're being funded through NHSX to support the evaluation of the Tytocare project.
Anne Cooper:And what about you, Megan, tell me a bit about you and how this journey started for you.
Megan Dale: I'm a pediatric registrar, I'm doing my training to become a pediatric consultant here in the Yorkshire and Humber region. And I took a year out of my training to do a health education England leadership fellow, and as part of that, I was asked to lead on the Tytocare project at Bradford Teaching Hospitals, NHS Foundation Trust. So I was clinical lead for that project and that's how I got involved.
Anne Cooper:Megan, tell me a little bit more about Tytocare and how it works.
Megan Dale: It's a handheld telemedicine device and allows you to have a virtual consultation. So like you would chat with someone on Zoom or MS teams, you can see the child or young person at the other side and they can see the healthcare professional. But it also allows you to be able to examine that child, young person, or adult as well. So you can have a listen to their heart sounds, their lung sounds and their breathing, and see the electronic stethoscope. You can examine their ears, their throat, their mouth, and it's got a really good inbuilt camera so you can have a nice look at the weird and wonderful rashes that children present with, and you can measure the heart rate and the temperature as well. So it just allows you to take that next step from a video consult that we've all become familiar with during the pandemic and just be able to examine children and young people as well.
Anne Cooper:I think you were starting to use this equipment before the pandemic started, is that right?
Megan Dale: Yes, the trust journey with Tytocare, we first heard about it back in 2017. My colleague Matthew Mathai heard about it at a conference. And then in 2019, I guess we were intrigued about the technology. And I guess our first question was, does this really do what it says on the tin? So back in 2019, we kind of took the device and we examined 16 children right from a baby of six weeks, up to 16 years, we examined them using the Tyto device, and then we examined them like we would do normally in person with our normal stethoscopes, and normal otoscopes and things. And we compared the two and found actually it does do what it says on the tin. There were some difficulties as there is with any new technology, especially around connectivity, but the device can be utilised in two different ways.
So you can have that live online consult that I kind of described earlier, but you can also record an examination. So a parent or even the young person themselves can record an examination or a health care professional that's with them. And then that can be reviewed by a clinician or another healthcare professional at a different time. So that journey started in 2019 and started with that really. We discovered another interesting fact, there's some artificial intelligence built into the device and that's wonderful. It's there to ensure that the video quality and the sound quality is good enough for somebody to be able to utilise, but as any of who has ever met a child will know, they don't sit perfectly still or perfectly quietly all the time. So that if you're doing it in that offline mode or that kind of forward and send mode that I described, the AI will kick in to say, "Hang on a minute that child's moving and you need to re-record," but you can get over that by doing the live consulting. So there was lots of learning from that initial kind of usability pilot, and that enabled us then to do an actual clinical pilot using patients.
Anne Cooper: It sounds like it's quite important then to have some early experiments with these technologies to work out how you actually can use it in practice. Did the pandemic last year accelerate the way you were going to do the project?
Megan Dale:Yeah massively so. Back in 2019 when we started, trying to get staff, healthcare professionals and patients involved in the pilot was really quite tricky. And then when the pandemic hit, obviously everybody had to really rethink the way we work and the way that we see children and young people. And it kind of really opened everybody's eyes seeing us do things in a different way, being able to do things in a different way. And I think for families as well, the way that they access health care, it wasn't just a one way route. They suddenly saw that there was different ways to access health care too. So I would say that the feeling from both families and healthcare professionals was much more receptive to the idea of doing things in a different way. So it was much easier kind of once the pandemic hit.
We also changed our focus about pilots. I think initially we'd been hoping to utilise the device in our ambulatory care experience. That's our hospital at home children's team. But actually when the pandemic hit, I think all of us working in health care really were quite worried about the children and young people that we wanted to protect and particularly vulnerable children and young people. For us that was our children with lung problems, chronic lung problems and our children with life limiting illnesses. Those groups of children require a lot of input from the multidisciplinary teams. So they're not a group of children that you'd want to keep away from healthcare professionals, but equally they're a group of children and young people that you want to protect. So we didn't want them anywhere near the hospital as well. So we really changed our focus really to seeing how we could utilise the device to really be able to make a difference to those children, young people during the pandemic.
Anne Cooper: That sounds like it really acted as an accelerant. Paul, I know that you're passionate about properly evaluating projects and work that we do. And I also think that you're interested in that from multiple perspectives. Do you want to tell us a little bit about some of the evaluation work that you're doing as part of the project?
Paul Dimitri:First and foremost I think, Anne, is to say that the evaluation part of this is enormously important. This is a really big project headed up by the Yorkshire and Humber academic health science network. And we got involved in the bit that you described, the evaluation side. Evaluating this piece of technology, even at a regional level, is going to be hugely important as we move towards a national level. So we approached this through service user and end user evaluations. So it's about making sure that the service user is comfortable with using the piece of technology. And it integrates very well into the service. And of course the problem if we don't have service user acceptance, is that often technology then falls by the wayside because people fall out with it, they say that it doesn't work. And in fact, the technology may work perfectly well, but actually the service user isn't either comfortable with it or it doesn't integrate well with the clinical pathway or the service that it's intended to be in.
In terms of end user evaluation, we regard that as highly important. So when we started NIHR children and young people MedTech cooperative, we made sure that the ethos of everything that we do was health technology designed for children with children. The importance of that is such that if the end user doesn't like something, it doesn't matter how much the service provider is pushing for that technology and advocating the use of it. If the end user doesn't like it, they will reject it. And they'll move back to the more traditional ways of doing things. So the evaluation is about ensuring that the technology integrates well with the service, that it fits with multiple different clinical pathways. And this is the advantage of working across multiple different clinical pathways within the different NHS Trusts. So this has been rolled out across both paediatric and adult healthcare, but also that the end user will accept it as well.
And that we gather the data to ensure that's the case. There is also a third part to this as well in terms of the evaluation, which is making sure that actually from the technical side, things are running smoothly. The key to this is to say when the project has been evaluated and it's finished and the report is written that when it comes to working with other parts of the NHS or other regions, that we're able to provide the necessary data to those regions to ensure them that on those three levels, everything is acceptable so that the technology is acceptable to the service provider and integrates well with that clinical pathway. It's acceptable to the end user and in this case, it will be patients and their parents. And that's, again, important because actually there is a transition between parents using this technology and ultimately patients using this technology as they mature from being young people through transition into adolescents and adults.
And that in terms of the technical side of things, that it is that the technology is implementable in different regions. So there's a fair bit to the evaluation. As I mentioned before, we were funded through NHSX to have a full-time project manager to support that evaluation because it's an extensive evaluation. I mean, there's a significant number of trusts that have adopted this technology within Yorkshire and Humber. So the amount of data points is sizable. So you do need somebody with both the expertise and the time to be able to do this. And I think going back to your point as well, Anne, about evaluation being important, the evaluation side of things is important for every technology that we integrate within NHS clinical care.
Anne Cooper:I agree with you. And I think actually it can help us to better outcomes if we do it well and do as you say, which is to properly share the outcomes of that evaluation. Megan, you will have some early feelings having worked with families using the technology about how they're responding to it. What are your reflections about what's happened with actual families?
Megan Dale: I'll kind of reflect back about what families have found, and then just how that's impacted me as a clinician, if that's alright Anne. So in terms of what families found, our specialist nurses utilised the device, but we also gave seven families a device to keep within their home. And then of those seven families, four of those families wouldn't have had the technology or the ability to be able to even just do a video consult, which is what we were using as kind of our main consultation method before the Tyto pilot. So I think first of all, it opened my eyes. I think sometimes we just automatically assume that everybody can do a video consultation that it's quite a simple thing to do, but actually it's really not. So I think it really opened my eyes and challenged me to always think about how a patient might be able to access what we're offering as healthcare professionals. But also it's just really wonderful to be able to enable those families, to be able to give them the technology they need or the internet connectivity, or give them the training that they need to be able to access healthcare in that way. I think what the pilot really opened my eyes to is really the impact that chronic illness has on our families and the person's circumstances they're in. So I think often you might see a child or young person in a clinic, but we don't tend to think about how they got there or the impact that's had on their family. So one of our families that we utilised the device with is a mum who's registered blind and has four children with a chronic lung problem. And so for her, most weeks she's at the hospital for some kind of appointment for one of the children. And that involves either her getting on two buses, which obviously creates a lot of anxiety, she can't see. And so trying to travel into the centre of Bradford and out again is really distressing. The children are young as well. And so trying to feel that they're safe while they're doing that, is really difficult. Or involves her husband taking a day off work and he's self-employed so that's no income for them for a day. So as healthcare professionals, we think we're providing really good care for that family by seeing them in an outpatient appointment, actually we've caused lots of emotional and psychological stress by getting there. So I think it just really opened my eyes to think about the practicalities for our family, of getting to the different types of appointments that we offer them. And so for her being able to utilise this device, being able to sit in her front room with the device. It's colour coded and she can see bits of colour.
So we were able to find ways around so that she could utilise this device completely independently. So for her being able to see somebody. And we've even managed to because of the ease of it and the efficiency savings from a health care point of view, we were able to see them even before school. So the children weren't missing full days of school, the older ones. And mum was able to sit in her front room feeling safe and reassured and not having the anxiety run up to appointments about the journey to and from the hospital. And so for me, really being able to challenge myself as a doctor about not just that patient in front of me and the healthcare problem, but actually thinking about those wider deterrents of health care and the stress on families and being able to see how utilising the device have made a difference to that. We can use video consults, but for these children it's really important to be able to hear and to be able to examine the chest. So that was why we were having to kind of bring them up, or their ears, because of the condition. So being able to still examine them remotely allowed us to be able to manage them most of the time at home, which really made a big difference.
Paul Dimitri: Can I maybe make a comment on that. I think Megan's raised a really important point. And you alluded to the pandemic earlier on in your question and I think the pandemic has pushed healthcare professionals to think differently about how we deliver care. And with the simple question, do we actually physically need to see a patient? Do they need to be in front of us to do what we do? And I think Megan's beautifully described there that actually there are a number of patients where we don't need to see them to necessarily deliver care. I mean, I've heard stories in the past about this, where patients have traveled for hours sometimes because they've been in rural settings. They've traveled to city centre hospitals to receive test results. So they spend hours getting somewhere. They then wait for an appointment, go in, they spend 15 to 20 minutes during that consultation receiving positive test results only to travel back again, which could have easily been done through a different process, a telecommunications process. And this project, the Tytocare project has essentially enhanced that. It not only allows us to communicate with patients, but it allows us to provide almost a complete consultation with having the facility to do things like auscultate a patient's chest, to look in their ears, et cetera. And the impact on the families that we look after, even for those that may not necessarily have to travel far, or may not necessarily have challenging conditions, if a patient comes to hospital, the process by which they have to get somewhere to park, to check in, to wait for the consultation and to leave again, can often take up to half a day. And for parents that could be half a day of work lost and for the children and young people that could be half a day of education lost. And so if you think of1 utilising this type of technology now, in the sense of saying, well actually if the consultation only takes 10 or 15 minutes, you've saved half a day of work loss than half a day of education loss. And that can only be a good thing. And in fact, the speed at which we can deliver these consultations is also accelerated as well. So I think there are clear advantages to trialing this and other technologies to support delivering healthcare in a different way.
Anne Cooper: I absolutely agree with all of that. And I think that Megan illustrated how there's a number of barriers too to why those parents might not actually end up in clinic. They can't afford to take the day off work, et cetera. So the technology's reducing the bar to entry really for them. Megan, how did colleagues that you worked with respond? Was everybody universally positive about using the technology?
Megan Dale: It would be wonderful if we could say universal for anything, but I don't think we ever can with health care, can we? As you know, I think it's helpful when people are sceptical because it makes us think about why we're doing something and how we do it in an equitable way and if we're taking the right approach. So I really welcomed the sceptics because it really made us think about the different pathways and whether they were appropriate or not. But I think what we managed to find with our thing and what will be really wonderful to see as the project expands across the region is we managed to find a group of children, young people, families, that it was really effective with. And I think we've recorded some videos of parents giving feedback. So I think the colleagues that were sceptical, once you've been able to see and hear that were really not. And I've got to say, even the ones that were sceptical were so incredibly supportive because I think the real heart behind this was really trying to make a positive impact on children and young people so nobody's going to argue that. I think sometimes in technology projects, people that are a bit skeptical of technology, I've got to say, I'm one of those sceptics, we think, "Oh, they're just making it harder for us or it's not as good for the family. It's always better for them to be there in person." But I think what the pilot showed me and my colleagues that were a bit sceptical as well, was that actually what we think is best for the patient, isn't always better for the patient and family. And then that technology, when it's used in the right pathway can be really beneficial. So the right technology and the right pathway can be really beneficial. I think the pandemic did help as we alluded to earlier, open up the acceptability to different healthcare professionals. But one of the other things that I think was really helpful about the pilot was how it was utilised really by a multidisciplinary team. So our chest physios were heavily involved, our specialist nurses. So it wasn't just doctors saying, and I think that's always really helpful. The fact that the whole team found it really useful and actually our nurses and our physios were probably more proactive in kind of highlighting the benefits than anybody else really, so I think the multidisciplinary team approach definitely really helped acceptability across the whole team. And it wasn't just the clinical team. There's an informatics team, the IT team, the clinical engineering team, the senior leadership within the trust, multiple trusts. And I think when you think about the different infrastructures and teams involved and kind of taking them all on that journey with you, really kind of allows for everybody to come out the same end with the same feeling and same understanding of what the pilots have been able to achieve really.
Anne Cooper: One of the things in my experience of working in the informatics space is about clinical safety. Did you have to do anything specifically to make sure that you weren't introducing risk and that we were keeping everybody safe? How did you handle those things?
Megan Dale: There's a massive amount of work that went into that because obviously that is the most important thing, isn't it? We don't want to do anything that's not safe for our patients. So we did a lot of work on risk assessments and things, and for the families that had the device in their home, I think the really important thing for us was to clearly communicate when to use the device. So if your child's there with an acute breathing problem, that's not the time to turn on your Tyto device. That's the time to call 999. And I think the benefit of working with a group of patients and families that we knew really well was that we could do that, but we also utilised individual care plans to be able to really clearly illustrate that with kind of a colour-coded red, amber, green process. So there was a really clear process for the clinical team of when the device was to be utilised, but a really clear process for their families and the children and young people themselves of when the device was appropriate to be used. And actually when it was totally the wrong thing to use and when we needed to do other things. And so we were able to utilise things that already exist about red flags for children, some wonderful things that the NHS have already produced. So we're able to kind of integrate those signposting systems within an individualised care plan for each child and young person. So they'd really clearly knew not just on paper, but we went through it with them in person, when the device was to be used and when it wasn't.
Anne Cooper: Paul, bearing in mind the range of partners that you're working with on this project across the region, how are you making sure that you all stay connected to each other and learn as you go along?
Paul Dimitri: You're right. This is an extensive project, we're all in this project across the whole of Yorkshire and Humber. And so there's multiple NHS trusts involved in delivering Tytocare. And of course we're evaluating this across all these trusts. Now that the plan is, is potentially to spread out to the North East as well. And so what we needed was a platform to be able to exchange information and support this collaboration. Now, the Innovation Collaborative digital health platform has done exactly that. So for those that may not know about it, it is hosted by NHSX digital health team. And it's been established to provide a community working together to deliver technology enabled services. And of course when you're working across multiple different sites like this, you need a comprehensive platform to be able to share information, to support collaboration, and importantly, to avoid duplication as well. So it's been an enormously successful platform and I know there's an opportunity for other collaborative working groups and healthcare professionals to access the innovation collaborative digital health platform in the future.
Anne Cooper: I think listeners just can join the innovation collaborative workspace on future NHS. We're coming towards the end. And I just want to conclude really, by asking both of you very briefly to tell listeners if you had one piece of advice that you would offer them, one thing that is a single really important thing, what would it be? Paul?
Paul Dimitri: I think my key message here will come in one word, which is evaluate. So the technology in the NHS is hugely important, but actually ensuring that it works and it works for everybody, this is those that are delivering the technology, those that are providing the service through the technology, and those that are using the technology, it needs to work for everybody. So my one word, my take home message is evaluate.
Anne Cooper: Thank you. Megan?
Megan Dale: I'll go for a question, actually. Question and challenge, two words. So I think I'd just encourage my colleagues in the healthcare profession to question and to challenge just to ask that patient how they got there or to ask that patient how they'd like to access healthcare. And so really, I guess a challenge to me personally, has been to open my eyes to think about the patient and the family in front of me, and how we're delivering the health care, how they're able to access it, and is that the way we want, or is that the way they want? And if it's not the way they want or not the way that's easiest to them, how are we able to support that? Is there technology available? Is there a platform available that can help us support them being able to access health care and in a way that suits them in a way that actually provides benefit, a positive benefit, for that family.
Anne Cooper:Back to Paul.
Paul Dimitri: Can I come in because it would be remiss of me, and Megan has of course prompted me with her question. It would be remiss of me not to finish with a key message about children and young people because this project has been primarily about children and young people and for the listeners to remember that children and young people make up a significant portion of the population. They are 25% of our UK population and 100% of the future ahead. So working with them and with the families and with healthcare professionals to support the rollout of technology for children and young people is going to be vitally important for how we deliver healthcare in the future.
Anne Cooper:Thank you both very much. I actually feel quite inspired by your story about how you're using remote monitoring to work with children and families, actually. And I think you're both exemplars for the things that we need to do as we move forward into a new era around using technology for care. So thank you both very much for your time.
Anne Cooper Thanks so much for listening. I hope you enjoyed the conversation. And remember to follow the podcast series and sign in to the Innovation Collaborative on the Future NHS platform.
Episode 5: Digitising care homes: how can remote monitoring technologies help care homes improve the health of residents?
In London care homes remote monitoring technologies are enabling care home staff to take a range of clinical readings and observations to improve the way they monitor residents’ health
Rachael Lomax, deputy manager of a care home in Edgware, and Matthew Nye, NHS England’s regional director for digital transformation, discuss the impact that remote monitoring technology is having across London’s care homes, reflecting on the implementation journey and what the future may hold.
Digital devices have enabled care home staff to take a range of clinical readings and observations to improve the way they monitor residents’ health, enabling them to alert health professionals to early signs of deterioration while providing added reassurance to residents and families.
Episode 5 transcript
Non-verbatim: Text adapted for improved readability
I don’t know about you, but I’m always inspired by great stories, about how people have done great work especially if it centres on empowering people to look after themselves at home well supported by clinical teams. If you are like me you are in the right place. My name is Anne Cooper and I’m a nurse with a passion for how we use digital technology to help us to care for people. In this NHSx podcast series I will be chatting to people who have done just that. Come together and work out how to use technology in new and innovative ways to improve care, all against the backdrop of a global pandemic. These are stories of clinical transformation with technology and they form part of the NHSx National Innovation Collaborative. If you want to know more about the Collaborative please join the conversations on the National Innovation Collaborative Workspace. You can find more information and a link in the show notes. So get your ears tuned in and get ready to be inspired.
Hello, everybody. Welcome to another Innovation Collaborative podcast. I'm delighted today to be here with Rachael and Matthew. And the first thing I'm going to do today is ask them to introduce themselves to us.
Rachael, can you introduce yourself to the people listening?
Yes. I'm Rachael Lomax. I'm the deputy manager of a care home in Edgware; Sydmar Lodge. And we are currently using Whzan. We have been using Whzan for about three months, four months, and we're enjoying the experience.
That's fabulous. Matthew.
Hi. Matthew Nye. I'm the regional director for NHS England/Improvement. I lead on digital transformation across primary care care homes and supporting a remote monitoring program across London.
That's fabulous. Thank you.
I'm going to come to Rachael, first of all. Can you tell us a little bit more about what Whzan is and what it means in the care home? What do you actually use it to do?
It comes in a blue box, and in the box, we have all the tools to monitor people's observations. So we have blood pressure, temperature, and oxygen. In this blue box, also, there is a tablet, and all the devices that are inside this blue box link up to the tablet. So the observations automatically go onto the tablet, which gives a correct reading of that resident's observations, which then, in turn, that then helps the team leaders to give them an idea of when they need to call a GP, or whether it's a GP; if not a GP, to send them to hospital.
That's great. How often do you do the observations with the residents?
We do the observations on a 28 day basis. So every 28 days we do their baseline, and then apart from their baseline, we do their observations if they appear to be unwell in any way, if we notice something out of character. It could be anything. As simple as a urine infection. If they seem out of character or seem confused, we then do their observations. And it gives us a baseline of whether we need to act further.
And does it enable the GP to see the results?
Our GP has access to the results. Yep. She can access it. She was given access by the home. And I understand that the ambulance service is going to have access to the scoring, and I understand that 111 has access.
That's really interesting.
Matthew, how many of the care homes across London are doing similar projects to this that you are aware of?
So we've got 1300 care homes across London, and the aim by the end of this year is to have at least 600 of them using a remote monitoring type product. We've got five different areas across London, and they've all gone for different types of products. They are similar to Whzan. They capture vitals and they've got dashboards. And the whole idea behind remote monitoring in support for care homes is to empower the staff within the care homes to start to improve the quality of care for the patients. They're monitoring them on a regular basis, they feel more upskilled in using the products as a support for the patients, and actually, if they feel a patient is unwell, they can record the vital signs and then have a conversation with a GP. I think one of the other key benefits on this in supporting the care homes is that it will actually help focus those conversations, where the practices who are supporting the care homes, they can then focus on the patients that need the support now, or they can pick up early signs of deterioration and actually stop them from going into hospital.
Okay. I've got this picture in my head, across London, of all of these care homes with these blue boxes with this equipment in, with the teams scurrying around monitoring residents to make sure that they're as well as they can be.
Rachael, how have staff responded to the new innovation?
The team leaders are the main ones, and myself, that use the Whzan, the blue boxes. They have taken to it quite well. They do enjoy doing their baselines each month. And it gives them an idea, if they're not quite sure about the observations, whether they need to call someone. That's where they find that it helps them very much.
Do they have to do a lot of training to learn how to use the systems?
We have myself and two team leaders that are nurses. We are the super users. So we then pass on our knowledge to them and we do the training with them.
Rachael, you're doing the readings every 28 days to keep a record of the patients. If a patient's deteriorating in the month, or you think that they're unwell, do you then go and do some further observations?
Yeah, we do their observations again if we find that they're deteriorating or they don't seem to be themselves. Yes, we go on and do their observations again. And we repeat them as much as it tells us. Because we have scores; the NEWS2 score. The NEWS2 score gives us an idea of whether we need to monitor them again. So then we normally do two hourly monitoring. And then if it is just monitoring, we do that. If it wants us to go further to the next step, then we go to the next step, which is normally the GP or clinical lead.
How do the patients perceive this remote monitoring? Do they feel actually privileged to be using it, or actually get excited by understanding their own readings and how they're progressing?
Some of the residents take note of what's ... They listen to what the tablet is saying. So some of them will say, "Oh, what is my blood pressure?" And they'll comment like that. Some just don't actually respond to it at all. Some just sit there and allow us to do it.
Has it been difficult, Matthew, persuading care homes to adopt this new technology in general?
It's been a mixed challenge across the whole of London. Some areas were, I think, especially with COVID over the last year, some care homes' staff and managers are stretched, they've a shorter staff. So some of them have struggled to embed and sign up for them. I think the key for this and the key learning we found from different areas is building up the engagement before trying to roll the products out, engaging with the care homes through different forums, through the managers, and trying to explain the benefits that will be for the care home itself, for its staff, and also the benefit for the patients. And actually, by collecting the clinical readings, will actually support them, manage the patient, and also support the carers, whether it's health staff or social care staff, provide the right support for them, and also focus the care where it's needed within the care home. So it's been a challenging year for all of health and social care, and care home staff, but where we're finding the devices are being rolled out, the actual care homes, once they start using them, continue to use them because the staff feel more involved. The feedback we're getting, the staff feel more involved, more empowered. And when they're having a conversation with a GP or a nurse, they've actually got, I suppose, more clinical information to discuss and provide to the practices.
You were just talking about, you know, during COVID, and that. We actually found the monitoring system of this to be very helpful. It gave us an indication one day that one of our residents wasn't well, and we used that and it actually turned out that we had a case of COVID then. So we found that really, really useful, and it was really good for the team leaders then as well, because obviously they might not have spotted that at the time.
Does having the devices, Rachael, help for you when you're discharging or taking patients potentially from a hospital, give you more confidence to take a patient earlier, so at least you could monitor them and feel that, actually, if something does deteriorate, you can call the hospital back or the GP?
Yeah, because as soon as someone is discharged from hospital, we do their observations the day they come back. Yeah.
It sounds to me like there's a lot of benefit for everybody. How have families responded, Rachael?
Well, obviously, when we mention to the families that we've got this new device that we use and we try to explain the NEWS2 score, they don't understand it, but the ones that we have had residents that we've used it on and they've needed to go to hospital or have needed a doctor, obviously they've been very grateful that we've got that, and that we're able to flag something up that's needed straight away before this resident gets really bad and requires to go to hospital, because the aim is to try and stop them from going into hospital, if we can.
Yeah. It's about early identification, isn't it, of issues, so that the resident doesn't deteriorate? Matthew, you talked about, across London, having, I think you said 600 homes. How are you sharing the learning across the homes? Do you share and get them to help each other in their learning journeys?
In terms of the individual homes, that's normally worked through a local borough STP level, but across London, one of the really good benefits of doing the remote monitoring work over the last year has been all of the improvement collaborative that we've pulled together across London, and also nationally. Because this has been a learning journey. Not just for the care home staff and the GPs. It's also been a learning journey for the commissioners to understand, "Okay, how do you procure a remote monitoring device? What is its specification? What does it need to look like?" And engaging with the care home managers and the GPs. Trying to understand, what do they need and what do the devices need to look at, and what type of clinical measurements are useful for working.? So across London, over the last year, every Friday we've had the key commissioners, and NHSX and NHS England, all the people involved in supporting this have been coming together to share their journey, to share their questions, because even putting together a specification was really challenging. So each area was sharing their current drafts, and we were borrowing bits and pieces from, not just from in London, but we use some of the specifications from the Midlands. So there's been a collaborative approach, not just across the region, which has been really good to see, but across the whole of the country, as we've been going on this journey together. And it's not just the specifications, it's been trying to work through some challenges that have been fed back from the team trying to implement this on the ground with the care homes and the practices, around, when should you alert a GP to a certain change? When should the GP log in to look at the dashboard? How do we support the training of the staff in the care homes? And then actually, what devices are working well? So the improvement collaborative, not just in London, but nationally, has helped shape our whole journey over the last year. And everyone involved in this whole project has been completely open. And when someone's had an issue, someone else has already solved that issue somewhere within London or nationally. And we've been benefiting from that. So that whole process of being open and working together across the whole system, and thinking, "Actually, this is a learning for all of us," I suppose, has benefited, not just London, but I suppose the other commissioners across the country.
That's absolutely great to hear. Transparency and openness in this sort of space is definitely a way to accelerate people's learning, I think, isn't it? Matthew, I understand that you're doing some work with the 111 services across London as well, and integrating some of the work with care homes. Do you want to tell me a little bit about that?
So in North Central London, with a small number of care homes, we're trialing a pilot of, when the NEWS2 score reading changes with the patient, there'll be an automatic alert sent into the 111 clinical assessment service. So they will get an alert into their clinical queue and then they will call the care home back within a certain time period. So we're trying to identify support early. As soon as a patient changes their clinical conditions over a certain NEWS2 score threshold that will send the alert in, and then they can proactively call the care home and offer advice and support. And hopefully, we'll find that that stops further calls into 999, and patients going into hospital. But it's in its early stages. We've got two or three care homes working with 111 to actively trial this, and then hopefully we'll see the benefits and then we can roll that out across other areas across London.
That sounds like a great example of how remote monitoring can be integrated further into the health system to provide the best support for care homes and their residents. Rachael, to come back to you, you've talked a little bit about NEWS2. I wondered if you can elaborate a little bit more for people listening on what that really means.
Okay. So the NEWS2 score is a score given as a result of the scores for the observation. So when the observations are entered into the device, into the tablet, on each observation that's put in, when we get to the end of it, we've put all the observations in, we have to put in whether they were breathing normal air and whether they're more confused than normal. That then gives us a score, and the score sort of goes from one to seven most of the time; obviously one being to monitor, and then up to five ... For instance, today, I had a lady that was five. So that is to review. So again, we would have to review her again in the two hours. And then obviously, before, I have had it where it's gone up to seven, even into the eights, where it's escalated then to an ambulance needed to go to hospital.
It's a standard scoring system, isn't it? It's a recognized scoring system, NEWS2, isn't it, Rachael?
I was just wondering, I think there's tremendous work that's going on, and having elderly relatives myself, who are in care homes, it's great to hear and it's reassuring to hear it's going on, but I'm interested in, I guess, what you might tell somebody in a care home who wasn't doing this, where to start from, and perhaps the steps that they should take to move forward. I'll start with Rachael first.
We find it a good asset to the home. I like it, again, because like I said, I can be reassured that the team leaders know when to call someone. I would really, really recommend to anyone, any care home, to start using it and to try it.
Matthew, what about you? If you were advising a care home out there somewhere, where would you advise them to start?
I think remote monitoring provides several benefits to the whole system and to the care home. And I think it provides a level of confidence and assurance to support, I suppose, patients being discharged from hospital, that that care home can confidently manage that patient and monitor them on a regular basis. So if they've just recently had an operation, to support that patient come back to their place of residence and into their safe room. I think it gives confidence to the family that they're being monitored. It gives constant assurance to even the staff that they are capable of looking after these patients. If they're worried about a patient, they've actually got metrics to help them monitor the patient, "Oh, actually, they haven't changed," or, "Actually, they are deteriorating," or, "Actually, they have improved." So I think the whole area of remote monitoring just provides a level of assurance and confidence from the family through to the staff, to the care home managers, to even the nurses and the consultants discharging patients in hospitals. So a 999 crew who's come round to have a look at a patient, if they know that the care home has got devices in place, they can say, "Actually, monitor this patient. If it deteriorates below this level, then please call us again." So I think it's that ability to look after the patient in their place of residence and look after them safely. And it also improves the quality of care, because the care home can act quicker if they can see a deterioration that may not be visible from the patient, if they're regularly monitoring them on a regular basis.
That's fantastic. Thank you. Final question from me. Rachael, you're allowed to give one single piece of advice to another care home who are not using this system. What would be the one single piece of advice that you would give?
My advice for them would be to go for it. 100%, go for it. It's been so good for us. We've found it so, so helpful. Very much. So helpful. Even our GP is so on board. She walks into her weekly visit and the first thing she says is, "Let's Whzan. Let's Whzan." She'll have us Whzan everyone when she comes on her weekly visit. So go for it. 100%, go for it. It's worth it.
Thank you. And same question to you, really, Matthew. What would you say? I know you've talked a lot about the benefits of the system, but if somebody was just at that tipping point of thinking whether they were going to do it, what would you advise them to do first?
I would advise them to go and have a conversation with the GPs and the clinicians that are supporting them as a care home, and go and have a conversation with another Rachael or another care home that's using it, because the feedback that we get, that if care homes are using it, they see the benefit and the staff feel happier supporting the patients. But one of the key learnings that we've identified is that, before you implement it, work out the pathways of, when something happens, when do you contact the GP? What are the escalation points? And working with the GPs that are looking after those patients; what are the measurements when they need to be alerted? Just working through that. So the simple operational process of what to do next if a reading goes to a certain level and actually how to implement it.
That's lovely. Thank you. And of course, they can always go to the Future NHS Innovation Collaborative site and find information on there, like, I think, Matthew, the specifications that you were talking about earlier on. So that's fantastic. It's been wonderful to talk to both of you. You're both great advocates for this technology, and I hope other people are inspired by the conversation. Thank you.
Thanks so much for listening. I hope you enjoyed the conversation. And remember to follow the podcast series and sign in to the Innovation Collaborative on the Future NHS platform.
Episode 6: Successful partnerships - aligning the worlds of Digital and Quality Improvement
In episode 6, Anne talks to Bob Kalber and Kevin Jarrold from Imperial College Healthcare NHS Trust. They discuss their journey in aligning their two worlds to drive improvement in care delivery enabled by technology.
Episode 6 transcript
I don’t know about you, but I’m always inspired by great stories, about how people have done great work especially if it centres on empowering people to look after themselves at home well supported by clinical teams. If you are like me you are in the right place. My name is Anne Cooper and I’m a nurse with a passion for how we use digital technology to help us to care for people. In this NHSx podcast series I will be chatting to people who have done just that. Come together and worked out how to use technology in new and innovative ways to improve care, all against the backdrop of a global pandemic. These are stories of clinical transformation with technology and they form part of the NHSx National Innovation Collaborative. If you want to know more about the Collaborative please join the conversations on the National Innovation Collaborative Workspace. You can find more information and a link in the show notes. So get your ears tuned in and get ready to be inspired.
Hello, everyone. It's a really great pleasure to introduce you to this particular podcast from the Innovation Collaborative. This one is slightly different from the other podcasts that you might've listened to. In this one, we're looking forward into the next phase of the Innovation Collaborative and it will be increasingly important for us to demonstrate how technology contributes to quality improvements. And I'm hoping that the two people that I'm going to speak to can help us to understand how that's the case. So I've got the great pleasure of having Kevin Jarrold with me and Bob Klaber, who are both from Imperial but I'll let them do the great honour of introducing themselves to you. So, first of all, Kevin, can you tell me a little bit about yourself?
I'm Kevin Jarrold. I'm the joint chief information officer for Imperial College Healthcare Trust and Chelsea and Westminster. And I also have a similar role across Northwest London CCGs and the Northwest London ICS. I've had a career in health service information and IT, and been driving forwards the whole transformation agenda over a good few years now.
That's lovely. Thank you. That's a big job. That's a really big job. Bob, what about you?
So I'm Bob Klaber. I'm a paediatrician and I'm also the director of strategy research innovation, which is a really fun and somewhat infinitesimally big job here. But I have a real interest in learning and how people learn and teams learn and systems learn and I guess through that, improvement. And have done quite a lot around quality improvement and more broadly thinking about how you improve things, how you change things. And I guess really focused on the people side of that.
That's another big job, isn't it? So I guess in my experience over the last decade or so, you two are probably two unlikely people, partners to be working together. So how did you realize that the work that you were both doing was interesting to each other, and how did that synergy arise? Do you want to start Kevin?
I guess the issue around technology and around sort of moving forwards the whole digital agenda is that technology's only part of it. So the key thing for any successful implementation of a large and complex system, it's about the people and the processes as well as the technology. The technology's got to be there and the technology's got to work. So I guess Bob and I sort of started working together and as an organisation, we have a real tradition of some really strong clinical leadership around our whole digital and quality improvement agenda. So it's through that collaborative working around making sure that when technology comes into the organisation, it really delivers the benefit for the organisation. I guess that's how the dialogue started. And then Bob has been driving a whole quality improvement agenda and we found that we could really usefully apply that quality improvement agenda to the way in which we were taking forward the delivery of the digital strategy. So Bob you'll recall some of the... using that big room methodology to the digital and then we had some really fantastic sessions with a lot of different people in the room, where we're brainstorming how we can drive a particular project forwards. I remember a whole series of discussions around the way in which we were driving forwards the implementation of a North West London Care Information Exchange, which was an initiative that puts patient records in the hands of the patients and fundamentally changes the relationship between the patient and the way in which they received their care.
Thanks, Kevin. You're bringing about loads of really happy memories of all sorts of really good things. I guess the bit of the jigsaw that I'd want to just add into that is if you... and I think your point about clinical leadership is really, really well-made. And we're really fortunate here as an organisation, as you say, that sort of culturally that's been something that has been really valued. And so as a youngish consultant, I've been a consultant about 12 years now but early on in my career as a consultant here, I felt a real sense of opportunity to really try and get things done and to try and improve things and transform how care was being delivered. Now, if you follow that through and the world that we were living in, in the sort of 2010 onwards, it was becoming incredibly obvious that technology, digital skills and opportunities, how we use data was just going to become a bigger and bigger and more important thing. So there was me thinking about, right, how do we improve the lives of our patients? How do we start thinking about population health? How do we start tackling some of the issues of quality and equity that we've got in our system? And you'd be absolutely nuts to not want to utilise everything that we've got in terms of our digital capability. And I felt incredibly lucky to be at an organisation that, strategically, for a long time had been really focused on thinking quite big and bold about digital capability and the sort of plans... We've long had an electronic health record. We were early on in the Global Digital Exemplar phase. And that gave a great opportunity for us to really think about how these things land. But I guess it was easy to watch perhaps some of these amazing technologies being somewhat under-utilised. And I think that's often because we've not really done the people piece. So exactly as Kevin said, the opportunity for us as leaders to work together, to work with our staff, our colleagues and indeed our patients. And we can maybe come a bit to how we get patients involved in this because I think that's another important dimension. Getting people really involved around that early on and recognising the more we could do together, the sum of our parts would be greater, has been really key. So it's very much an ongoing journey. I think we've still got a bucketload of work still to do and there's more we want to try and do around this, but I think we're both really convinced that if you can marry up the people with the processes and some of that really big vision around what tech, what data can do for us, we could get to a really exciting place.
I guess once you two had both realised that there was some synergy there and there was a meeting of minds, you had some work to do to persuade your colleagues, I guess that that was the case. So Kevin, how did you persuade all of the hard IT folk that this is what we needed to do.
So what we have is we have some really high quality technical leadership within Imperial. Really high calibre, really good quality and over, I guess, a period of more than a decade now, we've established really good working relationships with the clinical leadership within the organisation and the operational leadership. I always think of it as there's like three sides to this. There's the clinical, there's the operation and there's a technical and all three of those have to come together in a synergistic way if you're really to deliver the benefit from implementations. So as an organisation... I mean implementing an electronic patient record and as Bob says, we've had the benefit of it for years but it wasn't a simple and straightforward implementation. A really complex implementation that, for a whole variety of reasons about the way in which systems have emerged in the past, that took us a good few years to actually get to the stage where we were putting something in front of clinicians that they could actually use and really drive benefit from. And through that whole phase, we had some real engagement from the clinical leadership around that digital agenda, who had a commitment to start with but stayed through all the challenges and the ups and downs as we were going through that implementation. And then I think they arrived at a stage where we've now got an electronic patient record. They'd been able to help shape that electronic patient record. And we're now really starting to be able to drive the benefit out of it. And it's a benefit in terms of both the way in which they can interact with the patient, but also the value that they can start driving out of the data. And as Bob mentioned, the Global Digital Exemplar programme helped us escalate the way in which we were able to take that agenda forwards, by enabling us to put in place a cohort of divisional chief clinical information officers. So we'd had chief clinical information officer at the trust level, but we were able to have divisional chief clinical information officers. And we were also able to put in clinical leadership around our data agenda and around the way in which we were driving transformation. So I guess it's, coming back to your question, it's about the way in we've been able to collaborate across the organisation over a lot of years, working together to actually tailor that whole agenda forwards.
The other thing I might just chip in on is how we have a real privilege as clinicians in that we're spending lots of our time there in interactions with patients and with their families and with their carers. And that that is an absolute privilege. We work as an organisation where whatever the job you do, you're trying to contribute to that care. Whether you work in finance or you work in IT, or you're the cleaner, or you're helping with the administrative side or in my case, you're the paediatrician. We're all trying to do the same thing together. The privilege I have is that direct interaction. If you like, you're closest to the user case. And I think one of the other key arguments about why this marriage up of people who are working clinically, who understand the improvement and change at a people level, with the technical capabilities, you start to get into conversations around the workflow. You start to get into conversations around what is the user case that we're trying to solve and tackle here? And I think one reflection and it's really lovely to have this conversation actually think, think about the how of how we got to where we've got to over the last decade. It is a genuine, an openness and a real curiosity on both sides of it, the sort of story, to really understand and understand each other's worlds. I'm never going to be a technical expert in the way that Kevin talked about the technical leadership but actually I don't need to be if I'm working in close partnership with the teams. And what happens is over the years is friendships build and people will, if you like the threshold for asking questions and flagging things just goes lower and lower and lower. And people will catch up with each other at the end of the day for a coffee or a beer and say, "Well, how's this going? Let's talk this stuff through." And I think this stuff is hard. It's really... it's difficult. A lot of it's not being done before and doing it in a way that's open, where you're trying to share and learn together as you go along becomes really key. And I just do want to bring in the patient piece. So one of the things I think we've tried to be quite bold about and from quite early on, is bringing... we've had a very strong patient involvement and engagement approach across the trust that we've really looked to build over the last six or seven years. And this area around digital transformation was one of the key places that we started to point that expertise and that input from local patients, from carers and at really quite a strategic level. So I think there's lots of good examples across the country and across the world where people use patients' lived experiences to influence how things are set up and that's incredibly valuable. But I think we've also found that many of our patients can have a very good strategic view around how we utilise data, around how we think about digital implementation, about the acceptability to people around how technology may well change the way care is delivered. And that's been absolutely invaluable to bring them in. So almost there's a third arm to this partnership around the technical side, the clinical and operational as Kevin's described, and then this where's the patient view and voice in and around this. And that's been really rewarding as well.
So Bob, I'd also reflect in this, the way in which we've worked closely with colleagues in our communications department. So not everything works well straight out of the box, does it? And kind of like we've learned a lot of lessons so we do almost like an after-action review when something hasn't landed right. And we've used the quality improvement methodology to reflect on why didn't it land in the way in which it did? And through that process, you'd identify, there's an absolute key role to be played in terms of using professional communications approaches to actually get some of those messages across. So we've had a member of the comms team embedded in the IT team, who sat in those meetings with clinicians, who's worked with us, who's then helped us hone the messages that we've then taken out to the wider organisation. And that's really helped, I think, those messages land, and they've also helped us with the... bringing in the patient voice. So as an organisation, we developed an approach where we've had a group of lay partners that have helped the organisation in terms of its wider planning initiatives and its other approaches to the way in which we're redesigning services. And then we've had a subset of that group that has really helped drive the digital agenda. And we've got to know some of those people really, really well. And they've had a fantastic input into the way in which we've shaped and designed projects. They've sat in the big rooms when we've been discussing how we do up drive the improvement. They've been absolutely material to the way in which we've taken a whole range of initiatives forwards.
Yeah and Kevin, it makes... I totally agree. And I guess when I look to some of the challenges ahead, digital inclusion would be right up at the top of my worry list and I suspect lots of people listening to this conversation. The idea that we would try and approach tackling that agenda without having members of our local community, patients from some of the groups that are most likely to be disadvantaged or excluded, front and central to that, would be absolutely nuts. I mean, you can bet your bottom dollar people are trying it without them, but I think in a sense, the longstanding trust that one builds and I think trust is probably a really important word to come in. But this is based on trust and based on relationships and that's spending time together, that's getting things wrong. And exactly as Kevin said, being able to have this space and reflection to be able to look back and think, actually, we really didn't get that right and we need to try and learn from that so this continuous learning piece. One other bit that I think it's worth just drawing out at a quite strategic level is, I'm interested in, Kevin you and your role, there's sometimes some big things you need to try and land across an executive team, round up a case for investment would be a really good example. And in lots of ways, the case seems dead obvious to you and you've done all the hard work and the business case completely stacks up. But the risk is, is to a big organisation that's busy with a lot of stuff is it can feel a bit on the side and the returns are in the long-term piece, aren't they? The value to patients might be three, four, five years down the line around some sort of impact in long-term conditions or the like. And I think it's been really helpful, Anne, for us to work out about the strategic collaborations across different members of the team. So in fact, Michelle, who Kevin mentioned the communication team. Michelle Dixon, who's our director of communication engagement, really strong advocate for the patient voice. She would really pile in behind some of this stuff. I can come and bring in some of the change aspects and some of the people aspects around the clinical side. I think if we look how we've been as an organisation, Kevin, it's helped us land some of the perhaps quite big, difficult decisions that maybe in years gone by, we might've kicked down the road a bit. I don't know what your thoughts are on that.
No, it's absolutely true. So it's an enormous challenge getting an organisation to want to spend money on IT, isn't it? So you're in a competition with... you've got buildings that have got backlog maintenance on them, you've got medical equipment. Do you want to spend the money on a machine that's going to save a small baby's life or do you want to spend it on IT? You have those kinds of dilemmas, don't you, in the organisation all the time. And it's really about building a coalition, isn't it? Where it's kind of like it's creating a compelling case about why the investment needs to be made, being really clear about the benefits. And I think that the patient voice was... when I think back on the Care Information Exchange and I was just reflecting on... you'll remember we had Parker Moss do a presentation to the annual general meeting around the way in which the Care Information Exchange had had a material impact on the way in which he was able to manage his daughter's health. That was a really powerful message to the organisation about the value of technology, wasn't it? And I'm sure that that was material to us being able to sustain that until we were able to secure ongoing funding for it.
I totally agree. And there's something isn't there about how people whose jobs and roles are in technology and in digital transformation, in the sorts of roles that you've got. There's something about helping the people around you who may be slightly technophobic or certainly the language. I mean you accuse us doctors, Kevin, of talking in strange, in Latin and stuff like that but I mean, you guys take it to a different level. But there's something isn't there about us, about helping people to really understand. And as we touched on earlier, I don't need to be a technical expert in this, but I need to understand enough. I need to know my way around it to have the confidence that I do. And I think thinking about chief execs and boards who've got to make decisions on this stuff, there's something about the capability around technology and digital transformation. That there's a responsibility on us all to make sure that the capability is high enough for people to recognize some of the really key issues. One we haven't touched on, cybersecurity would be another good area to go that good proactive organisations can be taking that stuff very seriously in a proactive, preventative way. It feels to me that we've got quite a team effort in trying to build up that capability across our colleagues.
Yeah, just brought to mind, Bob, you remember we did those digital showcases?
Where we took over one of the education centers and we had a whole series of different presentations aimed at trying to get... in a way it was the, before I die, I just want my PC to be proud of me. It was like, we've got all this digital capability, we just need people to start using it and exploiting it. So we ran these showcases and we must have had several hundred people pass through the event in the course of a morning. And then we took a cut down version of that and we did it for the trust board and the focus of that was it wasn't techie, describing something with 47 PowerPoint slides. It was clinician talking unto clinician about, "Look how I can do this voice recognition and this is really cool." So it was about the clinicians saying how they'd been able to use the digital to transform the way in which they were interacting with their patients and delivering care. And they were sharing that with other clinicians who could then understand it and take it away and exploit it.
Yeah, they were really fundamental for mainstreaming change and actually, you and I always looking for more work together. It just strikes me as we hopefully start sneaking out of COVID and having a few more opportunities, we should really think about getting those going again because I think so much has happened. There's a bit of catch up, isn't there? For everyone who's coming along. So there you go Anne, you might get yourself an invite to one of these crazy showcase events.
I think one of the things that I'm reflecting on is how you've both obviously come together to coalesce around a single idea, which is about improving services for people who need them. And in that you've developed I think, a single language, that you can share across the organisation that everybody can sign up to. So it strikes me that the quality improvement style way of thinking is the thing that's coalesced you around a single purpose. That's what I'm hearing, I think.
Yeah, I think that's a really good spot Anne, although one of the things I... in the sort of quality improvement community that I've hung out with for the last decade, one of the things that I'd be quite critical of us of in a reflective way, is we've slightly shrouded quality improvement in overtechnical language. And if you think about in a sense, I mean, the word quality has complexity to it and lots of different definitions around it. We talk about SPC charts, statistical process control charts, will be plenty of people listening who know exactly what they are, but there'll be other people who will switch off the podcast and not listen to anything more now I've mentioned it. And I think part of the art of being actually good at any job is how do you explain things in a way that is accessible to people, that encourages, that supports people. That's my job as a clinician, to try and explain things to people in the most straightforward way. And I think there's a lovely, sort of shared problem, is that people who've got great expertise in tech and digital are absolutely, as I was teasing Kevin earlier, able to talk in a language that's completely impenetrable, when they're talking about Hadoop clusters or something like that. And likewise, us quality improvement folk, have made the same mistake. And there's something we've done in QI that it's almost as if we've tried to... almost butting up against research have said, look, this is a serious practice quality improvement. It has rigor behind, it has methodology and therefore it's got lots of long words to describe it. And we sort of shot ourselves in the foot because the risk is it gets stuck with what I call the innovators, the early adopters and the evangelists. They're the only people who do this stuff. This has to be, this is the work. This is mainstream, the work. The idea that you can deliver care without thinking about continuously improving it. And without digital technology supporting you and data underpinning it, is nuts and it's only going to grow in that way. That has to be how everybody's delivering care. We've got to make it more accessible. And I think a combined effort across the community who are brought up in a digital sphere and the community who were brought up in an improvement sphere, there's a real chance for us to come together and actually have quite a deliberate conversation around it. How are we going to really make this understandable? And I think as Kevin's pointed out, the clue is to really ask our patients and the communities we're here to serve. How does it land best for them? Because I think that'll also pick up the digital inclusion piece that we just flagged a bit earlier as a bit of a worry.
So then if I was CIO or CCIO in a trust and I was listening to this podcast and I was thinking, yeah, I think they've got something here. I think they're really onto something. Where would you think that they would be best starting?
I think it goes back to Bob's point, it's about relationships really, isn't it? It's about building the relationships between the teams within the organisation and building those coalitions and alliances around a kind of shared set of objectives. And I know that we, as an organisation, have put a lot of effort into developing the values of the organisation. So there's a way in which it resonates with the leadership of the organisation and the direction the organisation is going to travel. Coming back the point about how you secure investment in the digital agenda, you do that by making sure it's aligned with the overall direction of travel that the organisation wants to go in and it's delivering the things that the organisation recognises that it needs. So I think it's about forming those alliances and, and developing those relationships.
Yeah, I totally agree. And I think there's also, with those alliances is finding people who you really deeply get and understand the people side of it. So Kevin talked about his team. Over the years, I've got to know lots and lots of people in the ICT team. And I have a really deep and fundamental belief that their reason for coming and working at Imperial College Healthcare and the NHS is exactly the same reason as my reason for coming in, working as a paediatrician. It really is the same thing, about trying to deliver patient care. And they've got a skill set that I don't have and I've got some things that I can do around. I'm sure some of them would look at trying to put a cannula in a child and think, no thanks. And that's great. And we've all got our skills, but I deeply believe that we're here together to try and achieve the same thing. And what that leads into is all sorts of things. So a little story from COVID is the extraordinary people in Kevin's team, who were right in the heart of our intensive care unit. So all of the pictures in the newspapers and everything, everyone listening saw on their news channels was of doctors and nurses and therapists doing absolutely incredible and extraordinary things. But some of Kevin's team were out there also doing extraordinary things in full PPE, trying to set up communication mechanisms for families to be able to talk to their loved ones because they couldn't come and visit, be a really good example. And quite understandably, a number of people in those situations were very, very anxious about getting COVID themselves. Kevin had a whole load of members of his team, isolating in local hotels, not going back to their families because they were so anxious about taking COVID back to their families. Now, of course we were worrying about that sort of stuff as doctors and nurses but one of the privileges we've got is we hang out with other doctors and nurses and experts in infections. So it's dead easy to say, "Hang on. How worried should I be?" And "Does this PPE really work?" And all these sorts of things. Much harder for Kevin's team, the technical guys who are getting out and setting up the Wi-Fi and the screens and things. So one of the things that I did with the help of one of Kevin's senior managers was, with a lovely colleague of mine, Fran, is we ran a couple of webinars just to basically make ourselves available to, "You can ask us anything you want about this COVID thing. And there'll be a whole load of stuff I don't know the answer to, but we'll have a really good go." And that was just a really nice example about recognising we're all people, we all got our same things that we're so worried about. We're actually all one team trying to do the same thing so you've got to look after each other. And I think that culture is absolutely key and how you get that culture is through leadership and the leadership approach. And that's lots of hard work and lots of commitment to really saying we value people. So I think that story perhaps underpins a really long-standing commitment say, "Look, we're really all in this together. Let's look after each other and let's do our best together for patients."
That's a lovely way to end, I think. And I'm very grateful for both of your time to tell some of this story. I'm really heartened that both of you have seen people, relationships and patients really at the heart of what you're trying to achieve. So thank you. I'm sure lots of people will want to talk to you about this. Thank you very much for your time.
Anne Cooper Thanks so much for listening. I hope you enjoyed the conversation. And remember to follow the podcast series and sign in to the Innovation Collaborative on the Future NHS platform.
Episode 7: Moving the dial towards digital inclusivity - people, purpose and the potential of technology-enabled remote monitoring
When it comes to health, how do we bridge the digital divide? This podcast, hosted by our reporter Nigel Thompson, explores the relationship between digital inclusivity and health and care equality and has been released by the National Innovation Collaborative for digital health.
‘We’re rapidly becoming an online nation, but what about those who aren’t online?’ This episode takes us to Leeds in West Yorkshire where Dr Bola Owolabi, Director of Health Inequalities, NHS England and NHS Improvement and Roz Davies, Managing Director of Thrive by Design, discuss the needs and expectations of seldom heard groups, reflect on key learning, progress, and offer advice for teams working to support people through digital innovations like technology-enabled remote monitoring.
Episode 7 transcript
Nigel Thompson: We are rapidly becoming an online nation. By the end of 2020, research by the communications regulator Ofcom showed around 94% of UK homes had internet access, up from around 89% in 2019. But what about those who aren't online? 6% of households do not have access to the Internet and 14% of adults make use of the net infrequently. Older people are less likely to have Internet access at home. Ofcom's research shows 18% of over 64s don't have access at all. So, when it comes to health, how do we bridge the digital divide? Welcome to this National Innovation Collaborative podcast. I am Nigel Thompson, and I have come to Leeds to hear from two people who are both working to make a difference.
Bola Owolabi: I am Dr Bola Owolabi, Director for the National Healthcare Inequalities Improvement Programme at NHS England and Improvement.
Roz Davies: Hi, I am Roz Davies and I'm a director at Thrive by Design. We are an inclusive digital innovation and improvement team hosted by Leeds and York Partnership Foundation Trust. There is about 10 million people in this country who are digitally excluded, and they are older, living with disabilities, living in poverty. These people are more likely to need health and care services meaning this is a disproportionate issue.
Nigel Thompson: How has that happened, in your experience, over many years? You have had a ringside seat to what has changed. I imagine years ago you were excited when people were sending emails and yet it seems that people have been left behind. So how has that happened?
Roz Davies: I would like to say that I am excited by the potential of digital, and we need that and everything else that we can throw at these problems. We have limited resources in healthcare, and we have growing demand. We need to use digital as much as any other tools that we have in our kit. Personally, I am benefiting from this as I have Type One Diabetes and have a sensor attached to me. I use my phone to swipe the sensor and I can share that information with my clinician. To be honest, it is sort of saved my life. So, it's important to me, but it's also important that everybody has that access, and it isn't disproportionate. If we're not careful and if we don't address those and understand those exclusion issues, we're going to create a two-tiered system here, which is what nobody wants. People have been talking about digital exclusion for several years. I used to work for the Good Things Foundation, which focuses in on that specifically, but it was COVID that really helped the NHS and health and care system to really understand this is a problem we need to deal with too.
Nigel Thompson: When it comes to your experience as a diabetic, how has it changed compared to how things were before digital, how have things improved?
Roz Davies: For me personally, before digital, I had to prick my finger five to seven times a day. I had to write everything down and can remember the little book I wrote all my records in to take to the clinician and share. It was really different. Now I am a mum, I'm a chief executive, I work hard, and I can just swipe my arm any time of day as I'm running along. I did so on my way here, got off the bus and swiped my arm to make sure my blood sugar levels were even. I'm also able to share that with clinicians. I'm able to look and see data trends. It really transforms the way that I'm able to manage my own condition.
Nigel Thompson: That really sets out the problems that we've had and opportunities for the future. From your point of view, how do you see the role the NHS has in trying to bridge this gap and level the playing field?
Bola Owolabi: I think from an NHS, particularly NHS England and Improvement perspective, we set out our strategic priorities for tackling health inequalities. Five priorities. The second of those is to mitigate against digital exclusion. Therefore, it sets the tone very clearly about our strategic intent. But more than strategy, what we have is a call to action and we've talked extensively to the system that our vision is exceptional quality healthcare for all, and we underscore for all, and that is by being attentive to three dimensions. It's about equitable access, it's about excellent experience. The combination of those two is what will deliver the third leg of the vision, which is optimal outcomes. It’s great to hear that lived experience of how digital has transformed Roz’s care. What we want to achieve is for that to be the story of all our communities, including those who find themselves at the peripheries of society, whether that is people experiencing homelessness or rough sleeping, whether that's our gypsy Roma traveller communities, whether that's people from ethnic minority communities, segments of whom may struggle with digital engagement. It really is about that exceptional quality health care for all. I would say that digital is an accelerant. It's an accelerant of care, and it's a key enabler in narrowing health inequalities as long as it's handled carefully. So as a GP, I know during the pandemic that my patients with learning disabilities, my patients with severe mental illness were able to continue to access their annual health checks, which is important, particularly for that group of patients, because they could join on video. It was easier for my patients, it made it easier for their carers. To that extent I do see it as a potential accelerant. But as Roz said, I'm also mindful that not everybody can afford the devices. Those who can afford the devices may not be able to afford the data and therefore don't have the connectivity. Even if you have all of that, you may well find yourself in a household living with lots of other people not amenable to talking about your personal health care issues with a health care professional. So, it's the handling. I think it's a great opportunity. I think it's an accelerant for narrowing health inequalities if handled well we achieve that, if handled badly we are at risk of achieving the exact opposite, which is to exacerbate health inequalities.
It's important to say that the quality of attention must be the same. It is probably not correct to say that going digital necessarily increases efficiency and productivity from a time point of view. Because what we need to bear in mind is you need to be even more attentive because you don't have the non-verbal cues that you would tend to rely on if somebody's sitting in front of you. You are having to be far more intentional, far more proactive in listening to non-verbal data that you can't see. You find that your history taking is far more detailed than it would be if the person was sitting in front of you. In terms of your safety netting, what happens afterwards, you pay a lot more attention in a digital environment. I suppose it's not so much a matter of productivity and efficiency. I think it's probably more a question of convenience from a patient's point of view. My patients don't have to take time off work to talk to me. If somebody is on a zero-hour contract, making the time to come to the surgery is a lot of investment on their part. If they can just stay at work and have that conversation, it's more convenient for them. It's time saving. For some people it's better from a socio-economic point of view. But productivity wise, I'm not so sure. I think you do need to invest more time and attention when you're using a digital footing.
Roz Davies: I wanted to talk a bit more about appropriateness and multi-channel as well. To me the gold standard in the future is multi-channel and is centred around the person, not around the system. Everyone is going to have a unique set of circumstances and those circumstances change over time. We look at digital exclusion and the complexity of three categories. We look at life context, and I think Bola has been talking about some of that. It might be that people have got very precarious lives. They've got other stuff going on at home, physical and mental health conditions that that don't make it easy to use digital. For some people living with severe mental illness, both the treatment and the condition means that they can't concentrate so easily or they're paranoid, etc. Then there's the obvious different digital skills, access to devices and the cost of data. A third leg of the stool that we need to consider is the accessibility from a system side. Our systems, tools and apps are not all accessible, even though there are standards. The way that we imbed them into our services are not necessarily accessible for everybody either. On top of that, there's something around the digital skills and competence and capability of staff and that's a huge issue in the NHS and a well discussed issue you've got Health Education England, who will talk much more about that. Then finally there's the sort of Wi-Fi quality in both the service side and the system. We're working in Norfolk and Waveney at the moment. It's a rural area with pockets of deprivation and older people living in rural areas and that stacks up to quite a lot of complex digital exclusion issues. And the other thing I wanted to say is listening in to that, it's appropriate at different times. You talked about people who you've had a long-term relationship with then going online and you wanted to maintain that relationship. What we discovered in one piece of research that we've been involved in with Trish Greenhalgh over at Oxford University is that it's helpful to establish a relationship first and then go online. There are some important things to consider about when it's when it's okay, appropriateness and so on.
Bola Owolabi: Roz makes a really important point in terms of one size most certainly doesn't fit all in this scenario. You may find, for example that younger, working age, highly mobile people prefer to engage with health care services in this way because it fits better with their lifestyle. But on the other hand, you may have people who for various reasons, some of which Roz has been outlining, this may not necessarily be the most appropriate intervention. If the organising principle is about it being person centred, that really is the crucial thing. If we think about the design of our digital offerings, whether that is in terms of our products, clinical pathways, or our services, I tend to think about it across those domains of pathways, products, and services. If we are mindful about the design of those, their implementation and how we evaluate their impact is incredibly important. We often talk about a quality improvement approach to tackling health inequalities, and we speak about three methodologies, the first being data for improvement. When we are designing these digital pathways, products, and services, are we building into that design how we're going to collect the data about who is using this offer, who is accessing it and how representative is that of the wider population, the idea being so that we know who is falling behind? It's what we did with the COVID vaccination programme, when we began to collect the data and to disaggregate the data in a particular way, we could see that certain communities were not coming on that vaccination journey with us. The same applies to digital. There is something about collecting the data and presenting the data in a way that helps us to surface the inequalities. That's the first thing. And then the second thing is to take a strengths-based approach. It's important to not proceed on the basis of an assumption that certain types of people or certain communities cannot use digital. I think if we look to the developing world, we will see how the mobile phone has absolutely transformed people's lives in terms of health, in terms of social mobility. The story I told earlier on about my patients with learning disabilities and how their annual health checks went up dramatically during the pandemic, it's that strength-based approach that starts on the basis that digital is an enabler of addressing health inequalities as long as we make the reasonable adjustments and all the necessary provisions. That's the second thing. The final thing is co-production. It's absolutely crucial that we design our products, services and pathways with the patients and the individuals who will use it. Because if we don't do that, it's possible to design things that theoretically work, but in practise don't make sense. Which goes back to the vision I was talking about earlier, that it's not just the access, it's the experience, particularly as Roz was saying, when you talk about older people, you know, starting on that basis of what matters to them. I remember in my local system in Derbyshire talking to Age UK during the first wave of the pandemic about digital literacy for seniors. What we discovered was older people were more prepared to have a conversation about how they can keep in touch with their family, how can they keep talking to their grandchildren during this lockdown and starting with what matters to them then became the conduits to the further discussion of this same technology could be useful in their conversations with their GP. I think it's those three things. It's tracking the data so that we know who is being left behind. It's a strengths-based view of our people and communities and it's co-producing things with them intentionally.
Nigel Thompson: Where do you think we are when it comes to digital and helping people to self-monitor? Is the NHS poised to build on the impetus caused by the pandemic to push it even further forward? What do you think we're up to Roz?
Roz Davies: We did a piece of research with NHS England around mental health and digital inclusion. Then more recently we've been working with Bola’s team on digital inequality, pioneers working with integrated care systems across the country. What we've learnt is if you look at the diffusion of innovation curve you have innovators, then early adopters, then mainstream, then what they call laggards, what we call late developers. We think that we're probably early adopter stage. We've got a group of integrate care systems and people who are really up for it, championing this agenda and have done some really good stuff. We've got early adopters starting to look at that innovation and going the battle's won really, everybody knows that digital exclusion is an issue. They need to see this good practice before they move into that. We think we're about there. We know that the whole system is recognising this is an issue. We know we've got some good, good pockets of good practise. Now what we need to do is create the conditions where the early adopters in the mainstream can take this on. I think that includes things like the policy pushing forward on the policy. I was delighted to see the recommendations and digital inequality moving into the health and inequality policy agenda because I think that's where it'll get pushed forward and certainly, I know people are talking about that at a local level and the same time integrated care system being given a policy objective around health inequalities, so it links in. So that's the first thing. The second thing is about, the need for a push forward on leadership. If we've got leadership at a local level understanding and backing this, it will become a priority now. We experienced this with the ten pioneers that we're working with, that there's some real champions within the local integrated care systems, but they're a little bit isolated. They're struggling to get the brilliant work that they've been doing into the main system. We must get national policy pushing forward. There's another element around partnership working, I think it's interesting listening to your story about starting with what matters to people. We also need to start with the relationships of trust. We believe that for people that are particularly excluded, that may need health care services but not accessing them, we need to look at where are their trusted touchpoints and often that's in the community and voluntary sector. It’s important that integrated care systems work closely with the community and voluntary sector and there are some good examples of that.
Nigel Thompson: I was going to ask you about how you get the word out because that's the real challenge you've got. It is to make sure you don't overlook somebody who is doing some great work in CVS, people like that that are already involved in communities. The NHS could come along and say, “How about this?” And they say, “Actually we've already doing it.” How do you get the word out? Or is that the challenge your facing now?
Roz Davies: I think it's not hard to find those good practise examples. On a local level, you go to your Healthwatch, your voluntary action council, you go to the local networks that there are and they're everywhere. They really switched on during COVID and they've really proved their worth. It's not that hard locally. At a national level we've created a workspace, a Future NHS workspace community which has about three hundred champions of this work on there that anybody can access. We've put all the research that has been done that we can find, and all the tools and good practise examples so they're easy to access which is step one in that process. The other thing that's quite important that all the people we've been working with have talked about is funding. The kind of funding that goes into digital is very capital, very short-term sort of base. What we need to do is push that digital inclusion is important enough to fund. Secondly, that this is a long game, not a short game. It's not going to happen overnight, and it is going to change over time. That quality improvement approach should continue. Checking in and checking the context, looking at the data and developing is important to tackling this problem.
Nigel Thompson: Strikingly that's the challenge, before you can chart where people are as it’s going to get harder the further down the chart you get because those are the ones who are hard to reach.
Bola Owolabi: Yes, I completely agree. I think it's more about people being seldom heard rather than being hard to reach. Roz pointed about, setting the strategic direction but putting the funding behind it is really important. I often tend to think about it on three levels. What is the role of us in the national team? What is the role of systems and what happens in the neighbourhood? I think from a national point of view, we have three roles. One is we do need to set a very clear strategic direction and we've talked about the vision earlier on, but also the policy context. Just as Roz was talking about there. I think the policy context is so clear now. We've got the Laura Wade-Gery report on the behalf of the secretary of state, which talked about health inequalities and digital health inequalities being joined at the hip. And that's important because people then don't see it as two separate and disparate agenda. So that's the first thing, to set a clear direction, have a clear policy framework. The second is to create a culture of improvement. That culture of improvement is what we were seeking to achieve by funding the Digital Health Inequalities Pioneer Fund, because it's about using the vehicle of organisations like Roz's to go and find out what is happening out there, who is getting this right, showcasing what they're doing, amplifying what they're doing, because suddenly others in the system can see that it can be done. But more importantly, how can it be done? There are places that are doing things like digital cafes for those who just want to drop in, maybe do their consultation in a particular place because they can't afford the devices themselves. We've got places that are repurposing devices, all devices. I know Vodafone have a huge digital health inequality programme which is collecting old devices and repurposing it, making it available to people who can ill afford them. That's another example. It's really about people understanding what's happening out there. That's part of our role is to create that condition and culture of improvement. The final one is holding to account. We do have a really important role as the national team to hold our regions and systems to account in terms of to what degree are we delivering on that strategic priority to mitigate against digital exclusion. Nationally, I think that's sort of our triumvirate role. But then, as Roz was saying out there in the system, it's about what is the role of the NHS as a key partner within the integrated care system, working with our health and wellbeing boards, working with our local authority partners, working with the voluntary sector and the communities themselves, as we did again as part of the COVID vaccination deployment programme. How do we harness all those partnerships and all those networks and divert that energy now towards that digital inclusion piece? I think that's the thing that can really happen most effectively at local system level, but it's the combination of what we do nationally. That funding piece is really important. Therefore, we've been making funding available through projects like the ones that Roz is talking about through dedicated funding for health inequalities. Every CCG in the country has a health inequalities adjustment in the CCG baseline. These are the sorts of things that would be incredibly helpful to use that for. As part of our 22/23 operational planning guidance, we've been able to release 200 million into our integrated care systems in service of supporting the health inequalities agenda. It's about the strategy, it's about the policy, it's about the context of improvement. It's about hold into account, and it's about providing that tangible support in terms of funding. That's not to say that the job is done.
Nigel Thompson: That was my next question, it sounds like the job is done.
Bola Owolabi: The job is never done. My door, my team's doors are always open. We want to hear what Roz is finding at the frontline so that we can continue to tweak and adjust what we are doing to be genuinely responsive to the voices of our communities.
Nigel Thompson: You've got a fantastic way of putting the project there. I just want to have Roz's point of view. Talking here in Leeds, your area, what are you seeing on the ground? Are people willing to back you up and give you the kind of support that you clearly need? It sounds like the plans there, the kind of route is set, but you can't do it on your own. You're going to need support. Do you get it from your local providers?
Roz Davies: We are a sort of conduits enabling sort of a team and we work with all sorts of systems across the whole of UK. Leeds do quite well in digital inclusion and not necessarily an inclusive digital transformation which is something different, but they have an amazing team, 100 hundred percent Digital Leeds and that's been a long game strategy. It's been in place for at least ten years, working really hard and that's come through local government. It just shows you it's always driven through health, but they are beginning to work more and more closely with the health system in Leeds. At the same time, we're working with our own trust on what does inclusive digital transformation look like in mental health and learning disability services? We're working in partnership with people who are experiencing services. With people who are delivering services to try and look and unpick a very granular level what gets in the way, how can we create more inclusive digital transformation of services? We really have to collaborate and work together on this.
Nigel Thompson: This has been a been a five to ten-year project. How soon before we finally get to the point where it's near 100% engagement? Where we've put this to bed once and for all.
Roz Davies: Although I talked about 100%, I don't believe this is possible. And although their title is 100% Digital Leeds, I don't mean that everybody has to use digital. What we mean is that everyone needs to have good quality services in the way that Bola was talking about. This is about multichannel, it's about appropriate. It's about using digital for all its worth but not letting the tail wag the dog. Digital is just an enabler, that's all. It's the stuff we're using at the moment to provide what we're really after, which is as good health and wellbeing as we can possibly get. That's what we're after. I think we've got a lot of other challenges besides digital to overcome to get there. We're not working in isolation, but we all get the last two years have been awful, but it's also enabled the health and care system to want to accelerate the use of digital and to recognise digital exclusion as an issue. Once we've done that we're a step in the right direction.
Bola Owolabi: Look, I don't think we will ever get to a place where 'jobs done'. It's what Roz was saying earlier on that it's about different people at different points in time, and the landscape can change quite significantly, even for an individual. Never mind the system, because people grow older. We know that things like dementia or other cognitive impairments may be reasons why, if you take a life course view and that's what we must do, that deliberately personalises our intervention depending on where in the life course the person finds themselves and that we're prepared to adapt accordingly. I think as long as we hold on to that central vision, that it is about equitable access, that it is about the quality of people's experience, and that the combination of that is what then will yield the optimum outcomes that we're looking for. If we hold close to that as our organising principle, that will guide us in terms of is this still appropriate for this individual at this moment in time in their lives. Or do we need to, as Roz was saying, take a multi-channel approach? Understanding that digital is important and powerful, but it is one of a number of approaches that could be perfectly legitimately appropriate for an individual or a community, depending on the point in the life course, is what I would say. We must avoid the temptation to think that this is a purely health and care agenda. I hosted a roundtable recently co-hosted between myself and Lord Pryor, former chair of NHS England and Improvement where we brought together 25 business and industry leaders to discuss what is the role of business in tackling health inequalities. Out of that came the ten ways which is available on NHS England and Improvements website. In those ten ways we talked about digital inclusion so that it becomes a whole societal agenda, not just health and care. If our business colleagues, whether that is in banking or other sectors, begin to think about digital by design, then it creates the conditions across the system so that whatever the touch point of the individual into the system, because people don't necessarily make a distinction between, “Am I now in conversation with the NHS, am I now in conversation with the local authority, and now it's my bank?”. What we need to do is to have a cross-sectoral, multidisciplinary, multi-agency whole system, digital inclusion by design ethos. I think that really is the answer. Recognising that innovation travels across organisational boundaries. I think of some of the banking organisations that have been streets ahead of this before the pandemic, supporting their customers to be able to use, online banking for example. What can we learn as the NHS from them in terms of what they did, what worked and what didn't? I think it's that whole societal approach, that life course approach, recognising that one size doesn't fit all, and just bringing our collective wisdom to this and I'm going to finish on what Roz said. This is not a sprint. This is a marathon. We need to stay the course. Stay the course with people, stay the course with our communities and commit for the long term into the digital inclusion space.
Nigel Thompson: You both sound very upbeat. I was coming here today, thinking I'm not quite sure what you're going to be saying, if it would be, “If only we had more money, if only we had a plan”. It sounds like you have a plan. You are both speaking very firm and very closely in agreement. Is there one final bit of the jigsaw that would make things even easier and would make your job a little easier?
Roz Davies: I don’t know if I’m going to answer your question a straight way, but I think there's three things that's important going forward. One is to be clear about the vision of the society that we want, and I think the vision of health we've heard today as well. What kind of society do we want to live in? Do you want to live in one where people are left behind and are desperate and so on? I don't. I think we've got to hold on to that vision. Everybody who cares about this stuff, everyone working in digital has got a responsibility there. So that's the first thing. The second thing is about future proofing. I don't think the world that we're seeing now is going to be the world we're going to be in in five years’ time. I'm going to talk about well, I mentioned in brief the climate change, for example, these are really difficult times. We've got some difficult challenges ahead. We've got to think, what is it going to be like? We've got a decent, probably very educated guesses about the context in five, ten years’ time, I'd say. Then the third thing is to really value the power of community and people working together collaboratively, because that's what really helped people who were really struggling through COVID and it's always been and always will be. We have to create the conditions community and community cohesion and so that they are there at the front end of all of this. I think the more the health system can work with community, the better.
Bola Owolabi: Absolutely. I mean, how does one follow that? I think Roz has encapsulated where I think we need to be. It's that commitment. It's that long term commitment. This mustn't be a fad. This mustn't be the end theme now. We need to understand that we need to commit time, we need to commit resources, and we need to commit our investment in this space for the long term. I couldn't say it enough because what worries me is that we set ourselves some arbitrary fixed point in time by which it's all going to be done. Then when we get to that point we recognise there is still a lot to do but we artificially stop. That would be a disservice to the people and the community who have come to rely upon us. Just to say, based on what Roz was saying earlier, people and communities have the most creative, innovative, sustainable, and cost-effective solutions to these challenges, if we ask them. We should go forward on the premise of co-production with people and communities.
Nigel Thompson: Thanks for listening to this edition of the Innovation Collaborative Podcast. Be sure to share and subscribe for more and if you'd like to read detailed information on the projects mentioned by Bola and Roz, check out the Innovation Collaborative Workspace on the Future NHS website, where you'll find more resources to help your team deliver technology enabled remote monitoring projects.
Episode 8: Supporting continuity of care through technology enabled remote monitoring – what it means for patients and for nursing and medical professions
This episode explores the potential impact of technology enabled remote monitoring on care continuity and the nursing and medical professions.
Featuring Dr Vin Diwakar, Medical Director for Transformation and Secondary Care, National Medical and Transformation Directorates NHS England, and James Bird, Chief Nursing Information Officer (CNIO) and Deputy Director of Nursing at Imperial College Healthcare NHS Trust and CNIO of Chelsea and Westminster NHS Foundation Trust.
Their discussion includes fresh insight and advice on how technology can personalise care now and in the future from a nursing, clinical, ICS and national perspective.
Episode 8 transcript
Nigel Thompson: Hello and welcome to this edition of the NHS Innovation Collaborative for Digital Health Podcast, I am Nigel Thompson, in this edition we're discussing ways to support continuity of care through technology enabled remote monitoring, examining what it means for patients, and for nursing and medical professions. I am joined by two guests to look into this detailed area and give us some indication, perhaps, of how life is changing in the future, and what difference it might make for both patients and clinicians. I will begin first by asking them to introduce themselves, their full titles, and perhaps explain the roles they have now and previously, and how it relates to this area of health.
James Bird: I am James Bird. I am the Chief Nurse Information Officer and Deputy Director of Nursing at Imperial College and the Chief Nurse Information Officer at Chelsea and Westminster NHS Foundation Trust. I also have an ICS role across acute care in the North West London ICS.
Nigel Thompson: You said you come from a nursing background.
James Bird: Yes, I am an emergency department nurse by background. I spent 14 years in emergency nursing across a range of Emergency Departments across North West London.
Nigel Thompson: I am looking forward to the conversation. I am sure you have had a real insight into how things have changed over the last couple of decades. We will talk more in a minute, now our second guest today.
Vin Diwaker: Hi, I am Vin Diwaker. I am NHS England's medical director for Transformation in the National Team and 'Remote Monitoring Virtual Wards - Supporting People at Home', is within my area of responsibility, amongst others in NHS England at national level. Just prior to this job, I was the medical director for the London region and again this portfolio sat within my remit but for the London region. James will probably remember me as part of that and then I am a paediatrician by background. In addition, I have had a lot of experience over about 20 years, not so much in monitoring, but certainly in managing children and young people with long-term conditions and thinking through the ways in which we can support them with remote monitoring as well.
Nigel Thompson: I am looking forward to exploring this topic over the next half an hour or so. To start, can you draw on your past and your current roles, from a clinician’s point of view, how things have changed and what role do you think technology enabled remote monitoring really has now in delivering the continuity of care that people really need in this day and age?
Vin Diwaker: I would probably best illustrate that by giving you an example of a respiratory ward that I visited during the pandemic. My background is a paediatrician and my speciality area of interest is in cystic fibrosis, which I do not do anymore, but I still keep in touch with old colleagues. Therefore, I was asking a colleague, what has been different about the care of children and young people and adults with cystic fibrosis? They said we have been doing it through remote monitoring. They said coming out of the pandemic, we will never look after a patient with cystic fibrosis in the same way again. We do not need to get them to hospital on a routine basis. We can monitor them at home and using technology, we can then start to spot those people that need some help and get them in to give them some support. Then they can go back to remote monitoring again. If you apply that to any one of a range of long-term conditions, I think the same sorts of principles would apply.
Nigel Thompson: I have often heard, during making the podcast series, people tell me that the pandemic in some way has boosted, I will not say helped, but it has enabled this way of thinking, perhaps that that would not have happened had the pandemic not taken place. From what you have just said, that is another illustration of something that was in the wings but through the pandemic has been accelerated.
Vin Diwaker: Yes, it has. I also think as clinicians, we proved it to ourselves that it could work. Clinicians tend to be slightly risk averse and we worry about patients. We do not like introducing new things into practice. What happened in the pandemic was that we were in a health emergency. Another example, I went on a visit to somewhere in the Midlands and the clinician said they had patients who were coming into hospital and they were unwell. They always thought they had to be admitted in order to monitor their condition. This was more risky during the pandemic, because they might catch COVID, with their chronic respiratory condition. Therefore, they started monitoring at home and they realised they could do this really well, and the patients were happier. Particularly for a frail, elderly person, every day that they spend in a hospital bed, in their pyjamas, they lose a significant portion of their muscle mass. I think for all the patients I have ever met, the best bed is their own bed. When we are deploying remote technology for a virtual ward environment, it is for patients who would otherwise have been in a hospital bed, but now we know they can be cared for through remote monitoring. There is a moral imperative to look after them in this way, because it is the best way that we can both care for them, but also protect them from all the downsides of being in hospital.
Nigel Thompson: I am curious about that, because I think the moral area is something that has not been properly debated or discussed, at least not publicly. However, I am sure it is thought about by many of your colleagues. Do you think about that frequently?
Vin Diwaker: As a clinical leader, I think about it all the time because it is actually by framing things and describing it in that way that we can take our clinical colleagues with us. Inevitably, the workforce and people in the NHS are tired now. We had to make many changes in the pandemic that were not very easy, changing the way you practice so quickly. Therefore, people's capacity, I think, to keep changing at that pace is limited. Although, when you can start describing things in terms of the benefits for patients, and then demonstrating to people that the technology can work in ways that it can make your working life easier as well as proving benefit for patients. I think that helps motivate people to finding this new way of doing things.
Nigel Thompson: James Bird is with us as well. You were nodding throughout those comments, what is your reaction to what you have just been hearing?
James Bird: Obviously, I agree. I would quite like to use somebody else's quote, “health care is too important to stay the same”. We also have a resource problem in this country with health care. It is not unique to this country. It is across health care across the world. Therefore, we cannot keep doing more of the same and expect to get the different results. Thus, we need physically to change the way of doing it. I do not get to go on visits, but I do get to play around with new toys and technology. During the start of the pandemic in June 2020, we had some remote monitoring technology that we were planning to use to support some early discharge. That stopped because all surgical procedures stopped. However, we then put them into our local care homes and there was an 80% reduction in patients attending the emergency department. We know that patients from care homes that come to emergency department have a very high conversion rate to inpatient. We were able to stop them coming into ED because we were caring for them adequately in their own environment, which meant that they were getting the best care. They got the same care, as they would have if they had been brought into hospital and going through the system, deconditioned, and then back into the care home. All of that was a very positive experience. We were not taking up inpatient beds with patients who could stay in their own home and get the same level of care. Therefore, it is morally the right thing to do. We are, and as Vin said, very risk averse in the in our professions. However, we still need to make sure that we change. We have technology available to us now, that was not there ten years ago, was not there when I started my training.
Nigel Thompson: Can you give us some examples - we keep hearing about technology and things have changed. However, what kind of examples can you give?
James Bird: I suppose virtual wards have been a thing that we have had for many years aa part of community care for well, certainly as long as I've been practising, but we now have that technology piece on top of it. When I say technology, we now have Bluetooth enabled devices that are doing continuous monitoring. We have four solutions in north west London, one of them is Current Health and it provides real time continuous monitoring of your vital signs on a on a minute by minute basis. Therefore, I can look and find out what the patient's respiratory rate, temperature, sats, and blood pressure, are as frequently as if I have them on a telemetry bed in my high dependency unit. It is exactly the same level of monitoring. That level of technology is now available to us. There is lower level technology as well, and that can be a Bluetooth enabled device such as a SATs probe connecting to a mobile device. Alternatively, it could be as simple as a patient having an app on their device, which they can use to record vitals or symptoms. Therefore, there is a spectrum of technology just like there is a spectrum of acuity in hospitals, there is a spectrum of acuity on virtual monitoring and virtual wards as well.
Nigel Thompson: I spoke to an asthma patient in Northamptonshire recently, and he was delighted that you could use a mobile phone just as you described. However, I could not help think afterwards what about the patients, and there are many of them, who are not used to technology, do not even know what Bluetooth is, who think it is something dental. How do you get through, not just to the patients, but also to some of your colleagues who are still of the mind that face to face care is the best care, which of course it is, isn't it?
James Bird: I think so, we need not to think of this as a replacement for face-to-face care, because actually that face-to-face care still has a role and will always continue to have a role. We should also not think that there is a technology understanding issue with our elderly patients. My wife's 96-year-old Gran quite happily sits there and uses her iPad. She would not be able to describe Bluetooth to you. As far as she is concerned, things work, and that is as all they need to know, that is the epitome of good technology. It just works. However, that is one side of the spectrum; obviously, it assumes you have such a device. There are obviously a group of patients who will not have a smartphone or broadband, etc. That is where systems such as the Current Health solution do actually come into their own. The Current Health solution we use comes with its own little, for want of better terminology, hub and that is a 4G enabled Wi-Fi router that then sends data over the mobile phone bands. The patient needs nothing more than a three-pin socket in the wall to put the power on and that is it. It is completely inclusive and it does not require the patient to enter any details. That is how we used it in the care homes, in a completely passive mode. As long as you could wear the device on your arm, everything else was done from the hospital end. Therefore, I do not believe that there is a concern about digital exclusion. There is obviously a concern about technology adoption amongst some patient groups. However, I do not believe we cannot solve that with the technology that we have.
Nigel Thompson: It is a journey, and as Vin was saying before, perhaps the pandemic has maybe helped people sharpen their minds and make things easier.
James Bird: It certainly did, it has moved us ten years on in probably ten months, would be the way I would describe it. Not just on virtual wards, but also certainly on outpatients. We obviously wanted to do virtual outpatients in our organisation and we had made some progress. Nevertheless, in the space of ten weeks we flipped the entire organisation to be virtual, as all organisations did, moved to virtual outpatient models. Suddenly, now at the other side of the pandemic, we know that is safe. We have successfully done that and we can keep doing that. It allows a different model because actually, why does the patient need to come in. If you run a specialist centre like my hospitals , patents are from right across North West London. Why do you need to travel from Watford down to Hammersmith for your renal appointment when actually you can just get on the phone? I am taking then 10 minutes out of my day to have the conversation with my consultant rather than an hour to travel, sit in a waiting room for an hour and then an hour back again, and I just lost half a day to a full day. It allows patients to get on with their life rather than being solely health focussed.
Nigel Thompson: Vin back to you, we have heard about how things have changed from James' perspective. Where do you see things going now from your perspective? You must have a view of the horizon, both for technology and training. Can you give us an insight into what you think is coming up soon?
Vin Diwaker: Firstly, I think the technology industry is moving very quickly. It is important that we work closely with industry, not just in a way that means that industry has a product and they are trying to sell that into NHS, but actually that we do something called demand signalling. So we are working with clinicians and patients, co-producing with them, use cases to say, well, if we have this bit of technology, here are some of the issues that we could solve that James has already really nicely described and we are doing that work already. That is a core part of the role that you can do, as a national organisation, is work with technology and work with innovators in this area. The second piece I think is working with staff, although I have to say in my experience, staff adapt to this way of working quickly. When you see the benefits for patients and you realise that many of the things that have frustrated you historically can be solved by working with technology, actually it is tremendously motivating. So certainly, the places I have visited, the staff are asking to work in remote monitoring or virtual wards. They are not saying this is somewhere I do not want to work. In addition, the third element of that is that we are working with patients and with the public, so that they understand that this is a new model of care. You may have seen some of the media and the work that we have done where we have talked to patients in virtual wards who are being monitored remotely, and they can talk about what the benefits are for them, which are enormous. Therefore, I think there are all sorts of issues really that we are pulling together so that this becomes part of a whole set of changes that we want to make. It is a bit like a movement to change fundamentally, the way that we are delivering healthcare. In supporting patients to stay healthy but stay healthy in their own home. There is a bit of a spectrum for me as well, we were talking about this a bit earlier, within a hospital environment, you would be observed and have your pulse, your blood pressure, your respiratory rate, your oxygen levels monitored. But the frequency with which they are monitored and the type of care you get are more intensive nursing in an intensive care unit, less intensive nursing in a rehab unit, but with a wider range of disciplines, you can apply this in a virtual environment as well. Therefore, in a virtual ward environment where you are unwell, you previously would have been in hospital. We would monitor you much more intensively using James's team. However, increasingly when we are older, we have multiple long-term conditions. There is a range of things that you are being monitored on but less intensively and less frequently, and then you are being seen when you need to be. Therefore, this is really going to change the way that we offer health care. I am not sure it is not an awful lot different to the way our lives have been completely changed by technology anyway. It is just generally in health care, things tend to move a bit slower than they do, say, in banking or in commerce or in the retail industry. We always follow on for all sorts of good reasons. However, we are going to see this revolution happening anyway and patients are going to be asking for it.
James Bird: I think it is exactly that, patients are asking for it, because if I can order something from Amazon that arrives tomorrow to my front door and gets me my answer to my question, etc., I expect that in my life now that is how I bank, that is how I shop. That needs to be how I do my health care, because it cannot be 'sorry you need to take a day off to go and do that appointment', or you cannot do X, Y, and Z part of your life because of this. That needs to be revolutionised. As you say, health care is catching up with where some of the sectors are, but it has to be done safely. I suppose one of the key things, you do get very enthusiastic clinicians who are absolutely driving this, but we do need to take everybody with us on this journey because it is not the Wild West. We have proven that this is safe. Actually, the monitoring is as good as sat in a hospital bed. As long as your staffing ratios are set appropriately, you can do your remote monitoring, and as long as you are able to then recognise deterioration and escalate the patients accordingly. This is no different from sat on a ward and in fact; we run an OPAT service, which is designed for...
Nigel Thompson: Sorry, what is OPAT?
James Bird: It is Outpatient Antibiotic Therapy, patients who we ambulate and get them to come back in for antibiotics or they receive the antibiotics at home. We already do that it pre-dates the pandemic. This is just adding another type of tool in that toolbox and saying you do not need to sit in a hospital bed for any of this, be at home.
Vin Diwaker: There is also an important role for us in national organisations. Therefore, number one, I think we really have to emphasise that the technology is safe. We define at national levels what standards the technology has to reach. It goes through a very rigorous safety testing process. We know those are safe. The second bit that we do at national level is working with professional bodies like the Royal Colleges. We can define what a clinically safe service might look like, learning from examples because there are different ways they have done it around the country. Therefore, we can set standards about how these services should be governed and staffed in practise. Then the third element of it is that we can publish evidence, we gather case studies together, but also we can work with academics so that we are publishing the evidence base on this as well. Therefore, this is not something where we are letting the technology industry lead us. It is something that very strategically we want to introduce into the NHS. However, we are clear about things like safety, governance, clinical cases, and publishing evidence.
Nigel Thompson: I think I am contractually obliged to mention the role that the Academic Health Science Network has in this area as well to make sure that there is a way of getting good ideas through to the front line, which I am sure you're both very well aware of. One thing that strikes me as you were saying before, James, about the way that technology is being moved to other areas of health and social care, care homes, for example, doing work that would normally be carried out in a hospital setting. Do you think that technology and remote monitoring is helping share the job of monitoring patients? Therefore, it is not the case that if you need expert monitoring, you have to go to hospital. If you need lower level monitoring, it is in a care home. Do you think that this is the system now and the movement that we have is enabling other people to do the job, which normally would fall on very broad shoulders of clinical staff.
James Bird: I would not phrase it as you have just phrased it. I would not say that somebody else is doing the job that I would have previously done in the emergency department. If we look back ten or 15 years we had silos of operations. There was a community silo and an acute silo, and actually 20 years ago, information did not move between the two. It was that you got X care here and Y care there and there was nothing in between. What this effectively is doing is starting to blur the middle bit and it needs to be a more smooth, this transition between the two. It still surprises patients when I say I cannot see what your GP has written in your record. Now we can in our organisation, but only ten years ago, patients would come into ED and say, “you know why I am here?” I would reply, “I have no idea why you are here”. They would look surprised, "but you can see that on my GP record?” and I say “no, can't do that”. I can now, but the patients expect that seamless transition. Therefore, it is not that it would be somebody else doing the work, which I previously did in hospital, because patients will still need face-to-face care. That is still going to be a key component, but there will be a larger component in the community setting and that will encompass a wide range of roles. Probably wider than is currently done in the community setting because it will encompass more patients, but acute care is still there if you need to be admitted, but it is probably going to be a lot sicker because if you are not quite so sick, we can manage you in the community. Hospital beds are very expensive, by their very nature. As technology develops, for example, if you need blood tests, you have to come into hospital. If I need to scan you, you need to go to hospital. Actually, we are not a million miles away from having blood tests that I post to you that can be collected by a courier. You take a small sample and you send back or the result is delivered to you there and then. Some of that technology exists already and it will not be a long time before that is the way that we do all blood tests. You do not come in for routine bloods. Why would you come in for routine bloods?
Nigel Thompson: Also, I think people are used to taking swab samples now because of COVID. We used to rather...
James Bird: The technology will blur the boundaries. Nevertheless, I do not think we should look at it as somebody is doing somebody else's work because that is not what it is.
Vin Diwaker: I think it can enable people to do their jobs and with more confidence. For example, if you are someone who is working as a carer in a care home, that is not the same as being a nurse. Probably only five or six years ago it was really challenging as a care home worker, if you knew that the resident you were caring for was a bit unwell, to have the confidence to be able to say, I think we can monitor them because you would say, I am not a nurse. How do I know if they are okay? It was challenging 24 hours a day to get access to a health worker that could come and visit them. Other than ringing the only 24 seven service we have, which is ringing an ambulance. Then as James said, we know that if you ring an ambulance, you are more likely to go to hospital and be admitted. Through technology, not only can we do the monitoring of the patient's vital signs, but we can build into the technology the ability for a carer to interpret the signs that they are seeing and then also link them up to the various services in order to support them in making decisions. We know that when we put technology into care homes and support people who are working in care homes to know how to monitor signs, how to interpret them, we build their confidence. The number of patients who, when they are unwell, are then conveyed to hospital can go down by about 30% and that is beneficial for the patient. Therefore, we have talked about the risks of being in hospital, but it is beneficial for everyone because we have all seen pictures of ambulances queuing outside hospitals. If there are some patients who could be more effectively cared for in their own bed or in their own home, that is beneficial for all the patients who do need to visit an emergency department.
Nigel Thompson: Looking at governance, I know we have hinted at it before, the organisations that you manage are involved with a very large number of people. They must, amount to several million people.
James Bird: Two point something million. Yes, northwest London.
Nigel Thompson: Goodness gracious, that is a lot of people, so to achieve the level of governance to make sure it is always working well, how do you do that? How do you make sure that the systems you are changing, the new kind of techniques you are bringing actually pass muster?
James Bird: We have a hub that spans four acute organisations and two primary care networks. The first piece of governance we have always had is the responsible clinician for the patient today is the responsible clinician tomorrow when they are on the virtual ward. Each virtual ward has its own responsible clinician and therefore a responsible division, for governance, inside an organisation. Therefore, there is a clear governance route for the Standard Operating Procedure that the virtual ward is using. Therefore, I am not creating new governance pathways. Therefore, a medical director today knows what is going on in all their wards, as they have governance feeds coming in. This is just joining those governance feeds because it is another ward in the hospital bed base. It just happens to be the patients are at home, but it is no different from if you if you added 30 beds in a new ward in the hospital. Therefore, from a governance perspective, it is tied into existing channels. It is not something completely different. That has been key to how we have it established and how we have buy in from our medical teams across the organisations.
Nigel Thompson: When it comes to health inequalities, one of the earlier podcasts in this series looked at that and I wanted to ask you both briefly about the choice that patients have because it is great to expand the range of technology out there, but people may not want to take it on. So, can I ask you both, when it comes to be given that choice, how do you feel? How would you expect clinicians to react? Should a patient say thanks very much, but no thanks?
Vin Diwaker: Well, the first thing is we're not taking anything away as part of this, so the ability to have a face-to-face appointment is still there, the ability to be admitted to hospital, if for whatever reason you can't be monitored in a remote environment is still there. Therefore, we are not removing anything. The second thing is, I think, we should not make assumptions about health inequalities. The way we really understand health inequalities is by getting out and actually working with communities and co-designing and co-producing services with them. Then you find that, some of the assumptions you had made are not actually true, but you also find that those communities will have things that you have not even thought about that are important to them. Therefore, it is important that we work alongside communities, tackling the things that concern them and making sure that their concerns and worries are addressed. For example, if like me, you are from an Asian background, or if you are from a black background, one of the things that we know has concerned people has been whether the oxygen monitors work adequately. The only way we are going to reassure people is by working alongside them and developing the technology in a way that represents their needs. Therefore, I would say in answer to that, do not make assumptions about health inequalities, actually go, and work with people who are most affected by health inequalities and design services with them. That is the way we are really going to be able to tackle things. With technology, if you design the services with them, we can empower them to care for their own health and give them more control.
James Bird: I would give the same answer, but put just slightly less eloquently. If you give patients that level of control, most patients will take that because it works for them and if you give me something that works for them, they will prefer it to something that strips them of control, of their independence. For example, admitting someone to hospital. There is always that option; you can still admit them, if required. We are not about to get rid of hospitals. Hospitals with inpatient care will continue. There will always be a need for it. Therefore, I do not think this will perpetuate inequalities at all. I think this will probably help address some of them as we see them today. However, I really like what Vin said what we see as health inequalities is not necessarily, what other people would see as health inequalities.
Nigel Thompson: As you have said, it is good to have options that people would not have had a few years ago, it is good to have choice.
James Bird: I think it is Norfolk and Norwich or Darlington, one of the other organisations that I have really admired how they have set up virtual wards. They have created posters to explain virtual wards and the patient takes the opportunity to request virtual wards rather than a clinician deciding. I really like that way round of playing it and saying any patient could go onto a virtual ward in their model. That is a nice way of setting it up. If you want to go on a virtual ward and go back home, ask for it because it might be appropriate for you. That is so much more powerful than a clinician sitting there saying, yes you, no not you. It is much better to have the patient wanting that.
Nigel Thompson: Well, it is great to talk to you both; it is a fascinating insight into what is happening. Just final thoughts for the future. If you had such a thing as medical crystal ball, what do you think we can look forward to seeing or hearing about perhaps this time next year? Have you anything that you are working on at the moment, or anything you are excited about, or any areas you think we need to plug where something that has not yet come on the market or started helping people that would really make a difference.
Vin Diwaker: The first thing I would say is that the technology is moving fast all the time. With remote monitoring, we are going to be collecting a lot more data. We know even now that you can completely anonymise data. Using a lot of anonymised data opens up new ways in which we can use supercomputers and computing power. We will be able to look at the way in which say vital signs interact with each other and then come together in patterns. That might mean in the future, we are even more able to say, well, that patient over there is deteriorating, not because a nurse or a doctor looked at their signs and used their professional judgement to say, but actually because we've got this algorithm that tells us these different things are coming together. I think that is an exciting development that we are going to be able to leverage in the future with data, artificial intelligence, and machine learning. Therefore, we are just going to keep getting better and better on this. One of the reasons I took the role that I am in is that I think technology and the use of data is going to transform fundamentally the way we support people to keep healthy and support them when they are unwell in the future. It is going to have a bigger impact, to be honest, than, I think new hospitals or new waves of buildings. Therefore, it's just really, really important that we're right at the forefront, particularly in the UK being able, in the world's largest socialised health system, to be able to get these technologies from development, in a safe way, to clinical practice, to create real benefits for people.
James Bird: I agree, absolutely, everything that Vin has just said, and again, more eloquently than I will ever put. I am just going to focus differently, on staffing and what the staffing model will be in two to five years’ time. I think it will be very different to what we see now. Whilst a portfolio career is quite usual for medics, it is very unusual for nurses to have portfolio careers. I think that will change. COVID burned quite a lot of nurses out on the frontline and I have had no problems filling any of my vacancies in the virtual ward, unsurprisingly. I think nurses will think, “I do not want then to go through that mix again in five years’ time”. What I think we need is a portfolio model which allows people to do one or two days in a physical clinical capacity, doing direct patient care, then bring in that skill set, because you need that experience of seeing the sick patient, back into the virtual piece, and then going back into clinical practice. That can be from the community into the virtual ward and from the acute into the virtual ward because both the skill sets are needed in the virtual ward. So I think we will see a much more portfolio career become established, which crosscuts the bureaucracy of cost codes, budgets and everything else. If we can put all of that to one side, I think in the next 2 to 3 years we will see a portfolio career model established for many nurses that just does not exist today.
Nigel Thompson: A kind of hybrid way of working that other people in other sectors enjoy now. However, for clinical staff?
Vin Diwaker: I think we will see that because then you can see a future in which say you might work two or three days on an acute unit, you might have a day where you're doing community visits, visiting patients, and you might have a day or two where you're working remotely, potentially from home, making calls to patients, but don't require you to actually do that long commute into work in the same way as other sectors have. Every person I have ever met is working in that way, and there are parts of the country that now work in that way. The staff are so motivated because it is a very different way of working and much more productive and satisfying for them.
James Bird: It has so much opportunity. We have such a nurse vacancy problem in this country. Doing more of the same for the next 20 years of my career cannot be the same as we did for the last 20 years. We cannot keep doing what we are doing and expect different results. This needs to become a more portfolio based. It needs to for that work life balance; it needs to change for some people. This will allow that and give them that reward back, give some time off the frontline to do still do worthwhile good care. However, you are not directly in the coalface every single day. I think that is actually important.
Nigel Thompson: Exciting times, thank you both very much for your time this morning. It has been great to speak to you both, great insight into what is going on now and what is happening in the future. So, thanks for taking part in the podcast from the Innovation Collaborative and thank you for listening as well. There is a whole range now, a whole series looking at this topic and others as well. You can find out more information on the NHS Futures website. Thanks for listening.
Episode 9: Building capability and confidence in technology-enabled remote monitoring pathways: voice of the patient, consultant, nurse and GP
This episode explores how people with asthma in Northamptonshire are being supported from the comfort of home through technology-enabled remote monitoring.
Recorded in partnership with Northampton General Hospital NHS Trust (NGH) and Integrated Care Northamptonshire, this podcast features retired teacher and grandfather Ian Mcllroy, who has asthma and was one of the first to be supported at home virtually by the trust’s specialist respiratory team.
Ian’s story is told in this episode which also features NGH Respiratory Medicine Consultant Dr Fiona McCann, Asthma and COPD nurse specialist Frances Mulligan-Evans and GP Dr Rob Gale of Langham Place Surgery, Northampton.
Episode 9 transcript
Nigel Thompson Welcome to this Innovation Collaborative Digital Health podcast. Like colleagues in other regions, clinical professionals here in Northampton are seeing an increase in asthma cases, many of which can result in a visit to hospital. But here technology has been introduced to reduce the number of patients who need to come to clinic. It’s the end of a busy chest clinic here at Northampton Hospital in Area D. The area itself is now the hub as well for a brand-new digital service which has been going for just over a year. You can hear a bit more about it now from Dr. Fiona McCann, the respiratory medicines consultant, and Frances Mulligan Evans, who's an asthma specialist based here at the hospital. Good to meet you.
Fiona McCann Nice to meet you.
Nigel Thompson So tell us, was that a fair description. This is the hub, the epicentre of a piece of work that's been going on for the past year, that's benefited quite a few hundred patients already. Fiona, tell us a bit about how it first came to be.
Fiona McCann At the start of 2020. We were given the opportunity to develop some virtual monitoring pathways for patients with COVID. Having got together with a company called Doccla who deliver virtual wards, we initially set up a pathway really rapidly just at the very first surge of COVID. We were able to allow patients to go home in a really fast and rapid, timely way to allow them to be cared for at home and looked after in a safe and effective way. This was really before any of the other innovations for home oxygen sats monitoring things, came about. Having developed this pathway, we then used that experience to develop further pathways and one of those was in asthma. And really it came about over a lunchtime conversation one day where we decided that we would trial it for patients with asthma. Frances and I set about trying to develop a pathway, identify patients who could go onto this pathway, and really, it's been going from strength to strength ever since.
Nigel Thompson Tell us, then Frances, from your point of view, as somebody who's involved in this area of health, what difference does it make the fact you can actually involve patients to look after themselves and monitor themselves remotely?
Frances Mulligan Evans It makes a hell of a difference because most of these patients had uncontrolled asthma symptoms in the community. They would pitch up at A&E because there was nowhere else to go. They didn't have any management plans. So it gave us the opportunity to see them in A&E to expand the workforce in asthma so that we could have extra nurses, we could see everybody that presented and we could improve our best practice tariff as well, which was pretty poor prior to bringing in the home monitoring. People were acutely unwell and instead of just giving them treatment and sending them away, it meant we could monitor them when they went and we could make sure that they did improve. It was about seeing them, making sure that they were improving, monitoring their observations, speaking on a daily basis. We have a video call feature as well on that equipment so we could see the patients if the patient was struggling.
Nigel Thompson This sounds amazing, but just take us back a step. how was life or how would you say that your life was for the line of work you're in before this? What was a typical kind of day two years ago?
Frances Mulligan Evans A typical day two years ago was clinics. It was seeing patients getting referrals from patients and seeing them in A&E, then they were going home. So there was no follow up. Once they left, it was advising them to go and see their GP within two days, which didn't always happen because of COVID, face to face contact with GP’s had ceased at that point.
Nigel Thompson I guess as well. You'd see returned patients, patients who you had sent off. If they didn't get the treatment, they'd come back.
Frances Mulligan Evans They repeatedly came back to A&E and they were repeatedly treated and then they were sent away again. They just kept coming back because there was uncontrolled asthma symptoms and sometimes hay fever symptoms as well that were left untreated and it was impacting on their asthma and making them very unstable and they were exacerbated because of it - the acute treatment wasn't enough. We needed to give them some education, management plans so that they knew what to do and how to manage their treatment at home.
Nigel Thompson We will speak to one of your patients in a minute, but when it comes to the sort of difference it's made to you and to staff here as well, I mean, I imagine a lot of frustration a couple of years ago when you were seeing the same patients coming in and out. And I guess a sense of frustration that you weren't really into the nub of the problem. They were coming back in. Probably they were frustrated. You were frustrated. Therefore, the system not really working is that fair.
Frances Mulligan Evans They were unhappy. They had no confidence in managing their own condition. And it was trying to change the culture in A&E, getting them to phone us, to let us know those patients were there and going down, reviewing the patient. Giving them early treatment as well. So, when they come to A&E, trying to give them their treatment within the first hour and I do prescribe for them as well so that they can take that medication home and then follow them up. It's a good seamless service in asthma, looking after them and giving them specialist support and follow up as well.
Nigel Thompson Just talk us through then practically how it works from your perspective and also from the patients as well.
Frances Mulligan Evans So this is the system here. This is what we've got. We've got lots of dashboards on here. If you look at these couple of people on home monitoring here, there's COVID patients on here. There are pregnant ladies on here as well who are being monitored because they've got COVID and you've got the asthma here - so these are all the asthma patients that are on there at the moment. And you can see here he's quite an unstable gentleman, when he went on first and then he started to become unstable. Do you have new symptoms? Yes. This would have brought him into A&E because he has new symptoms. And then he phoned us up. I brought him in here, reviewed him, gave him some treatment. And you can see here now he's quite unwell. So, this is him going through that pretty unwell patch, came into the hospital, we gave him the treatment, he improved a little and then he had some hay fever symptoms that impacted on. We've started some more treatment and he's pretty stable now.
Nigel Thompson Looking at the date and time on the top, this is regular updates isnt it?
Frances Mulligan Evans This is regular updates.
Nigel Thompson How useful is this?
Frances Mulligan Evans He’s doing these observations three times a day at home. So morning, afternoon, evening if he was more unwell he would be able to do extra observations and if he phoned me, I would be able to look at the observations and see exactly what's happening there, I'd be able to talk to him as well. And we can video call him as well. It would come up on the laptop that, you know, I'd be able to speak to him through the phone. I'd be able to ring him here. He'd be able to see me on the phone to see the uniform, see the nurse, and I'd be able to see him, see his colour, his work of breathing and, explain things to him. It works really, really well. It's regular information that's coming through and it's reviewed regularly by the nurse. When they acknowledge it, it lets the patient know that I've looked at it and I'm happy with it. If the patient was unwell here and he had new symptoms, he'd be able to type further to tell me what the new symptoms are and give me more information. And then when I come and check it, I'd be able to see all that information from the patient straight away. It asks you here, do you feel you need a phone call to discuss these symptoms? Yes, or no? If he answered yes to that, that would come up red and I get a red box, so I know to act on the information in there.
Nigel Thompson I guess because it's not just more information do you feel it is more accurate because it's taken when a patient is at home or relaxed? Have you ever heard of White Coat Syndrome people getting, you know, upset, stressed about having to come to hospital? Do you feel this is more kind of real world?
Frances Mulligan Evans They're in their own surroundings. As you said, they don't feel anxious, they're dealing with one person all the time, so we've got really good continuity of care. They know that when they're speaking that person is a specialist in asthma, which is the condition that, is affecting them now so it's really good.
Nigel Thompson Did you as clinicians have any concerns that, you’re kind of losing face to face as you were hearing there? You’re actually seeing the patient because it's a two-way thing, but it's not the same as being sat in the same room, is it?
Fiona McCann No, it's not. And I have to say, when we first took it on, I was concerned about the idea of using this for asthma, because it's traditionally a very acute, difficult condition to treat. And we have a lot of patients coming into hospital with it who become very sick. What we found, however, is kind of the reverse, that when the patients come into hospital, they're often on a general respiratory or general medical ward. They can be looked after by multiple different doctors, nurses, physiotherapy. All kinds of people are going in to see those patients and putting their penny worth of information to the patient and actually having a very dedicated, small subset of nurses who know what they're doing and can deal with that condition really well has actually been really beneficial to patients care and we're not sort of yo yoing between different treatments and not knowing when to send them home. It's really straightforward and actually the patients really value the continuity.
Ian Mcllroy My name is Mr. Ian McIlroy. I'm a 63 year old man from Northampton and my background is in teaching. I was a secondary comprehensive school teacher for all my working life and retired quite recently. Now I'm busy in another way, providing childcare for my grandchildren and doing other bits and pieces. I do some editing for a local author, and I also still do a bit of Spanish teaching.
Nigel Thompson Never been busier, I imagine.
Ian Mcllroy Exactly that, it's that old cliche that once you retire, you get on with so many other things you don't know how you fitted work in. There’s a grain of truth in it, I guess.
Nigel Thompson Well, good on you. Tell us about your health. How have you been for the past couple of years?
Ian Mcllroy I have had asthma since I was about 40, and it wasn't really a problem until several years ago when for some reason it became quite severe. I got to a situation where I was on a kind of monthly cycle of using rescue prednisolone to forestall exacerbation and then having a couple of weeks where everything was okay and then going downhill again. After some time, I guess a couple of years of that rather difficult merry go round. My GP referred me to the chest clinic here and to Frances's team.
Nigel Thompson I understand you were one of the first to make use of an android phone to monitor your conditions. Tell us about how that worked and what was your initial reaction when somebody said, you can have a phone, it will stop you coming into a clinic? What did you think about that?
Ian Mcllroy Yeah, well, that started really after a couple of near exacerbations where Frances suggested that I use I think it's called the Doccla system. The monitoring system to really pick up some data and also keep an eye on me for a period of time. I think it was somewhere between a week and two weeks that I used it. I was more than happy to do that really. I know the thing is based around one or two little bits of technology, but you know, I'm not really a technophobe. I'm happy to embrace it, it's only a mobile phone after all. I was very happy to use the doccla pack and I think it brought a lot of benefits.
Nigel Thompson What difference do you think it made than perhaps to you having to come to a clinic like this, perhaps on a more frequent basis, the fact that you could actually, rely on the phone to upload your information, your stats, rather than come in, what difference did that make?
Ian Mcllroy I think there's obviously the convenience that you don't have to drive yourself to the hospital, every other day. There's an uptick in the amount of data that can be collected because I was using that pack three times a day, so it's quite straightforward. I set my phone for three little bleeps through the day, and it reminded me. It's kind of a two-minute job just to do the pepo, the temperature, the various things, oxygen saturation and so on, and then upload them on the phone. It might seem like a lot, but it does only take minutes. Certainly, the app on the phone is straightforward to use. It meant that Frances was able to get ahold of a lot of data over a fairly short time. I do think that advanced the progress along the pathway to getting me to the point where I am now where I'm getting really what I think and the clinicians think is the right treatment for the type of asthma I have.
Nigel Thompson For family, and grandkids as well - this is great news because it means you're looking forward to a summer where you can be as active as they are.
Ian Mcllroy Yeah, well, we'll see what happens there. But no, you're absolutely right. And going back about three years, I was really scraping along the bottom there, having exacerbations every 4 to 5 weeks. That's no longer the case now, because my steroid use has been smoothed out a little every day, and then the benralizumab should eventually eliminate even that. That's the dream, that would be great looking ahead, to my health in the future.
Nigel Thompson So one satisfied customer there, what's your hope for the future? You've had 300 people come through it at the moment. What are your plans for the next year or so?
Fiona McCann We have so far focused on patients who are coming to an acute setting, say A&E, Acute Medicine or the Acute Asthma Service, because they're really unwell. What we would really like to do is move it back into the community and try to identify patients that are becoming unstable because either they are using a lot of reliever medication or because they're needing to have steroid courses. Depending on the amount of steroid courses increases their risk. What we have started to develop with one of the GP's in the community is trying to target patients who were in those categories to see whether by uploading the same app we're using within the hospital we can identify them exacerbating earlier and try to treat them and pick them up earlier so that they then don't end up coming to A&E or acute care settings or even going to their GP for an acute emergency appointment, because actually we've already picked it up and treated them. And in doing that, we hope that we can educate the patients to understand their condition a lot better and therefore know what to do in the future. It's trying to empower the patients themselves to understand their own condition and what to do about it and how to treat it in each kind of setting.
Nigel Thompson Dr. Rob Gayle is a GP, at the Langham Place surgery, and he's very excited by this prospect.
Rob Gayle I'm the respiratory leader in the practise and it's also an interest of mine which has led to me taking on additional roles outside of my GP hours. I work for Northamptonshire Carers in conjunction with NHSFT, which is one of the local community trusts, and we run support groups for people with chronic lung conditions, so primarily COPD, but asthma and lung fibrosis, we run various groups across the county. In terms of the digital work, I've been working with Dr. McCann, who's one of the consultants that's been involved with this at Northampton General Hospital on a couple of other projects.
Nigel Thompson What proportion of your patients do you think have asthma?
Rob Gayle So we've 10,000 patients on our practise list. When we last checked we had around 200 to 300 with asthma. We are sort of running searches to see if there's anymore that we may have missed so it’s probably around the 200-300 mark.
Nigel Thompson And what effect then do you think would it have if you were to be involved in something like this, this digital pathway where patients actually take control of their own kind of destiny, as it were?
Rob Gayle It would help us to prioritise more effectively, those people whose asthma control isn't as good, so that we can provide them with more intense support or follow them up earlier than we may have ordinarily. And, as you say, will also empower patients. Have them take control with a bit more confidence in the treatments and ultimately improve how their asthma is controlled, improve the quality of life and prevent them needing to seek out an hour's care or urgent GP or even hospital appointments.
Nigel Thompson And in terms of investment in the future, I mean, do you see this as perhaps the kind of the first in a wave of kind of systems that might help patients monitor themselves in a way that's more accurate but also has a longer-term benefit?
Rob Gayle I'd certainly hope that with this pilot we can demonstrate clearer benefits for the patient and in an ideal world, I'd like to offer this to every patient on my list of asthma, and pass that out across all of the surgeries within Northamptonshire. So, it’s something that everybody at the point that they are diagnosed with asthma, or have a long term condition, its gives them the tools to accurately monitor their condition and seek help and ultimately optimise the care they receive. In terms of the kind of remote aspect of it, I think that's something that we've become accustomed to over the last couple of years with using different software packages to assess people remotely using online platforms and cameras or you know, we've been using different packages to sort of monitor conditions and request information from patients in the form of pictures or answers to questions about their symptoms. I think this is being met with quite a lot of positive support from my colleagues.
Nigel Thompson That's Dr. Rob Gayle of Langham Place Surgery in Northampton. I guess with stories like that and, the support you've got from GPs, that's got to be exciting because it means, I imagine that hopefully in the future even fewer people will have to go through the service at this stage or be kind of picked up and looked after earlier in the process. Is that right?
Fiona McCann Yeah, absolutely. My hope is that we can almost push it all back to the point where the patients can manage their own condition and we're not then seeing them coming into acute care settings. Hopefully in time, Frances will find herself significantly less hard worked than she is at the moment. I mean, it's been going for a year. Frances, remind me how many people with.
Frances Mulligan Evans Just shy of 300 patients now gone through in the year. We've had four people come back into hospital while they were on the service and those four people were all acutely unwell. They had very difficult asthma. We did envisage when we put them on the service that we probably wouldn't be able to keep them out of hospital. We've had patients from 17 years of age, up to 85 is our oldest, they've managed really well with the equipment and the thing about it is some of those patients have come back to us. They haven't presented at A&E, but they have phoned us to say, I'm having a problem with my asthma at the moment. We would then bring them to chest clinic, do a face to face review, check them over, prescribe if they needed it, or track them to wherever else they needed to go, whether it was the GP and maybe it wasn't their asthma, we just sidelined them off to the GP, but if they need needed treatment, we give them treatment and then they would take another box and they would go back on the service. So, it's really good, anybody who we've seen has never come back to A&E. That's the thing. So, of all the 300 patients, nobody has ever come back to A&E. They phoned the service and we've dealt with it and kept them away from the hospital.
Three people die in the UK every day from an asthma attack and it's worth educating the patient as well and empowering them, so they know what to do when they're having an asthma attack. The other thing is, every 10 seconds, someone is having a life-threatening asthma attack as well in the UK. If we can impact on that and make a difference, and empower the patients, that's what it's all about, isn't it? It's about good, safe service keeping patients safe in the community and teaching them how to look after their own long-term condition.
I do think we've made a big difference and I think the patients would think we made a big difference. Looking at when I walk through the hospital now, I don't see as many asthma treatments, asthma patients, only the ones that need to be there, that need oxygen or are too unstable to send home at that time. I think we've made a big difference.
Nigel Thompson Thanks for listening to this Innovation Collaborative podcast. Please share and listen out for more. You can read more about the kind of work that's making a difference here in Northamptonshire by going to the Innovation Collaborative Workspace on the future NHS web page.
Episode 10: Technology-enabled remote monitoring as a catalyst for equality: supporting people with a learning disability or severe mental illness to access annual physical health checks
This episode explores how different regions are harnessing technology to help people with a severe mental illness or learning disability receive important annual physical health checks.
Paul McCourt, Digital Mental Health Lead for the North East and Yorkshire Region, and Dr Inder Sawhney, Consultant Psychiatrist and Clinical director at Hertfordshire Partnership University NHS Foundation Trust, compare approaches, learning, and discuss how technology can help reduce the disproportional prevalence of chronic conditions and reduced life expectancy among some of the most vulnerable in society.
Episode 10 transcript
Nigel Thompson: Welcome to our latest National Innovation Collaborative podcast. I am Nigel Thompson. In this edition, we are discussing how technology enabled remote monitoring can help those in real need of support. People with a learning disability or severe mental illness can now receive, amongst other things, the annual physical health check far more easily than before. Let’s hear how it is working in two different parts of England, the challenges, the benefits, and maybe the plans too.
We are joined by two experts, Paul McCourt. He is a regional digital mental health lead for NHS England, North East, and Yorkshire region, and Doctor Inder Sawhney is a consultant psychiatrist, and clinical director for Hertfordshire Partnership University NHS Foundation Trust; part of NHS East of England region. Thanks, both, for joining us.
Paul, I will start with you. Firstly, tell us about your current role, what you do, and the areas of expertise that concerned you.
Paul McCourt: I am wearing two hats, I am, as you said, the regional digital lead for mental health in North East and Yorkshire. However, as far as this work is concerned, I am the project manager for a project to increase the uptake of annual physical health checks for people with Serious Mental Illness (SMI) for the North East and North Cumbria AHSN. The projects that I am managing cover the northeast north Cumbria, ICS/ICB area.
Nigel Thompson: A massive area, we will talk about that in more detail. Inder, the same question to you too, as consultant psychiatrist and clinical director of different part of the UK in Hertfordshire. Just tell us a bit about your current role and the areas of expertise.
Indermeet Sawhney: Thanks, Nigel, as you said, I am a consultant psychiatrist, and I have specialised in adults with intellectual disability. That is where the prevalence of mental illness is a lot higher compared to the mainstream population. The other hat that I wear is that of a clinical director. That is the operational manager responsible for the services and for being innovative. It involves looking at how we improve services, experience, and outcomes for the very vulnerable population that we serve in North Essex. As you alluded to earlier, I am also part of Hertfordshire Partnership University Foundation trust for my clinical role.
Nigel Thompson: How was it before and how has new technology and new approaches helped to you achieve better outcomes and detailed assessment of people who need it?
Paul McCourt: That is a salient point, anecdotally, we do hear that people on SMI registers don't engage with primary care because they don't want to go into a GP surgery just to be told again that they're still smoking too much or they're having too many drinks on a weekend etc. Therefore, they do not go there for the physical health checks. The physical health check itself is relatively straightforward; it is thorough, but it is a straightforward check. It is checking blood pressure, blood sugar, HBA1C, lipids, and BMI. It is a few questions about physical activity, smoking habits, drinking habits, things like that. It can lead to onward referral where necessary. It can also lead to social prescribing, where relevant. It is a useful tool, so that we can monitor the health of people with severe mental illness. The project I am involved in is for those people who have not engaged with primary care, we are providing clinicians with portable sets of equipment. This includes blood pressure monitors, point of care, blood tests and other devices, everything that they need. They can put them in the car. They can go out and proactively go out and meet people in their own homes or in in a community setting of that person's own choice to do those checks where that person is most comfortable. We are working with clinicians who have the soft skills, the social skills to engage with the patients do that that check, but also do the onward referral or do the social prescribing, those things that can improve the health outcomes of this group of people.
Nigel Thompson: Is it working? I guess that it would take some time for both staff side to learn how to use the remote kits, but also the social side, the convincing people of the merit of doing this. You have made it sound a very clear and obvious thing to do. However, I wonder on practically on the ground, how has it worked? Are you getting the results now that you hoped he would get?
Paul McCourt: We are in the early stages of delivery. We have delivered all of the equipment out to the various areas and in a couple of areas it is in use. We are getting positive feedback. There is one team in particular, in South Tyneside, which has been in place for some time and they are successfully going out and doing the health checks for people. Anecdotally there and in other areas, we are hearing that there is some re-engagement with primary care. There is integrated work that needs to happen. The people in the team can get in touch with GPs and do the joint work. They have access to the GP systems so that if it is nothing too severe where they do not have to get in touch with the GP immediately, they can log things to be looked at by other members in the GP practice so that things are picked up and integrated work is done.
Nigel Thompson: Inder, where are you with that work?
Indermeet Sawhney: Similar to Paul. We have what is called a blue box. As the name suggests, it is blue in colour and it essentially contains equipment to measure some basic parameters, the blood pressure, the pulse, the blood lipids, the blood glucose, etc. The equipment is paired with a Bluetooth device, which connects to a portal. Once those parameters are taken, they are imported to our electronic records where we can see them in our work bases. I would like to think that it has been a big success for us. It is very hard to engage this patient group. They are dependent on others for a whole host of factors. The people who are doing this are people working within the learning disability teams, they have the competency and the skills; and a lot of them already know the patients too. However, we were seeing them for mental health or their behaviour, therefore, that relationship is in place. This is a very different context to when you are walking into a GP office and you are just seen for 10 minutes, by someone you have never met in your life.
Essentially, I would like to think it has been a big success. We are collating data on this, we have seen about 180 patients, including people in care homes, and about 15% of cases required intervention. For example, a case where high blood pressure was undiagnosed at that point of time and had the team not gone in it would have remained undiagnosed, therefore treatment has been initiated. Another example is where they were in treatment, but blood pressure was still uncontrolled and treatment was changed to bring it under control. It may sound innocuous, blood pressure what is the big deal, but I want to give a context and a background to this. The LeDeR Report looks at all the avoidable deaths that have happened in learning disability and has highlighted that 14% of them were because of hypertension. If you put that in numbers, it was 2000+ people overall and 40% of deaths were avoidable. Out of that, 14% were hypertension, 164 people would have been alive. I am just trying to stress the importance, the benefit it is bringing, going in there proactively engaging and then liaising with primary care, as Paul had said, because, clearly that is not something within our remit. We do not have the expertise, but we can flag up and have that integrated care.
Nigel Thompson: On the point about the difference the blue box has made already, if that was to be expanded, I guess by extrapolation, the number of people who would still be alive must be quite significant. Is that what you are thinking now for the future?
Indermeet Sawhney: The plan for us is that it now needs to be formally rolled out. We think that this is here to stay. The Blue Box should be used because we are picking conditions up. It is useful across all professions, if you are going out for a home visit, anybody can just pick it up and use it on the visit.
Often the behaviour, the mental state, the manifestation of an underlying of impaired behaviour is because of something like a urine infection, or the glucose is all over the place and it can save time and enable earlier intervention. I think there is going to be a reduction in unplanned activity due to using this equipment. It has not been formally evaluated, but that is the aim. Get in early, nip things in the bud, and you see less of the unplanned activity. Therefore, there is room for expanding it to other services within our Trust. There is also room for using it in other settings too, not just the community, but in the inpatient setting. We are collating feedback from patients as we are going along because we might think we are doing a great job, but we need to check. What we have heard so far is comments from carers who feel it is very reassuring to know that all is well, the reassurance that it is nothing physical, or that things having been picked up. Therefore, they are grateful and the experience has been positive for them.
Paul McCourt: Similar to Inder, as we are using a similar sort of portable solution, which has been developed by Healthcall in the North East, and they are an NHS owned digital health company based in Gateshead, and they have put together our set of equipment, which is very similar to the blue box. What they've also done, they've developed an app which sits on the tablet so that when the clinician goes out to the patient's room, they can record all the results of the physical health check on the tablet, and that will then push those results back straight into the primary care system. Therefore, that means that they do not have to go back to the office between visits and log into the system and do that. It pushes it straight back. It saves travel time, it saves the clinician's time, it saves them writing the notes out on paper and then going back and having to duplicate that into the system. Therefore, they have developed a great system for us. In addition, the kit that we have put together is probably very similar to the blue box, but you know, it allows us to choose the equipment that we thought was best for the job that the clinicians like too. We engage with clinicians to make sure that we have the right kit.
Indermeet Sawhney: One thing that is probably not tangible yet as we have not formally evaluated, is the empowerment of the service user. They can go to the GP and say, “I have had these readings”; it is hugely empowering for that population group. There is also self-management, knowing their numbers they can modify their lifestyle. Again, when they are going to see the specialist there can be shared decision-making. Therefore, there is huge scope for empowering service users.
It is also about having a digitally enabled workforce, as Paul was alluding. They have the tools at their disposal and the automated processes that have been set up, and can use them to their advantage, which brings in more efficiency. That is already a benefit. As the service expands and rolls out, there is also an opportunity to get intelligence and data, about the population to shed light for research into new models of care. It can also answer questions on demand, capacity, and assessing the population needs, but that is further down the line. The here and now for us is about the experience and the outcomes for the patients.
Nigel Thompson: I wonder both; as you have to look at two aspects. training staff to make sure they know how to use the kit and making sure that the patients are happy and content to be monitored in that way. What advice would you give listeners who are thinking they have something similar in mind they would like to roll out, but are not quite sure how to start? Thinking there could be pushback from patients who may be a bit apprehensive about it. What advice would you give people starting out on your journey?
Paul McCourt: The difficulty is in the boundaries between primary care and mental health care. It is necessary to work across those boundaries to do integrated work. Start those conversations early. Get the right people in the room or in the Teams meeting and speak to primary care and mental health colleagues. There are obviously issues around information sharing across systems and the information governance. Make sure that you get that ironed out early on because it has to be done. It can take considerable time. Just make sure that you speak to people, that the communication is there. You also need to ensure that you get the right equipment for the job. To think outside the box and bring as many things in that can make the lives of clinicians easier and the interaction with patients as smooth and straightforward as possible. Do that joined up work and make sure the clinicians have not only the clinical skills, but also the soft skills that I mentioned earlier. This enables them to be reassuring, interpret the results, and give feedback straight away to the patients in front of them, to give them reassurance.
Indermeet Sawhney: Can I add to that, start to co-produce with service users and carers right at the outset. You get the expertise and the knowhow from a different perspective. Frontline clinicians should also be involved right at the outset, not somewhere along the journey. I would also suggest having a Continuous Quality Improvement (CQI) model. Therefore, this is going to be an iterative process. You will not get it right the first time. You will have the feedback, so keep reviewing it, and keep going back to it. That is going to be important. In terms of project management, I would suggest you set milestones and keep reviewing. Communicate, both top down and the bottom up, what is going well, what is not going well. Look at the small nuances, which perhaps would make it difficult for someone, for example, the cuff is too big, or the pipette was too small to take blood, small nuances, which make a big difference. The other thing I would say is do not assume the staff, who are working in mental health and learning disability, are comfortable with medical devices. Therefore, the training has to be robust. Some would have worked in other settings and they would have experience, however, a lot of us are quite rusty because that is not our core expertise. Do not underestimate the need for sustainability as well. It needs to be operationally embedded in practice; that is going to be key as you move further along. That would be just a few of my top tips along with what Paul has already mentioned.
Nigel Thompson: That is good advice. Given what you have said, it seems to be working pretty well. You already have initial feedback from clinicians and from patients saying it is working for them. Therefore, what does the future hold? I imagine it is something you will be rolling out more widely and perhaps refining. What are your plans for both of your projects?
Paul McCourt: We are currently in the early stages of the deployment of the equipment, so I think we still have a lot to learn. We have had a lot of feedback from both service users and clinicians. I think we will need to do some longer-term research into the outcomes for the people that we are working with. It would be great to see hopefully three, five, or ten years down the line that the health outcomes are better, that that there is a greater proportion of people getting the regular annual physical health checks and that it is leading, where necessary, to proper onward care. I would hope it is also reducing the development of some of the conditions to which unfortunately, these patients seem to be prone.
Indermeet Sawhney: One of the challenges for us was the Information Governance (IG) system. We did not have the same IG processes across organisations. The vision would be rather than the traditional calling the GP with the data, instead they can see in it directly in their system. It has been input at the point of care in the MH Trust system and flows through to the primary care system for the GP to see, so that we are not working in data silos.
Another wider thing for me is enabling self-management using technology, because we know is there is a digital divide and people with learning disability always seem to fall on the wrong side of the divide. There are a lot of presumptions, stereotypes, and some real barriers, why they cannot access technology. I think empowering service users with this project will do something different where they can self-manage. They already have apps. I suppose it is the broader question that the technology is there for health care, even for this marginalised population. The form it takes may be different, time and research will tell us about what works, I am just putting them on the map so that they are not excluded from it.
Nigel Thompson: It is good to hear two positive stories from different parts of England. People listening to this may want to contact you, perhaps, to learn from what you have done, so that they can roll out in their own parts of the UK. I suppose this is the benefit of a podcast like this, and the fact that you are both involved in similar kinds of work that you could share. I am sure you have good experience to share about things to do and things not to do. As you have as you mentioned before, this kind of work can only be of benefit, not just in this area of work, but other aspects of health care making use of digital techniques and technologies as it evolves in the future.
Paul McCourt: Absolutely, as well as the projects that I mentioned in the North East and North Cumbria area, there are the sister projects in the rest of North East and Yorkshire region, and other projects up and down the country which have been funded to do exactly the same as our project is doing. Therefore, I think we will see some interesting research, feedback, and evaluation over the next year or two to see how all of these projects have fared. I think there is a lot of learning to be had over the coming months and in years to come. We have been supported brilliantly in the North East by the AHSN. In other areas, it has been run slightly differently, but with the same theme of trying to add another tool to the toolbox to improve the health outcomes for people who are on SMI registers and people with learning disabilities.
Indermeet Sawhney: Yes, I would be very happy for anybody to get in touch. All good things are meant to be shared. If there is anything that people are interested in, we would be very happy to talk about it, because it is about making a difference, improving the outcomes and the experience. Nigel, can I just add, I have spoken about the project I was leading for Learning Disability in the North Essex district for Hertfordshire Partnership Trust. However, this has also been rolled out for older people and SMI population within other parts of the trust. It could also be utilised for monitoring of medication, especially times of the pandemic, where patients were being seen remotely. This demonstrates the advantage of technology. It is here to stay in different evolved versions in times to come.
Paul McCourt: It has been evolving, for instance, the project I am involved in is specifically for people on the SMI Registers. However, some of the teams that I have been working with have said now we have this equipment, can we use it for the LD health checks, when it is not in use for the people on SMI registers. Get it out there and use it as much as possible for people with learning disabilities. Another thing that seems to be happening is, whereas there were one or two teams who were put together specifically for physical health monitoring, now physical health hubs are being set up because of the work that we do in other areas of the localities. I am encouraged that it has been bring this into focus and hopefully the development. I hope that the development of those teams will help the spread of the equipment, and enable better physical health checks with wider use for this population.
Indermeet Sawhney: I would say it transcends not just boundaries within the health, but within other teams as well, for example, social care. Therefore, within social care, some of the homes are getting staff trained up too, and then anytime they feel that someone is not looking right they have the tools to the hand. It is another tool in the toolbox, as Paul said. Rather than waiting for a GP to visit they have the information ready, the blood pressure, the glucose, etc. They do not have to wait for a health care professional to be there. That has already been rolled out in some of the homes here within our neighbourhood.
Nigel Thompson: There is a very good phrase that has come to my mind, which is steal with pride, because if it works well, why not? It has been great to talk to you. Thanks very much for your time. It is great to hear how it is working in different parts of the country. I am sure many people listening to this may want to take up your kind offer to get in touch and learn more about how it is working for you both. Thank you very much, Paul McCourt, the Regional Digital Mental Health Lead for NHS England, North East, and Yorkshire region. Doctor Inder Sawhney, the consultant, psychiatrist, and clinical director of the Hertfordshire Partnership University NHS Foundation Trust. You can read more information about this topic and the others contained in this series of podcasts. Just go to the Innovation Collaborative Workspace on Future NHS. This is Nigel Thompson. Thanks for listening.
Episode 11: Trust, opportunity, and options: building public, professional and personal confidence in technology enabled remote monitoring as an integral model of care
This episode looks at building public and professional confidence in technology-enabled care. It provides new insight from two senior leaders at Mersey Care NHS Foundation Trust, home to one of the country's most well-established clinical telehealth and technology enabled remote monitoring hubs.
Dr Rosie Kaur, Deputy Chief Medical Officer, CCIO and Clinical lead for Telehealth, and Trish Bennett, Director of Nursing and Operations and Deputy Chief Executive, discuss how the hub has grown, diversified and adapted its services and resources to meet the needs of people across Cheshire and Merseyside.
They explore how has this work has impacted not just on the way people and patients feel about technology-enabled care, but on the opinions and ambitions of health and care professionals.
Episode 11 transcript
Nigel Thompson Welcome to our latest National Innovation Collaborative podcast. I am Nigel Thompson. Today I am at Mersey Care NHS Foundation Trust in the North West, home to one of the country's best established telehealth and technology enabled remote monitoring hubs. Since launching just over ten years ago, the hub has grown, diversified and adapted its services and resources to meet the needs of people across Cheshire and Merseyside. So how have the team done it? and how has their work impacted not just on the way people and patients think and feel about technology enabled care, but on the opinions and ambitions of health and care professionals?
Trish Bennett My name is Trish Bennett, and I am the Director of Nursing and Operations and Deputy Chief Executive of Mersey Care. So, nurse by background, many years as a nurse and have worked in acute services and community service on mental health services and commissioning both in Cheshire and Merseyside, but also in Manchester, Greater Manchester and Lancashire and Leeds before that. So, I have worked in a lot of places, I am very passionate about community care and what can be delivered in community services, both from a mental health and lone disability perspective, but also from long term condition management.
Dr Rosie Kaur Hi, my name is Dr. Rosie Kaur, and I am a GP by background and in Mersey Care, I am the Deputy Chief Medical Officer for Physical Health, and I am clinical lead for remote monitoring for Cheshire and Merseyside. So that provides medical oversight to community vision, but I am very passionate about remote monitoring and telehealth. I mean GPs are our patients advocate, so we bring that experience with us, that clinical background into what I do. So, I am very fortunate.
Nigel Thompson We're talking at the headquarters of Mersey Care, this massive building. I've just been sat waiting to talk to you and I thought it's a bit like the tip of an iceberg because I know you've got something like a hundred different sites, you work with six local authorities, over eleven thousand staff and almost a thousand inpatient beds. I mean you are huge in terms of trust in the country - you must be one of the biggest.
Trish Bennett Certainly in community mental health and learning disability services we are, we have one hundred and seventy one sites, just under a thousand beds. So, if you think about our beds, acute beds, and mental health beds, we are as big as some acute trusts as well as running services from sites in the community, our remit is beyond Greater Manchester, and into Lancashire. So yes, a big a very big place.
Nigel Thompson You are also looking after the very most vulnerable people in society as well as a big organisation, doing a very important job in a challenging time. You have gone through a pandemic, an ageing population, you know all about it better than me I am sure the challenges that you face are getting bigger aren't they?
Trish Bennett Diverse services from pre-birth through to end-of-life prevention services, all the range of mental health services from acute and old people services to secure levels of care. We have one of only three high secure services in the country in Ashworth, and the same for learning disability. So, community services plus low and medium secure services as well. Predominantly, beds are for very acute levels of care, and we really focus on managing people where we can, as close to home as we possibly can.
Nigel Thompson Let us talk about technology, because I suppose that is the thing that has made life a little easier when it comes to having those challenges and that very diverse range of services that you offer. Where are you up to at the moment? What are the current challenges you face and how has remote monitoring helped?
Dr Rosie Kaur Part of the challenges we get is, as you quite rightly said, it is, ageing population and increasing co-morbidity. As we start to look after more people in the community, the question is how do we make sure we give the right care at the right place at the right time to them? And I think the pandemic helped. There was a bit of a sea change around how we use technology and principally around using video consultations and making it acceptable to for people to access their care from home. I think that has been a quite big sea change, both in how we run outpatient clinics and community services. The thing for us is the scaling up of our remote technology offer. Mersey Care has always had what we call a telehealth hub or remote monitoring hub. I have a bit of a problem with the phraseology because remote monitoring - I do not like the word remote, so I like to call it technology enabled care at home because this is about keeping people at home, but using the technology to support them, not replacing care with technology. So, we have managed to turn it from a Liverpool offer during the pandemic to an offer that now spans across Mersey City region and Cheshire and Merseyside. I suppose what the pandemic showed us is about how technology helps you to reach people far and wide in a way that perhaps you wouldn't have with your traditional workforce models. So yes, I think, you know, the pandemic plus the market opening in terms of the technologies means sort of the world's our oyster at the moment.
Nigel Thompson I think it is interesting you say that, because I think I have lost count of the number of people who said the pandemic in a way helped push things forward. So, before it, we were already thinking this is a route we need to go down and has it accelerated because of the pandemic?
Dr Rosie Kaur Liverpool has the remote monitoring telehealth hub since 2011 and it has used remote monitoring for what we call long term condition monitoring. So, that's patients with diabetes, heart failure, COPD. The idea about it was about empowering patients. So, you give them the technology to answer questions, set and monitor their peripheral blood pressure and pulses and things like that. But it does two things. One is they get to know their condition. The second thing is it helps us intervene at an earlier stage, because part of that is about shifting care further down the curve before they become unwell that we're looking at more workforce related care where they need visits or the top end of that is where they need to go into hospital so that base has already been in Liverpool. During the pandemic, well before the pandemic they had been monitoring about 2000 patients a day and then we shifted at one point to 6000 where we were monitoring all the shielded patients, for the pandemic. So, we were lucky that we had a good base already off an established clinical hub with a telehealth platform that we were well-versed to using. The pandemic opened those opportunities for us really to start looking at, well, where else could we use it and things have progressed since then.
Trish Bennett I mean, that illustrates the scale that we are operating at now. So, two thousand patients a day three years ago and six thousand plus a day is where we are now. Definitely the pandemic, as Rosie explained has helped people. But the other interesting point around the scaling up of this is this was originally a Liverpool service. So, Liverpool's area covers about six hundred thousand population, we are now covering Cheshire and Merseyside and beyond into the North West. So, in three years you can see the interest and the understanding of how this can help us manage demand and the opportunity it brings. The interest and the wanting to work with us in a different way is increasing across the whole areas of Cheshire, Merseyside, North West and beyond.
Dr Rosie Kaur I think the other thing it is brought along is collaboration, and I think collaboration between providers. So, pre-pandemic it was a community offer facing into primary care and you know, hundred percent of the GPs in Liverpool had taken up remote monitoring for their patients and since the pandemic it was not only sort of volume, but it was also access point. So, we were able to pivot our remote monitoring for oximetry at home, which is where we were measuring people's SATs levels, oxygen levels in the blood to prevent and identify deterioration. But we were able to offer the access point to 111, A&E, the ambulance service, maternity services, and by using that hub as a central point. And then as we have moved into our next piece of work, we are then collaborating with acute trusts. So, the Royal Liverpool Hospital, Warrington Hospital, St Helens, and Knowsley and using our partners in Liverpool. So, it's a truly collaborative piece of work and I think that's why I quite like it, it’s starting to bring down the boundaries and because for patients, there is no boundary - they are a patient and they expect their care to be seamless and so and I think it has scaled up in terms of numbers, access points and now collaboration as well.
Nigel Thompson So, a certain proportion of population will be early adopters of iPhones and things and they will have a go. But when you are dealing with people who are vulnerable, those are the people who are not up for change and do like status quo, like routines, you know, the kind of people about whom I am talking. So, to try and bring something new in. I appreciate what you said. There is a massive increase in number of patients you have seen. But as you hinted before, the quality of care and variety of care, as people have gone through that, their care pathway, their treatment as well, it is changed. Can you tell us, you know, how you have made sure that you have taken the patients with you, for want of a better phrase, that they actually understand what your thinking is? How technology can help? The reassurance that you would have given perhaps as a GP? How have you been able to do that given the people, the kind of patients you are looking after may be suspicious, nervous, or apprehensive.
Dr Rosie Kaur I think the thing about experiences, and we have been doing this since 2011, is we have gone through the learning curve. I think originally when we set it up, it was very technology focussed with an admin type of function and we realised quite quickly that this has got to be a clinical service, it has got to be based around patient need. So that is why then, the telehealth hub, which is staffed by different bandings of nurses and health care professionals who have experience working with patients, through their practise nurse roles or the community matron roles or other clinical roles. So, they have the ability to work with the patients and understand what they need. And we have got a very good partnership with our telehealth platform providers that they support the patients in using the technology, but then are health care professionals. So, you still got the interface, that clinical interface. And I think that is really important. It cannot just be about landing the technology in somebody's home and saying, off you go. It is not going to work that way.
Trish Bennett I think just to add to that point, to Rosie's point about patient engagement and understanding, bringing people with us, it is also very important to bring clinical staff with you because equally, they can be sceptical about technology in some cases. And I think when we started off with telehealth, it was limited in what we thought and what it could do at that time, whereas as its expanded and scaled up, it is almost limitless. What can happen here, that is what it is looking like just now, the amount of new pathways, the amount of evidence that we are gathering in terms of impact, but also bringing nurses, for instance, and other clinicians along as a career opportunity is what we are starting to experience now. This is an opportunity in your career to work in a different way, to have a different impact. And we are starting to see that interest more and more in terms of options. I think COVID, definitely, has sped that up, no doubt about it! So, because we see the number of pathways, new pathways coming online, the collaboration, as Rosie said, with other organisations, it is becoming a very attractive proposition for clinicians, and they are starting to see how it can help them manage demand. So, if we go back to the point about what has changed. Certainly, the demand and community are a growing base, it is just constant. We are seeing more and more people for all the right reasons, being managed in the community. It is what we want to see. But of course, with that comes workforce demands and comes different pressures. And as we are introducing and implementing new pathways with other organisations, clinical teams are starting to see the benefit realisation of that and with that is also coming the realisation that it might be an opportunity that is a career opportunity for me, that is where I might want to focus my efforts. Whereas at the beginning it was as Rosie said - much more of an admin type proposal where now it aligns itself with really good clinical practise.
Nigel Thompson In some respects, it is winning hearts and minds into this. This is the phrase that people use. But it is making sure that, clinicians like yourselves do not feel that this is in some way watering down the good quality care you would have given, you know, 10, 20 years ago without digital, but making the most of digital but not losing that kind of personal touch. That kind of realisation that there is a time for digital, but also there is a time when you have to, you know, face to face, you cannot beat it.
Dr Rosie Kaur I think the clinical leadership is absolutely key, and I say we can put in as much technology as we want and as many pathways as we want. But if the if the clinicians do not believe that the care is as good as they would be giving face to face, then they are not going to put the patients on it. And the second part for me, a colleague used the phrase "be better". I think we do have to be better, and I think we have to be better, if you are taking your patient out of hospital to put them on this, the care has to be better than you would get in the hospital. Once you can demonstrate that to your clinicians, who have these patients on their caseloads, I think it is almost like the patient case is slightly easier because if you said to the patient, where would you rather be? Would you rather be in the hospital or rather be at home? They are going to say I would rather be at home as long as they feel safe. And if you have the technology to make them, feel safe, linked to that clinical hub, and then you make the case for the patients and then the clinical leadership and the digital champions make the case for the clinicians. Those two things together are very powerful. The technology then is just the bit you add on, when you say to the clinician, and the patient, what would you need out of the technology for this to work for you? Rather than, here is a technology, have you got any patients that would fit in? It is not that way round, which is why I go back to its technology enabled care at home. I think one of the things that always gets thrown back at us is about digital exclusion. And I think we need to be mindful of that. Interestingly, I have just been having a conversation with a colleague of mine, around patients who have needs that they might be either disenfranchised through lack of access to technology or hardware or them in their mental capacity or the language or the deaf or the blind. You know, how are we going to look at what we can do to enable all groups to be catered for by technology? Because going back to the point, you said you do not want it to just be almost people who were 'Yes, I know how to use this'. It is actually the people that get left behind, that have the highest co-morbidity. But then, we do not see them because they do not approach us. It is about how we get the technology for them. And I think that's part of the exciting stuff. And that goes back to the there is a patient how is the technology going to reach those groups of people for that equality and diversity? But I do not think that we have solved it yet. It is absolutely key to the work that we do.
Nigel Thompson Can you give us an example of where you have realised this is an issue and you are looking, even if you have not achieved it yet, that your kind of thinking this is the way to do it.
Dr Rosie Kaur We're looking more around. So, for input, at the moment, the model we have got is you input your data into the platform. So, we are looking more at wearable technology, to sort of take away that need for people to have to put their readings into the platform. And we are looking at what we have in terms of different languages and even looking at speech analysis and then supporting a platform to help you support patients who are deaf. So, there's different strands that we have started to look at now.
Trish Bennett I think in terms of the Avatar work it was very much around our new buildings, our new estates. And that was really about making sure that because we have built a number of new hospitals and that was really about getting the estate to really improve patient's recovery, to absolutely fit with our ambition to improve patient care to the highest level. So, we have a hospital called Rowan View which is mental health and LD and the Avatar process helped us with those things and then going back to the equality and diversity issue. So, we have much, much more to do on this and we are exploring every way that we can improve. And I am thinking, Rosie, about how we looked at learning disability services on mental health and how this technology could help us monitor people differently in the community through the COVID periods and beyond. So, we are exploring all avenues now, and there is a change in us as an organisation. We limited our thinking at the beginning to long term condition management. As a group, actually, we are a group of leaders who were actually quite narrow in our own focus. But as we have gained confidence, we are exploring much wider and how we can use the technology in different parts of the organisation as well as outside of the organisation as well. And because we do provide such a diverse range, then I think for us everything is about how would technology help.
Trish Bennett Not - let us look at a pathway in a very narrow focus, it might work there. Everything that we do, how can technology help us?
Dr Rosie Kaur I think it is about the end-to-end care. So, we are working with colleagues in heart failure. But actually, it is about the end. Everything from the starting off with what tools do we have to identify patients who are at risk of deterioration? We've got our patients on our caseload with heart failure, which patients would be put on monitoring so that our community nurses know which ones to go and see sooner rather than later, while empowering the patient to understand their own condition. If we do identify them early and they are deteriorating, what can we put in place for our community services? And then if they come out of hospital, how do we support them at home? It is very much about looking at things all the way from the start to the beginning, following that patient through their journey rather than just that tiny bit. And the learning disabilities thing is a really key point. So, we went in with our technology to supported living, and they said oh, this is great. We will check your blood pressure pulse every day. And what came back was they did not like it. They did not like having their blood pressure checked. They felt it was invasive, which probably comes back to some of the wearable technology. But what they did like was the fact that they knew that if they put their readings in, somebody was keeping an eye on them, and they liked that. So actually, we have been working with the carers and the clients themselves to say okay, we will take away the physical measurements, but you can put in things like how are you feeling today? Are you feeling more breathless, less breathless? Have you had anything to eat, yes, or no? And then we have been able to prioritise. Well, we probably now need to increase our level of monitoring. And the thing that I like about the platforms is it is a continuum. So you go from the pointy end, which is all the, virtual ward stuff all the way down through the levels with community to primary care, to self-empowerment. And you can go up and down those levels depending on how you are, and that is what the technology supports.
Nigel Thompson So Rosie, tell us a bit more then about the two most recent projects or two of the projects that you are working on currently. One, I think with the Clatterbridge Cancer Centre and one the Innovation Agency.
Dr Rosie Kaur We've got several pilots going and one of them I'm really quite passionate about is we're working with Ernie Marshall at the Clatterbridge Cancer Centre and this is to work with patients who have lung cancer, who essentially may not be on active treatment now, but quite often develop chest infections and they do have a hotline nurse that the patient can ring but essentially a lot of these patients end up being admitted into hospital to be treating their chest infections because by the time they're identified, they've got to that point. So, we want to look at how we can use the technology to support the patients to identify early so that we can support them for the treatment in the community. Couple that with I.V. antibiotics at home in the community and I think if you are at that stage, if you have that diagnosis, the last place you want to be is in hospital, you want to be at home. So, and I think, that is the theme that will run through a lot of the pathways that we are developing. The innovation agency has been really key to a lot of the work that we have been doing and have supported us both in terms of the digital licences and funding, but two pieces of work that we have got with them. One is as we develop and look at more areas that patients are going to derive benefit from the technology enabled care at home, how do we know we are using the right technology? The market's mushroomed, there are platforms theres wearable technology. So, we are doing a piece of work with them to look at, well, what is a framework we would use to evaluate this as we go forward, patient led, clinician led, what are the key points? And again, hopefully that digital inclusion piece will come into that. Again, with the innovation agency, what are the benefits? What the benefits? This is new, how do we know it actually is making a benefit in the long term for patients?
Nigel Thompson Because that's a challenge isn’t it you've got this never ending massive range of people you'd like to help and you want to help, and you expand in geographically as well, coupled with this tsunami of technology that's coming and trying to decide what to go from which to ignore maybe or not adopt yet, it must be really hard. And that is what you are doing now at the moment.
Dr Rosie Kaur You've got to start with what are you trying to do, and then from what are you trying to do? Who you are trying to help, what do the clinicians need? And then what is the framework by with which you evaluate that technology? You can have something, so, Apple Watch, is it a key thing? Apple watches sound great. But actually, for our patients, and our cohort, they are not the right technology. So, you do not want something that you have to be charging up every 24 hours or something you have got to remember to wear. So, we need a framework which is where the innovation agency will be supporting us.
Nigel Thompson It is a scary thought, but if we've had this conversation maybe in a year or two years time, you know, some of the things you talk about now probably will not even be on the radar. Things may have changed. What difference do you think you are actually making to bed days and obviously patients’ day is ultimately key? What difference do you think you are making to their life and also the lives of their families and friends as well? Because behind every patient there is hopefully a support network. How do you make sure that patients come first, but also that you are making a justifiable impact on the rest of the health service in this part of the world?
Trish Bennett We are starting to see 20 to 25% reduction in bed days. We are also starting to see length of stay come down for particular conditions by four to six days in terms of normal stay. So, we will do more on the evaluation and we will gather more evidence that we can keep improving and learning from and share them with the system. The key to this, of course, is managing the demand that we have talked about and across Cheshire and Merseyside and beyond North West for underpinning all of this. For us, it is about following our patient’s time. That might be time waiting for something, an appointment or a hospital visit or an outpatient, whatever. Those things people wait for, and it takes them away from the family, the friends, the things that they like doing, the hobbies or the responsibilities in terms of jobs and family responsibilities or friend responsibilities. That is important to us. Very, very important to us. And so, therefore, underpinning everything we are doing here is about the patient's time value and how important that is to them wherever they are in the journey of us. Unfortunately, obviously, we deal with people sometimes at the end of their life, but who knows where we are in any of this? And actually, it is very important to us that we do everything we can to keep their life as normal as possible, where they want it to be. It is the least disruptive, but we use technology to manage their condition to help them manage their own condition in the right way.
Dr Rosie Kaur Yeah, I think the challenges for us over the next year or two as things sort of mushroom is to keep focus. I think empowering the workforce is really key. I think, upskilling the workforce in our hub, using different specialities. We have nurses, specialist nurses I think we could introduce in there, and some medical roles as well, to support that increasing workforce at home. I think that will help us keep our staff and give them different options too. I like the idea of rotational posts, so it is part of a seamless journey. I think technology makes sure we get the right technology, but always go back to what is the patient wants and value their time and keep them safe at home.
Nigel Thompson Thanks for listening to this edition of the Innovation Collaborative Podcast. Be sure to share and subscribe for more. Check out the Innovation Collaborative Area of the Future NHS website.
Episode 12: Listening, leadership, action – building sustainable services through teamwork and technology-enabled care. Podcast released in honour of a digital nursing pioneer
A podcast featuring one of England’s most innovative health leaders recorded shortly before her passing has been released in her honour.
Karen Downs, Lead Clinical Nurse at Wrightington, Wigan and Leigh (WWL) Teaching Hospitals NHS Foundation Trust, took part in a 2022 podcast to help support and inspire health and care professionals across the country.
She spoke with passion and trademark modesty about her pivotal role in leading the trust’s Monitoring@Home programme, which has transformed and continues to transform hundreds of lives for people and their families.
Released with the kind permission of her family, the podcast features Karen in conversation with WWL CEO Silas Nicholls and former NHS England Director Breid O’Brien, about how leadership and technology can support people and staff to thrive.
Karen and the WWL team also feature in an Innovation Collaborative for digital health video about the life-changing impact of technology-enabled virtual wards in Greater Manchester. Watch this video, Martin’s Story.
Episode 12 transcript
Listening, leadership, action – building sustainable services through teamwork and technology-enabled care.
Caroline Kenyon Welcome to a very special episode of the Innovation Collaborative podcast. It's special because it features an individual who's been her Trust's leading light in the development of technology enabled care and virtual wards, but who very tragically and suddenly died soon after the podcast was recorded. Karen Downs was the lead for digital care in the Community Division of Wrightington, Wigan and Leigh NHS Foundation Trust. Her family has kindly given permission for us to publish the podcast in tribute to Karen's fantastic work. Karen has been described by colleagues as someone whose mission was to improve care for patients and to support colleagues in continually learning and improving. You can hear Karen's passion in this podcast alongside Trust chief executive Silas Nichols. The conversation is hosted by Breid O'Brien, former director of Innovation and Digital Health at NHS England.
Breid O'Brien Hello and welcome to another NHS Innovation Collaborative Digital Health podcast. I'm Breid O'Brien, and today I'm in Wigan to find out more about the work of setting up a virtual wards program. I'm joined today by Karen Downs and Silas Nichols, and I'm going to ask you both to introduce yourself and say a little bit about your organisation and your roles. We start with you, Silas.
Silas Nichols Hi, I'm Silas Nichols. I'm the Chief Executive here at Wrightington Wigan and Leigh NHS Teaching Trust. We're a large district general hospital operating on a number of different sites. We're also a fully integrated service in the sense that we provide community services as well as our hospital-based services.
Karen Downs I'm Karen Downs. I'm the Community Divisional Quality Lead for virtual care and responsible for setting up virtual wards.
Breid O'Brien Great. Before we start on the virtual ward story, which is obviously what we want to talk about overall, I'd like to revisit a conversation we had some time back. I follow lots of people on Twitter, particularly looking at how we support people at home. I became a big fan of your tweets where you were actively sharing your lessons with others that were trying to do the same thing. I know you personally had harvested lots of information from others in the past as well so a really good example of sharing across the country. I contacted you for a chat with some of my team, and when I asked you to start by telling us your story, the story actually started quite a bit before virtual wards, and it was a very significant story because it was at the time, in the height of COVID and probably what a lot of people were feeling. So, would you be happy to share that again? Because I think that would be of interest to our listeners.
Karen Downs So my background is critical care. I had a role as critical care outreach where we bring in intensive care interventions and acute care out onto the wards. In the middle of the, I don't even know, remember what wave it was, it was really getting difficult to deliver the care that you wanted to deliver ethically. You were doing things that you might not fully agree with in normal times, but it was the only way to deliver what we needed to who we needed to deliver it to. When my line manager went off sick with COVID and I had to really step up then into shoes that I hadn't already stepped up into. I took some of her workload on and was involved in an investigation that was just an example of what system failures we were all experiencing nationally. And it was at that point that I just thought nursing isn't for me anymore. I can't deliver what I came in to nursing to deliver. I had met many of the exec team, you didn't blink twice to see one of them in a pinny and a mask, wheeling patients on the corridor to help us and assist us and move patients where they needed to be to be the safest. But in particular, we had a high respiratory ward that we were delivering CPAP. Which we would normally deliver in a high dependency or a critical care area, but we brought it down to ward level because we had no capacity. Nationally there was a shortage on intensive care beds and it was Silas that was down in the thick of it. I remember it clear as day, we were fully geared up in PPE, the full mask. It was like a boiler suit. He was wanting to know what were our experiences, what were our challenges, what were the successes that we were delivering to these patients. Dripping with sweat, steam in visors, trying to engage with our chief exec to get across exactly what we needed. And I remember the day he just said, left us on that ward and said, my door is always open. I need to know all these things. I need to know what you need. And we're only going to get through this pandemic together. It was a very loud message that was said to us months prior to my what I can only now recollect as a bit of a breakdown. I'd hit that point on top of it, doing the investigation and seeing the systematic failures in bringing inappropriate patients into hospital and exposing them to what they shouldn't be exposed to. I just couldn't do it anymore. But before I left, I thought I'm going to use that door, I'm going to knock on it, and I'm just going to make sure the people know it's not this organisation that's making me leave nursing it's the way we're running the NHS and I was just disillusioned to that point. So along with a few files, I was completely array, my hair was a mess, I'd just come straight out to PPE, organised a meeting with Silas and he just welcomed me in and opened the door at the height of my emotion. I can't recollect exactly what Silas said to me that day. But I'm not backwards and forwards, never have been as a nurse, I've always been the patient's advocate. And you are, in our years we've become jaded. Oh, they're promising something again that we know they're not going to deliver, or they'll change it halfway through and not see it follow through. But whatever Silas said to me that day made me stop and think about my PIN number, and that was why I brought it up in our interview, because I wouldn't have been in this position today. I couldn't have brought so much good for our patients and our staff using virtual ward, because I might not have been here had it been not what language Silas used to me to say, I can make this change, we will make this change. And the words that were around action that I hadn't heard before, in my 24 years of nursing and just made me stop and think and know I've got to I've got to stay and see this out cautiously, you know, will this man deliver? But by God, he has.
Breid O'Brien Thanks. Silas, what are your recollections of this conversation, it sounds like Karen spoke and was listened and felt heard.
Silas Nichols Yeah, so I think my personal philosophy without sounding too grand about leadership, is you're there to help and enable people to do the right things that you know 99.9% of the time the staff on the ground who know not just what the problem is, but they also know what the solution is. And then my job and the job of my colleagues in the executive team and the wider organisation is to help facilitate that and make that happen. But I think one of the things I stressed to Karen was not just that, but I also believe really strongly that people are very interested in what you say as a leader, but they're far more interested in what you do and it's the practicalities and it's the tangible difference that you can make to a patient or to a member of staff or to the community that that you're serving. Also recognising at the same time, we might not have all the answers, we might get a few things wrong. I think for me it was just a very sort of honest human conversation. This is how it is, this is what you're feeling, this is how I feel about, but this is what we can do together to work on it, really. I think at times there can be a perception that, the management, inverted commas, are only interested in the targets or the money or the whatever. And that's not true. We're all here for the same endeavour basically, we might come at it from different angles, and we might sometimes have different day to day stresses or pushes, but ultimately, we are all here for the same thing. I think at the heart of it, that was the conversation really.
Breid O'Brien Thanks. So then moving forward and thinking about your virtual ward, and we've just seen some of it today and its really impressive work can you just talk us through perhaps briefly, Karen, the setting up. How did you get from an idea and thinking care can be delivered differently to where you are today.
Karen Downs So I was approached by one of our Matrons that was setting up oximetry at home and with my background and interest in deteriorating patients’ prevention and management, she just felt I had the skill set to assist her to set that up. And to be honest, she wanted a cynic because I just didn't, as a nurse and a face-to-face nurse, frontline nurse, I could not comprehend how you could detect deterioration without seeing the patient face to face. And she very much wanted that input in any pathways that we were formalising. As an AIMS trainer, an acute illness management trainer, it was giving that insight into the triage and assessment of patients. So, we did that together, which was a national drive to detect hypoxia in community earlier to escalate patients, getting the patients the right treatment in the right place. But the way we designed the Wigan service model was that we were detecting so much more deterioration, preventing things like acute kidney injuries through dehydration and nutrition. We were getting involvement from the community dietitians in particular, patients that were struggling with fatigue and poor nutrition. It was just working differently with our patients. Then we peaked in Wigan, when patients were seeing the families, loved ones, neighbours coming to hospital and not come out. It was resonating with them that if I go in that place, I am not going to come out of that place, so we saw an increase of what they termed red refusals. Patients that don't want to go to a hospital, they want some kind of treatment here and now, and treatment in their home. And in the pandemic, like Silas explained, services had to really work differently and think about what they could deliver in a different way. And our community services contorted what they knew was normal service enabled by training and then backing by myself. We performed in community, we worked with chest community therapists to do perform chest physio with patients or utilised more of our hospital at home colleagues delivering more antibiotics and getting early steroidal treatment to patients. And that then had a knock-on effect that we saw a reduction of COVID to our front doors. We don't know whether it was coincidence or not, but the need for intensive care beds dropped in our Trust when we started using these interventions. So much so our lead nominated us for an Intensive Care Society award because she truly felt, she truly believed that we had a direct impact on that. Early treatments and early recognition might not have stopped patients coming into hospital, but it reduced the level of severity of the disease. So, they needed just a shorter stay, care on a normal level ward and then back out supporting under the oximetry at home. And we quickly realised that if we're doing this for COVID, why can't we do it for any other reasons? Every winter we enter the winter pressures with dread in our stomachs because it compromises the care we want to give and deliver and keep our patients safe. The little gem that we've been involved in oximetry at home we had to keep hold of as tightly as we could to evolve and grow it, which then turned into virtual wards.
Breid O'Brien Do you want to just mention a little bit then about how you started to think about how technology could help? Because it'll always be a mixed service. There'll always be face to face care, but you're obviously now doing something even more different.
Karen Downs So with the COVID oximetry patients, we used just a simple oximeter and soft signs of deterioration. We used an app, so the patients were engaging themselves in using the app and the average age was 62. It's not like we had a young cohort of patients that were tech savvy. Our volunteers provided the equipment and the technical support of using the app, and we could then monitor deterioration. We recognised early that there was appetite to use technology in self-monitoring and self-managing symptoms and they liked that it was, if I escalate, if I reach this point, someone will ring me. And that's what happened. The team then rang the patient because of the alert on the system. It seemed like a natural progression when you pointed me in the direction of what was happening in Norwich using current health equipment, which was a continuous monitoring, wearable remote monitoring device that has live stream data into a dashboard with 50-minute buckets. You can trend data rather than rely on a one-off observation that perhaps you don't know what has led up to having that observation from that patient. It could be skew-wiffed in a way if they've just walked upstairs or exerted themselves in some other way, you can trend the data. We were using this equipment, which then enabled all the services to use the app in different ways. To know what we would use the digital technology for would be patients that just require a trajectory monitoring. It seemed a simple transition into patients that were in A&E or in our early assessment wards that have had a diagnosis and a treatment plan in place, and they were simply there for monitoring to ensure that they were moving in the right trajectory. Myself and a colleague did a point of prevalence audit to ensure that there was an actual need out there for it. At the same time, we got the digital company to come. They gave us a kit that we could show our patients, “Would you be interested? Do you think you could use it?” I mean, it was all positive feedback. With Trust approval, we went ahead and did a two-week pilot, and we've never stopped since then.
Breid O'Brien Wonderful, wonderful and Silas, I mean, Karen's explained really well what's been happening on the ground and making this happen. But what does this mean from a Trust Exec perspective? What do you think in terms of what's needed to make it happen or what the opportunities are?
Silas Nichols Yes, I think there's several things that are important here. I think one is about how you so create the right conditions for success. I think some of that is about and it's very easy to say, but sometimes hard to deliver about being truly clinically led in how you identify innovation, have governance that's robust but light touch so you can get things up and running quite quickly and then learn as you go along. So that's one aspect. The second aspect is the mindset of the executive team. What I mean by that is ask a different question when presented to a problem. Traditionally, when we are presented with a problem, whether it be increased admissions or, delayed discharges will often reach for solution that involves people and beds and wards and it's quite sort of, what I say is a term of 20th century thinking. What we're trying to do more in WWL is think, what would a 21st century solution look like to that problem. So where could technology working with the people and working with the clinicians enable a different set of responses? Where could we be using A.I., for example, to intervene in a way that's helpful? It's almost the first question we ask is about where does this technology take us? What's available out there? I do think one of the challenges I think for executive teams and boards within the NHS is really coming up to speed what's available, what's the art of the possible. I think the third thing that's really important in all of this is the infrastructure that needs to sit behind it. Karen mentioned about the equipment, etc., but supporting all of that, say from a hospital environment, you've got to make sure that your Wi-Fi works. You've got to make sure that you have good connectivity that's not going to drop in and drop out. You've got to make sure that you've got the iPads and the pieces of kit to support it. The way which I look at it is that the virtual ward is almost like the train that runs. But the train can only run if you have got a decent track for it to actually run on. I think if you can combine those three things together, harness that together, you've got a really powerful sets of enablers, if you like, to see this work really flourish.
Breid O'Brien Karen, we've talked a bit about the technology, and I think it's got real opportunity for us. We've met today with some of your team and clinical staff and they're really I think were overwhelmingly positive. Can you say a little bit more about what it means for staff and where some of the challenges might be? And also, what do patients think about it?
Karen Downs So from a staff perspective, initially they've worked in oximetry at home for us, so they know the concept and they were behind the concept. What they were unsure of was the loss of that face-to-face contact with patients. Would that impede on the care delivery or the quality that they could deliver but using the technology and also having the flexibility in the team to support a community that quickly realised that it gives them so much more. It's one on one time that you don't get with a patient on a busy ward. The confidentiality that the patient has because it's just you and the patient, the finding out more, much more about the patient so they can problem solve. And almost, when I recently did a PDR, one of the team leaders said they're almost future proofing what that patient might need in future and putting plans in place by using the community services or our council services, connecting them early. It was particularly around the carer that was involved with the patients and more about the carers need, rather than the patient, supporting them because the condition the patient presented with is only going to progress. She was enabled to anticipate that and connect them. You might not need them now, but they will always be there because you've connected with them and she said she wouldn't have got that opportunity on a ward and it's we're very much acute nurses come into a community now we've been around about 12 months and they've had there, I mean I got excited when I moved into community because they were doing exactly what I wanted to do, which is prevention and management, early detection, getting the right patient to the right people at the right time. And they were enthralled that, you know, they've got the capability to do that using the clinical knowledge and skills and the technology that was on offer.
Breid O'Brien And how about the patients? What's your patient feedback been like?
Karen Downs So one particular gentleman said there's no better tea than me wife's tea. He was particularly enthralled that his wife was cooking for him, and he wasn't having hospital food. I don't think it's actually the quality of the hospital food. It's just having what you want when you fancy it. That was a pretty positive thing that he felt. But in general, it's you sleep better, you rest better. Everyone reports the more motivated to get up and move. They're not tied to that bed area or that chair that you are in in a hospital, they feel that the they can connect with the clinical caller so their nurse any time they want by just the press of a button, which often they do and sometimes it's not related to the health condition that we're managing, but it's something else that they're alerting or escalating for advisor really and pointing them in that direction. It's all positive.
Breid O'Brien And Silas, if we can pick up on, Karen's touched on the council in this, and I think you've been doing quite a lot of work. What's the opportunity here for wider, broader working? What does the system need to do if you want to look at these models and scaling?
Silas Nichols We're lucky in a sense that we've spent, you know, several years now working really closely with our partners in Wigan council and I think there's one key thing, one is about kind of interoperability between systems getting systems to talk to each other. One of the early pieces of work that we did actually pre-COVID was about information sharing, getting the governance right, making sure that we can actually flow information around the system. I think the other thing which we've spent a lot of time working on, we still haven't quite cracked it yet and there's more to be done. It is also about how we work with colleagues in the residential nursing home sectors. What we'd like to do in terms of the next step with all of this is think about how we prevent deterioration of patients in nursing residential homes. The text there, the pathways and protocols, I think have been developed elsewhere and we're developing our own the bit which we still need to work on, it's always like the human factors. It's actually working with staff in those areas, working with the owners of those homes, getting them to feel confident in the way that, you know, the patient cohorts that Karen's talked about feel confident as well. So, lots to go at, but we're starting from a really good base to think.
Breid O'Brien I could keep talking and listening for ages, but I think we probably have to stop soon. I'm going to ask you both with the value of hindsight, if you were advising someone else, because we know across the country everybody's trying to do this, what would your key message be to somebody starting on this journey of setting up a technology enabled virtual ward? What would be your advice? Who wants to go first.
Silas Nichols I'll go first then if that's okay. I think the first thing would be if you can get that buy in from the executive team, get that buy in from the boards, then that helps. It's not the only factor. That truism of what gets measured gets noticed. I think there's no denying that. Then I think the other thing in terms of getting that buy in is being prepared to have that mind shift. Shift your thinking away from what I would call those traditional 20th century views of, you know, trying to solve problems, to thinking differently about actually when we talk about capacity isn't necessarily about beds and people it is about technology, it is about using equipment to enable change to actually happen as well, so those will be my two bits of advice.
Breid O'Brien It's interesting because I always say to people, I think we've had this conversation as well, that technology is simply the enabler, but you need it at the ambition setting as well. Otherwise, you will just continue to think as we've always thought. Karen, what's your words of wisdom, your final words of wisdom for someone?
Karen Downs I think know your network and increase your network, your reachability is never enough when you're on the cusp of innovation, especially in something new. Be prepared to put the legwork in, be at the ground level, but also be able to elevate yourself up, delivering the information at Trust level, at the executive level. Because as Silas said, you know what? You know what it needs. We know what it needs, the people that are delivering this, it's how we communicate that back into the Trust.
Breid O'Brien Thank you both very much, both for having us visit today and for recording this and I look forward to coming back and seeing how things progress.
Silas Nichol Pleasure.
Karen Downs Thank you.
Caroline Kenyon Thank you to the family of Karen Downs for allowing us to share this episode. There are links to the podcast notes to two short videos of Karen. One is an Innovation Collaborative video called Martin's Story about the work of Wrightington, Wigan and Leigh's Digital Hub. The other is all about Karen. It was created when she was shortlisted for the Trust Staff Awards. Thank you for listening.
Episode 13: Achieving digital care equity for all across Greater Manchester in challenging times: in conversation with the city region’s mayor
This episode explores digital inclusivity in Greater Manchester featuring the city region’s mayor, Andy Burnham.
Andy discusses progress and challenges towards eradicating digital poverty and inequalities in health, care and beyond with Laura Rooney, Director of Strategy at Health Innovation Manchester.
They talk about Greater Manchester’s Digital Inclusion Action Network and the ambition of becoming a 100 per cent digitally-enabled city region with podcast host and digital nursing leader Anne Cooper.
Episode 13 transcript
Podcast transcript: Non-verbatim: Text adapted for improved readability
Achieving digital care equity for all across Greater Manchester in challenging times: in conversation with the city region’s mayor.
Anne Cooper: My name is Anne Cooper and I'm the lucky host of this podcast. I don't know about you, but I find the stories from people who've made exciting changes to the way we deliver care fascinating and compelling.
It's almost always about the people, how they've worked together and travelled on the journey to supporting people at home. Their stories, their successes, and things they might have done differently are shared in these conversations.
This episode of the podcast explores how people across Greater Manchester are working together in challenging socioeconomic times to close the door on inequalities, ensure digital services are open to all and achieve the ambition of becoming a hundred percent digitally enabled city region. To tell us more, I'm joined by Andy Burnham, mayor of Greater Manchester, and Laura Rooney, director of Strategy at Health Innovation Manchester.
I'm going to ask them to introduce themselves one by one first of all. I'll go to Andy first, Andy who are you and why are you interested in this agenda?
Andy Burnham: Hi Anne thanks for inviting me on the podcast. I'm Andy Burnham. I'm the first elected mayor of Greater Manchester, but people may also remember [I was] Health Secretary many years ago.
Anne Cooper: Thank you. And Laura.
Laura Rooney: Yeah, part of my role at Health Innovation Manchester is about deploying innovation and new technologies into the health and care system to benefit citizens. And I come at this from trying to understand how we learn from people's lived experience to shape and design these digital services rather than just trying to deploy the technology and expecting it to work for everybody.
Anne Cooper: So I'm going to come to Laura first of all. Where did the story of trying to tackle digital health and broader inequalities in Manchester start?
Laura Rooney: From a health and care perspective we've been on a digital transformation program for the last couple of years, and through covid that accelerated. So very quickly, for instance, all GP practices had to implement video and online consultation solutions. Hospitals had to move to voice and video consultation. A lot of progress was made in a short space of time. However, what we're now focused on is ensuring that we maintain the progress but don't exacerbate inequalities through the introduction of digital technology.
So from a health and care perspective, we're being much more deliberate about understanding people's experiences, lived experiences, and how to shape that into how we design and deliver tech enabled services. We are part of a broader, Greater Manchester agenda led by Andy and Andy will talk about that a bit more in a minute.
Where Andy's bringing together cross-sectoral support for closing the digital divide across Greater Manchester. So we are part of a broader agenda across the city region.
Anne Cooper: Andy do you want to tell me a little bit about that? How did you become more aware of digital inequalities and what inspired you to start tackling some of this in Manchester?
Andy Burnham: Laura's put it very well Anne, it was the pandemic that made us look at the issue differently. Because life moved online, so it wasn't just obviously access to health support and advice it was all kinds of services. All kinds of conversations actually moved online, and I was conscious that some people were definitely not in that digital room.
The thing that most brought it home was a disability survey carried out by our disabled people's panel in 2020. And it was quite stark actually to see the experience of the pandemic through the eyes of disabled people and the difficulty that many disabled people in Greater Manchester had in accessing the digital space because of cost or just availability of equipment or whatever, skills or literacy, whatever it might be.
The way I look at it is this, digital skills or digital inclusion had always been a sort of a talking point in Greater Manchester, but it was often the last item on the agenda and I felt living through the pandemic it needed to become the first item on the agenda because we were gonna see those inequalities widen that Laura touched on, if we'd just left the situation where the world had moved more digital post pandemic, but lots of people were excluded from that.
And in truth, the cost of living crisis is only intensifying those issues right now. So we did decide, or I did decide when I put forward my manifesto for the 2021 mayoral election that digital inclusion needed to move from the fringes of the kind of political conversation to the heart of it. And we set up a kind of goal at that point to see if we could get all under 25s, all over 75s and all disabled people online. And that has been the sort of mission of the digital inclusion action network, which was set up after that election.
Anne Cooper: That really is a bold ambition. Have you any idea about how you're progressing against that particular ambition?
Andy Burnham: We were making good progress. There's lots of good initiatives I could point to, particularly one with our social housing providers. I could also point to the Greater Manchester data bank that we've set up with an organisation called The Good Things Foundation that has led to over 20,000 sim cards being distributed to residents who don't have digital access. There's lots of other amazing schemes, some of which are our health colleagues have supported one called Tea and Tech in Salford which is amazing.
The truth of the matter though is it's been a case of in many ways, keeping people online who might otherwise have gone offline because of cost of living rather than massively, if you like, bringing everyone to a point where everyone's online.
So the goalposts have shifted on us with the cost of living crisis, to be honest, because when people are balancing food, heating, other household expenditure and digital connectivity, the honest answer is digital connectivity is often seen as the least important in that list.
And hence some people have definitely dropped out of the digital space. So our problem has probably got even bigger if we're being honest rather than getting closer to achieving our mission.
Anne Cooper: That's really interesting, isn't it? It's never been more important that we try and do some of this work I think. Laura, have you got any examples of the things that have been done in the health space that might be interesting for the listeners?
Laura Rooney: Yeah, so when we started looking at digital inclusion, people would come to me and say, what are we doing about digital inclusion? Like I could fill out some sort of a quality impact assessment form and, that'd be it, job done.
So what we did instead was start to understand the issues, work with the team at the combined authority and the kind of wider partners as Andy's just described, to understand how we build inclusion in how we design and deliver services at all stages. Right from design through to development, through to deployment, and then have that continuous cycle.
So we've been putting that to the test in some key flagship projects. One of them is virtual wards. It's been rolled out across the whole of England, each region will be deploying it in a way that meets their local needs. And from our perspective, we've been very conscious to build user experience design into this because these are new models of care.
Shifting care for patients who would've otherwise been in a hospital bed to their own homes using remote monitoring technology is a massive shift both for the clinicians and for the patients themselves. And actually when we did go and speak with patients, a lot of them were saying yeah, I'd much rather be at home. I don't wanna be in hospital. It's noisy, makes me feel anxious. I'm interrupted all the time. There's always bleeps and monitors going off, so I'm quite disturbed.
So actually, from their own experience perspective, the majority said, oh yeah, isn't it good when you get home? I feel much better when I'm at home and I can recover in my surroundings.
Interestingly they didn't really get into what their condition or treatment was. It was more about all of those societal factors and the benefits of their own mental health and wellbeing and anxiety that helps their recovery. But actually what we're also looking about is how accessible these products are in the real world.
So there's a great difference from what a technology is intended to be used for, and then how when you put it in a patient's home and the kind of clinician and or practitioner goes away what they're actually doing with that on a day-to-day basis. So when we had the heat waves last summer, for instance, we got reports of alerts coming into the service increased, and nurses were thinking, oh goodness, is this patient, you know, what's going on? And when they rang, people had the cuff still on their arm in the garden enjoying the sunshine. And all these different things count of when you try to deploy these technologies into a real world setting. We also want to understand the communities who this isn't gonna be suitable for.
So what does that mean and what's the alternatives for them? So we're not saying it's all digital. It needs to be suitable for the individual's needs, but as Andy said the more we can do to help communities get online the more they can benefit from these types of services and offers. So yeah, we've been very conscious about how we do that in virtual wards and we're in year one, finishing year one of deployment into year two. I expect we'll be getting into that even more at off the back of the cost of living crisis.
We've had anecdotal feedback of whether or not patients are less inclined to want to use these types of technologies for any implications of an increased cost to them in their homes. On the flip side, for instance, with people with disabilities, when we talked about accessing primary care GP practices through digital means, they actually felt it did provide them with an even platform compared to other people.
Other people who were able to jump in the cars and go and stand outside the practice at 8:00 AM, they were actually on an equal footing with them. So yeah, there's pros and cons to it all, and that's part of what we're trying to explore is to bring that out so that healthcare is accessible for all.
Anne Cooper: One of the interesting things I think about Greater Manchester is something that Andy briefly mentioned earlier that this is a cross-sector initiative and I think that will be interesting for other people to hear about. Andy, I don't know how you've managed to bring all of those people together.
What mechanisms do you use to make sure it's not a single sector thing that you're trying to achieve?
Andy Burnham: That's a really good question Anne. What I did was I actually based the model for our digital inclusion action network on something we'd done with homelessness early in my time as mayor because, same with digital inclusion, homelessness is a problem that no one agency can fix alone. It's bigger than all of us. It's a societal problem. And I remember when I stood up at the Homelessness Action Network, which had charities, big and small community, voluntary groups, big public services. I said, everyone's gotta leave the ego at the door and everyone's gotta like face in the same direction towards the problem and pull in the same direction.
And we try to adopt a similar approach with the digital inclusion action network. So you've got public sector, private sector, charities, whole range of organisations are involved in that network. And I mentioned the data bank and sadly, it is the new food bank, if you like, that we have to have a data bank.
But the private sector's been very generous in contributing. So if you can set a common cause and a common mission that everyone can believe in, and that's the key isn't it? Something that everyone re recognises is a good thing to do, be it end rough sleeping or ensure full digital inclusion, then everyone starts to pull in the same direction and all public services can see that it's part of their responsibility as well.
And I think this is to pick about what Laura was just saying, such an important point she was making, but to amplify it a little. If public services have moved more into the digital space, post pandemic, as I think pretty much everyone has, and I know the health service has. If you are to ensure that the universal service obligation is upheld and access is equal, as Laura said, it follows to me that public services are going to have to do more to support patients or residents online because how otherwise can you justify providing a service that may be unequal in terms of the levels of access people have to it? Well they can't. So I'm not sure cause of all of the pressures on the health service at the moment, but also pressures on other public budgets that we've really woken up to this as a country. I personally feel that if public services are going to do more digital delivery, and they probably should because it's efficient and even as Laura said, it can aid the kind of cause of equality because disabled people actually find it easier not traveling to appointments or meetings or whatever. But if that is the case, then I think funding has to be put in place to support people to be in the digital room. And I'm not sure yet the world is fully caught up with that side of things.
And I'm pretty certain actually the cost of living crisis, as I said before has taken us some ways backwards rather than forwards.
Anne Cooper: Thanks Andy. That's another interesting point that you're making there really, and Laura, I'm interested, in how the health sector has found looking through the world through a different lens, really having to collaborate in a different way across the city.
Have you got any observations about how that's felt?
Laura Rooney: Yeah, I think in Greater Manchester we've got a kind of bedrock and a foundation of doing this. Building on the health and care devolution agreement, over the last six plus years we, we are used to collaborating with local authority industry, business, academia. We're lucky we've got some significant assets in Greater Manchester. So I think building on all of that, we absolutely naturally now, look to work with our universities. We've got some amazing academic assets in this space and inequalities and inclusion. So we're looking at how we bring that expertise in to this agenda.
And also how we work with our technology partners in a different way. It's in the technology partner's best interest to develop solutions that are accessible and meet the needs and requirements of users. I think we can be doing more to build good product design and user experience design in these products.
And we did, for instance, when digital GP practices were rolled out, we did some observation of patients trying to do basic tasks through different types of platforms and products, through booking appointments or just articulating what their condition and need was because quite often with these things you have to go on and type in what you think your condition is. But obviously you need a certain level of literacy to be even able to communicate that effectively to the physician. So we played a lot of that back actually to, to the primary care community. And they've been really responsive as have the industry partners because I think until you call it out and show what it's like on the receiving end, they actually don't really understand. So we've been lucky that we've had that support and the kind of the bedrock of the partnership working and collaborative approach in the system. But I think there's loads more we can be doing. And as well as, there is the shift of care into people's homes, but we're also looking at how we can use technology to deliver care in different ways.
So for instance, we're doing a project, again, that was part of the Innovation Collaborative on physical health checks for people with severe mental illness. Often these are people who don't routinely access services for physical health checks. It's the least of some of the problems that they're dealing with in their day-to-day lives.
So what we did, instead of trying to shift the responsibility onto the patient with technology, we worked with primary care to set up clinics in the community using technology in other ways where people can come and have a one stop shop health check. And in Oldham, for instance, we've got a practice where they went from kind of 17% uptake rate to 60% in a short space of time.
So technology can be used effectively when you understand the needs of the patient, the citizen and figure out creative ways of delivering that care to them that doesn't have, it doesn't have to be a, come to hospital or do it in your home. There are often creative approaches and I think our technology partners are up for trying to explore these new ways of working with us as are the patients and the public.
Anne Cooper: I like the sense that you're both giving me of everybody being in the room together and focused on the right things. It really makes me feel that's a way to a better future. Andy, to come back to you, obviously this is a journey where, it's, the work might never be done actually, but can you see what the next steps might be for Manchester over the next year or so?
Andy Burnham: Well certainly Anne it's going to remain a core priority of the city region. So we like to talk about ourselves as the UK's leading digital city region. And increasingly we are from an industrial point of view in terms of the number of digital and tech jobs that we have here. But I've always said you could only justify that title if you are helping all citizens be part of the digital economy and digital society. Because I say there's so many conversations happening now in rooms like the one we are in at the moment aren't there? But if people can't access that conversation, that is going to make us more unequal as a society. And I think this is the issue with digital, isn't it?
It is great and empowering in many ways and gives people access to opportunities that you might not have. And, all of that's a really good thing. However, if this is seen as something that has to be paid for and is a sort of more of a luxury item in a cost of living crisis. We could see levels of inequality increase actually, or certainly, let me put it a different way.
Levels of social exclusion can increase, and isolation can increase, and then there'll be a health impact, a mental health impact from that. So our vision of being a digital city region is about everyone involved. Everyone in the room, everyone accessing the opportunity that is there to be found online, be that, training related or work related or leisure related whatever it might be.
And I guess the logic of where I'm coming to Anne, with this sort of argument is digital connectivity increasingly needs to be seen as a sort of the fourth utility. It's as critical as water, gas, and electric. It really is because actually can you live your life safely and fully without it? I don't think you can anymore.
And we've gotta almost take it away from the realms of being a nice to have, if you can afford it to an essential that people need, if they're gonna live a healthy life, an involved life and an included life, so I think that's the way where we are going with it. Have we got all of the means in our city region to give that to everybody? Well no actually. And that's why we're doing the voluntary thing that we're doing through the digital Inclusion Action Network. But I can see a kind of point in the, some point in the rest of this decade where as a country or certainly the NHS will have to say, we are going to have to get everyone who's using our services online.
And if people can't afford that, we'll have to find ways of helping those who can't afford it online. Because otherwise, people are gonna start missing out on essential treatment. And I think we're probably not far from that point already.
Anne Cooper: Laura, in the health space, what are the priority things for the next year in the digital inequality sort of area?
Laura Rooney: I'd say over the last two to three years we've made some really significant advances in the use and optimisation of technologies and innovation, but we're in the process of re profiling our strategic plan and priorities for digital. And we think we still need to make sure the basics are there and the basic foundations are in place to enable these new services to grow and refine.
And I was reflecting on a patient group that I spoke to once in producing the strategy and, they said people aren't hard to reach. Services are just poorly designed. And I think that's so true because used properly and designed in a thoughtful, inclusive manner, digital enabled services can be really effective, but not designed properly can create some of the inequality and division that Andy's described. So from our perspective, our digital strategy and approach will not be just about deploying new technologies. It will be about inclusive digital transformation, and we are making an absolute commitment to that as a city region. That inclusivity will be top of our priority list as well as building the skills and capabilities of the health and care workforce. To be able to participate in this agenda, to understand digital inequality and what that really means, to be able to spot it, to be able to have a conversation with patients and citizens about it.
So we are making some really big commitments in our forthcoming digital strategy, not just about digital technology per se, but about inclusion and workforce as well, which are going to be so pivotal going forward.
Anne Cooper: That's really lovely to hear. And I'm heartened that you're putting these people at the heart of your strategy.
And I think that might be a good tip for people who are looking to do this, where they live. Putting digital inclusion at the beginning, not at the end, is a great tip, I think. And finally, really to come back to Andy, if you were to speak to other leaders in the system, not just in Manchester, but beyond who might be listening, what tips would you give them about how to make this real?
Andy Burnham: I think I would say no longer leave it as the last item on your agenda that often gets missed because the meeting's been taken up discussing everything else. It's more important now than perhaps we saw it a few years ago. And therefore make it item one every now and again and fully understand the implications of increasing digital exclusion.
If you imagine the area that you're responsible for where more people are digitally excluded, pause and think about what that means with regard to the health of your population. Their access to education, training, work. Social problems will store up from from that.
I think it was honestly the experience of the pandemic and the stories we heard from across our 10 boroughs of kids crowding around McDonald's in the pandemic, to access the wifi. That really started to sound alarm bells. And I think, schools were saying, you remember the problems, Department for Education had getting devices to schools and that because obviously that really brought home, well hang on a minute! This is essential and they're not able to access it. So just think about it in those terms. But from a health point of view, building on what Laura was saying, think about digital possibilities for people who are managing long-term conditions or are people that need mental health support. Actually what you can open up, with regard to a more everyday support service via a digital sort of service. I think you can really, in quite simple ways, find ways of reaching people every day that actually become a much more preventative approach to things. That's what my advice to them would be for far be it for me in many ways to tell other people how to run their areas.
But this is more core business than you might realise is what I would say. And the real risk of this kind of combined effect of pandemic, followed by cost of living crisis is the issues around digital exclusion have silently and quite quickly got much bigger than you realise, and that will have consequences for the health of the people you serve.
Anne Cooper: Thank you. Thank you to both of you. It's been lovely to hear about the story in Manchester. And I'll be watching to see what happens next. Thank you very much for your time.
Andy Burnham: No problem Anne.
Laura Rooney: Thank you so much. Enjoyed it. Thank you.
Anne Cooper: These stories add to the evidence base about the impact of digitally enabled care. If you would like to hear more about the Innovation Collaborative you can find them on the Future NHS platform. If you already have an account search for Innovation Collaborative Digital Health. For more information on how to join, please see the podcast notes.
Episode 14: Changing lives through Blood Pressure at Home innovation: experiences and learning from regional teams
This episode explores the impact of technology-enabled blood pressure monitoring in the north and south of England.
Since October 2020, more than 220,000 blood pressure monitors funded by NHS England have been distributed around the country as part of the Blood Pressure at Home, or BP@Home programme.
South-west London Integrated Care System (ICS) Project Manager Jacqueline Chapman and South Wirral Primary Care Network (PCN) GP and Clinical Director Thomas Wyatt discuss shared and different challenges, learning and outcomes on their respective BP@Home journeys.
They join podcast host and digital nurse leader Anne Cooper to discuss supporting people to be empowered, connected and well in the comfort of home while preventing life-changing conditions like health attacks and strokes.
Episode 14 transcript
Podcast transcript: Non-verbatim: Text adapted for improved readability
Changing lives through Blood Pressure at Home innovation: experiences and learning from regional teams.
Anne Cooper: My name is Anne Cooper and I'm the lucky host of this podcast. I don't know about you, but I find the stories from people who've made exciting changes to the way we deliver care fascinating and compelling.
It is almost always about the people, how they've worked together and travelled on the journey to supporting people at home. Their stories, their successes, and things they might have done differently are shared in these conversations.
It's my absolute pleasure to have with me today, Jacqueline Chapman and Thomas Wyatt.
I find it fascinating how people work on projects that really energize technology in communities. And I think these are two of those people. So, I'm going to ask them to introduce themselves to you and tell you a little bit about their work. And I'm going to start with Jacqueline.
Jacqueline Chapman: I'm Jacqueline Chapman. I'm a project manager, I'm currently working in southwest London with the long-term conditions team, and I work at ICS level. We cover a population of 1.5 million, 39 PCNs. I was working and still working to support a number of practices to put in place processes and support to enable them to do their job more efficiently.
Anne Cooper: That's great. We'll come onto a little bit more of the detail of that in a few minutes. But Thomas, would you like to introduce yourself?
Thomas Wyatt: Hello, I'm Thomas Wyatt. I'm a GP on the Wirral and one of the joint clinical directors of Healthier South Wirral PCN. And obviously I've been a clinical director since the beginning of PCNs and I'm particularly interested in population health approaches and how we can best use our general practice and PCN teams.
Anne Cooper: Thomas, do you want to tell me a little bit about the BP at Home Project and how you've been using it across the Wirral?
Thomas Wyatt: We decided that we wanted to try to develop a PCN population health approach to hypertension. And there was an opportunity to work with the Innovation Agency and one of our third sector organizations called One Wirral CIC.
And we used a tool called a BPQI tool, which has a dashboard and that can pull in information from the GP clinical system. And then also we had access to a website called the Happy Hearts website, which is really good, loads of really useful information. So, we had a source which we could use for our staff and also our patients and communities to use to get the best information about cardiovascular disease.
And then we wanted to try to change the way of reaching patients rather than the traditional first come, first serve or random nature of people presenting with blood pressure. We wanted to prioritise patient cohorts, so the BPQI tool helped us to identify patients who were likely to have undiagnosed hypertension and be at high risk or were known to have uncontrolled hypertension.
We then wanted to try to develop a flow of patients, which didn't put a large demand on practices and GPs. And we had health coaches and one of the health coaches had a particular interest in CVD cardiovascular disease, and we had a clinical pharmacist who had an interest as well. We thought we could put them two together, and then we co-produced a pathway or an approach by speaking to people, patients, communities, about how their previous experience of managing hypertension was what would enable them to engage better and get better outcomes. And then we developed a pathway where the BPQI tool would pull out those at risk and identify the cohorts, and then our health coach would contact patients first and use her skills to engage and connect and work out who was keen to get involved and maybe who wasn't. And then the pathway would then allow the practices to process this engagement in a way that would improve flow. We'd identify who would have blood pressure machines at home already and if they were suitable, if they were modern enough.
Where people didn't have their own blood pressure machines, we could provide some machines using the BP At Home project. We used the sort of Accurx system if people wanted to use the Florey to send in their seven day blood pressure.
Readings or if they preferred email, they could do that. Or if they just wanted to write them down on a piece of paper, they could do that. And then that information would come into the practice, but it would be managed by this sort of micro team that was pretty much led by our cardiovascular disease health coach. And then depending on the reading we would automatically arrange blood tests, urine, ACR (urine albumin to creatinine ratio). We would ask patients to get in touch with an optician so they could have an up to date eye test if that was appropriate. And then they would come in, so everything would be managed and packaged by the time they had a consultation with the health coach who could also pull in either the GP or the clinical pharmacist if prescribing was required. And then we developed a review thing. So it was that sort of process really to do that.
Anne Cooper: It sounds like it took a lot of people coming together to make it happen and perhaps I can come back to that, but I'm going to ask Jacqueline. What she can remember or knows about the origins of the project in London.
Jacqueline Chapman: It was very much a national top-down kind of approach I understood it. I'd only been in the team about two months, and this came down the line and it was actually a really good opportunity for me to get to know primary care on the patch. But essentially, we were gifted a number of monitors that we were asked to get out to primary care so that they could engage with their local populations. And there was a real recognition, I think, from Covid that people with hypertension hadn't been having their blood pressure checked and there was concern that patients were deteriorating or not managing their blood pressure in the way that they could.
And in fact, we'd seen a reduction in prescribing around hypertension as well as, at that time it was social distancing. People weren't coming into the practice and people were scared actually to come into the practice. So, this was an opportunity to actually embrace some technology. But more than that, to support patients to self-monitor, to understand what it was that was contributing to their high blood pressure and to start to take some ownership about managing that themselves.
In the same way that Thomas described there was freedom for practices to use different ways and to meet their different patients' needs. We also used a risk stratification tool to identify patients most at risk with the highest blood pressure. We used the UCLP partnership pathways that enabled practices to search for patients with the most risk factors and to prioritise those patients first.
That caused some issues in implementation, which I'd be happy to talk about a bit more. But essentially my role was a lot about supporting practices to take part. There was an awful lot of logistics work in getting the monitors to practices and mundane things like, storage. Where would practices be able to store these monitors?
Who would be able to engage with patients? And a whole workflow? It's a whole new workflow for practices and for PCNs. We really wanted to encourage PCNs to start to work at scale, to think about how they could work across a PCN rather than each individual practice have their own process and approach.
That worked up to a point and we did ask when we were distributing seeking engagement in the project for PCNs to put in an expression of interest. So, we were asking them really to think about how they would do it upfront. So rather than just bunging the machines out there and hoping for the best, we were encouraging practices and PCNs to think about who would do it. How they would engage with patients, how patients would get their readings back, and so we could actually use some of the information we were getting back from those expressions of interest to spread learning even before we got the monitors out.
Anne Cooper: It's interesting, isn't it, because it sounds really simple.
We're going to give patients blood pressure monitors at home, but as Thomas described, there's an awful lot of thinking and planning and working out how you're going to make that happen. How involved were patients, Thomas, in the design of how it worked out in the end?
Thomas Wyatt: We did, supported by the innovation agency, we actually run a workshop with some patients and some staff to try to understand what did work well in the past, what maybe didn't work well in the past, where things could be improved and there were certainly, feedback that we got lots of patients when they were talking about hypertension, either cardiovascular disease management, risk reduction diagnosis, and also the management of hypertension were quite keen to have more sort of face-to-face group consultations. They were quite happy with the process of being diagnosed, but they did feedback that they often didn't feel that medication had been explained that well to them or that conditions needed better explaining in a sense of the follow-on care. They felt that quite a lot of previous interventions maybe hadn't have worked that well. And obviously the old problem of feeling that they couldn't get access at a time that sort of fitted with them.
So there probably is something about the scale of teams to manage these, essentially cohort management, but also if you have teams that are too big, that don't know patients, that don't know where the patients live then when they connect with them, they don't really seem relevant. So, our health coach, because she knew the area, she knew our patients, she would start doing lifestyle advice at the very first conversation, even with people who didn't want to engage with the actual process. They would, just benefit from that conversation. I think it's that challenge really of, getting the grassroots stuff and also the data top-down approach together.
Anne Cooper: I'm loving the idea that the health coach was a key part of the team and in fact, it sounds like they were the sort of almost critical factor in the team. You also talked about there was an information website that you connected into the project. So, it sounds to me like you were looking at the problem holistically rather than just a technology challenge. Is that right?
Thomas Wyatt: Yeah, I think there's lots of exciting opportunities with technology, but technology fails at the first hurdle when it, when there's nothing that follows on from it if it doesn't actually make people's lives better or easier or healthier or whatever. I think that things like the Accurx Florey were really useful, but, if you don't have the capacity to then make the appointment with the nurse or the GP or the clinical pharmacist or the health coach, then it just becomes asking for information that then falls into a black hole.
And I think the problem is that there are significant cohorts of patients who are difficult to connect with and very easy to lose. And so, if you manage to connect with them and motivate them and enable them to do seven-day blood pressure monitoring, and then you encourage them to use their phone to do Accurx and do a Florey.
So, it fits with your clinical system, and it works really well. But then if the end point to that is disappointing for the patient, then suddenly they disengage and it's very hard to reconnect with them.
Anne Cooper: Yeah, I can understand how that would happen. Jacqueline, to come back to you then you are managing across a large patch, and you've got all of these practices, do you recognise some of the things that Thomas is saying, and do they coincide with your experiences?
Jacqueline Chapman: Yes, I do. I think that there was a lot of variation in the way that the PCNs and practices implemented the project, the amount of resource they might put behind it, the amount of thinking that they put into it. I think Thomas describes the gold-plated kind of approach that you would've loved to have seen across my patch, but I think in a lot of cases, the capacity, the concerns around what were the quite often very new roles.
In southwest London, new care coordinators, I had a new one care coordinator start, the month of the project. It was variable, I would say. But the concerns that Thomas describes about patient engagement and loss of patient engagement were felt strongly.
I think in primary care particularly off the back of Covid when we're trying to encourage people in for vaccinations. It's not the one question or the one barrier. You have to have a whole range of answers to different questions and concerns that people raise and be prepared to invest in that conversation so that you understand what's important for that person and you can help deliver some support for them. Their high BP may not be the most important thing for them right now.
And I think the health coaches, the social prescribers and others will have that holistic conversation and recognise that, actually the fact that they're about to be evicted is much more important for their high blood pressure right now and perhaps that's probably contributing to their BP, but don't get to the cause that's not going to help that individual or encourage them to continue to use the services and be signposted for support they need.
Anne Cooper: I'm really encouraged by both of you talking about how it's not about the technology, it's about the people. And it centres on the patients, and it's not, neither of you are describing projects to me that sound like they're mechanistic.
They're all centred on humans, and I take great encouragement from that. To come back to Thomas, if I was to say to you, okay, the practice down the road or whoever is going to start this project new today, what gems of advice would you give them based on your learning?
Thomas Wyatt: If we look back at how we all worked during Covid, if we took a similar approach to conditions like hypertension, cardiovascular disease risk, we would probably work very differently. We would do much more outreach. We would engage with third sector organisations, and I think that's where the system needs to support PCNs to really lead population health management. Because even if it's at an ICS level so much of the opportunity is lost due to the distance that they're looking at it.
And the real interesting bits are in that granular detail that you have to sometimes get close to the ground to see. I think one of the things that we did find as well was that you have to enable practices to also be part of this. I think sometimes as a PCN, we've in the past maybe tried to think, okay, let's just do it as a PCN, and then practices feel that they've been left behind, just like patients often feel they've been left behind and communities feel they've been left behind.
So, some of this is about how do you give people a role and some purpose in not just developing it, but also in participating in it later on. I think that having practices, managing the flow, letting practice and helping practices be involved in some of the patient identification. Obviously the BPQI tool is very good at pulling in data, but that's only part of it.
And then I think one of the other key things, we've got lots of different ARS staff that are available to PCNs, and I think finding out what their interests are in. So it may be that actually you have someone who's particularly interested in diabetes, in which case in your PCN you might be better off doing some sort of data driven approach to diabetes rather than to hypertension.
If you've got somebody who's very keen on exercise, then maybe CVD is particularly useful or if someone who's got particularly interest in mental health or certain age cohort. I think part of this is about moving for us to think about how do we best support and identify cohorts rather than just an open front door where it's just about access. And I think what Jacqueline described in a way was probably more about these projects are never a done deal. They evolve and as you evolve, you identify more cohorts that actually need something slightly different. So across at PCN we've got practices that cover very different areas.
And actually, for those practices, they probably need a slightly different approach. You still need someone who's got the overview and the passion to keep it held together because I think what is key is also getting some data from it, which is also why technology can be really useful, a dashboard or a data tool is much quicker than pulling data together, rather than someone having to sit through notes and fill out an Excel chart.
Anne Cooper: It's really interesting. I think one of the things that, for me, that you are exemplifying is there's something in systems thinking that Myron Rogers, who's one of the big thinkers about it talks about, which is going where the energy is.
And I think what you are describing is finding where the energy is in the system and going with the energy and using the energy and the technology as well to drive change. I think that's probably what you are exemplifying really. Jacqueline, you talked about using experiences to come up with, I suppose what I'm thinking is a list of things to help practices to understand what might work and what might not work.
Is that what you did, and do you want to tell me a little bit more about that?
Jacqueline Chapman: Yeah, sure. Our approach was very much about inclusivity, trying to get as many practices and PCNs involved as possible. And whilst we use an expression of interest to gauge where the energy was, we actually got very good buy-in.
The practice list size covered by the project was 75% of the population of Southwest London. 20 PCNs as PCNs plus an additional 10 practices took part in the project. So that gave us scale, which I think was quite unprecedented and unexpected frankly. Off the back of Covid, I think the expectation was that there would be minimal uptake.
That wasn't the case. Plus, as I mentioned, we had a number of new roles ARS roles coming in and this gave them a nice focus, patient facing focus.
The engagement process was very much about, telling the story why this is important, so you know, why hypertension, is silent killer, how many people it affects, the impact of covid and so on. But we were also able to develop a resource pack. The early conversations with our transformation leads suggested that, if we centrally could pull together a resource pack to support implementation, that would enable the practices and PCNs to hit the ground running essentially. We built searches, we created templates, we created diaries, we provided links for patients to be able to see how to use their BP monitor.
We facilitated learning sessions, so we had a weekly drop-in session where people could just come in for an hour over Teams and just talk about what they were doing currently. And that was just a very low level, soft learning forum really. We also had a working group that was a subgroup of the CVD clinical network, and they provided really good steering for the group and helped us to identify people who could write searches.
And we used them, so we provided a resource list and that to some extent worked. Others were completely overwhelmed by the number of things that they had in the attachments on the email. But then they had my contact details, so they would come back, and they would admit, I'm a little bit overwhelmed. I can't remember what we're doing now. Can you just tell me where to start.
And so you just put together a little checklist, do run research, find patients, work out who's going to do what, and so I think all of that support that was available, peer support plus a little bit of central support and the provision of resources did help practices and PCNs to, to get going.
Anne Cooper: That's lovely. I feel, it's making me feel really warm. I've got a really good example from Thomas of the granular project, and I love some of the stories about the patients and you learning and things, and then Jacqueline talking about how it's possible to scale something like that across a much larger geography and the things that you can do to enable that to happen.
I feel really encouraged by the conversation today, just as we draw to a close, I wondered whether you could tell me perhaps if you've got any examples of a story of a patient who's experienced the systems that you're talking about. I know that's catching you on the hoof a little bit, but Thomas, can you think of anybody that you can remember?
Thomas Wyatt: Certainly, lots of patients spoke really highly of the process and particularly the people who looked after them. In a way a lot of these people aren't ending up seeing a GP. Instead, they're getting to know a health coach, and they build confidence in that approach of how they're having their hypertension managed.
One of our evolutions next with it is to build in a lipid management pathway into it so that ideally in one conversation, one face-to-face appointment we can also look at their blood pressure and their lipid profile. We want to try and bring in some point of care testing into that as well, just so that we can reduce the chance of losing people in that gap.
When you say listen, go for some tests, then come back, and then they can't get back in. The other thing with patients is that patients often engage a lot in things and then they feel that, oh, it's just a little project, or it'll, it's only going to last for this time and then it's going to be finished and so forth.
I think the system, and this is about how the ICS invests in primary care and in PCNs population health management needs to be part of everything in a sense of how we evolve these sorts of projects because they all take time. And in our PCN of all our practices, some practices engage very early, and some engage a bit later.
But you have to have the investment and the sort of this becomes business as normal so that people can come in a bit later and then they can still be part of the next thing. And patients really appreciate, and I think the patients have had to really learn about how to, how different things are getting and how they engage with primary care. And so, this is a, an example of actually a good experience that, it isn't just about, oh, you can't speak to a GP, you can't... this is additional and it's better for some patients. Some patients will still, always need their GP and that's fine.
I think we need to keep several options open. And the, and again, going back to this, the system does need to ring fence resource for this because again, when the pressure's so high in primary care, if people don't feel that something's ring fenced or isn't protected time for it, or it isn't, so with these ARS staff, I think what we are probably going to do is avoid the risk of just opening the doors to them and they just have to have all these referrals no matter what, and also do this.
But I think we're going to make it so that a part of their week is protected for this project and similar projects that we're doing so that they can develop a specialist interest and knowledge in something which helps their experience of work and retention and so forth.
Anne Cooper: Yeah. I hear your message about sustained funding and the future. I think it's noted. And Jacqueline, have you got any stories from your end about the impact of what you've been doing?
Jacqueline Chapman: Yes. We heard a lot about individual patients who perhaps had felt that they were being left behind and weren't being looked after. And this was an opportunity for them to reengage and to, as I say, get that kind of real-time feedback on their BP. There was a woman who had a high BP in pregnancy who's, who was really concerned about visiting the practice and who on having the monitor, she was able to see the impact of things that she was doing on her BP, and she said it gave her peace through her pregnancy. There were a couple, both had BP would help each other, would badger each other in the morning and then in the afternoon to do their BPs, come on, get it, let's get it in. And that kind of peer support helped, I think. There were a couple of patients who had high recorded BP on the system, but actually once they had their monitors, they were able to relax, do the things that you're supposed to do when you have your BP, sit down, breathe sensibly, don't do any exercise, don't smoke, don't drink or don't have coffee. All the things that people do when they're just about to go into a general practice, of course, on the bike, whatever. They found that their BP came right down within normal range. We did do a little audit in fact, it wasn't huge numbers, but we did get before and after BP readings using the monitors at home and we asked practices to tell us what intervention they'd carried out. And we saw about half of people with very high BP come down within normal range as a result of the project. About three quarters had medication changes, but a vast majority had advice about their lifestyle about diet and exercise and so on, and so that you could see the impact of it for patients.
Anne Cooper: That's amazing to hear. Jacqueline. Thomas, did you want to come in?
Thomas Wyatt: I think the other thing that's interesting is that if you enable people in the community to know how to do their blood pressure, have machines, they look at the Happy Hearts website.
They become their own little champion of their thing. And then it's all that sort of unknown activity that then just spreads out across the community. And I think certainly that, a lot of the future of primary care will be about how do we enable that and almost take out these sorts of gatekeepers that aren't necessary.
And I think probably care coordinator, health coaches are probably better at, or have more capacity to try and start those conversations and almost coach people into being other people's coaches or into being other people's advocates for healthy lifestyles. And effectively, people's health is determined much more about who they live with, where they go, their environments than that one conversation once a year with the GP.
Anne Cooper: That's fabulous. And what a lovely place to end. I'd like to thank you both. I feel really encouraged and inspired by both of your examples, so thank you for sharing those with us today. These stories add to the evidence base about the impact of digitally enabled care.
If you would like to hear more about the Innovation Collaborative, you can find them on the Future NHS platform. If you already have an account search for Innovation Collaborative Digital Health. For more information on how to join, please see the podcast notes.
Episode 15: What happened next? Revisiting technology-enabled remote monitoring projects to explore the latest learning on challenges, outcomes and sustainability in the care sector.
This episode explores the sustainability of technology-enabled support in nursing and residential care homes has been released by the NHS National Innovation Collaborative for digital health.
It explores how health and care staff, residents and relatives in North Central London (NCL) have worked through new and evolving challenges to launch and sustain technology-enabled remote monitoring in almost all homes.
NCL Nurse Educator Lead Louise Keane discusses the challenges and benefits of rolling out digital technology to adult social care with Davison Chimenya, operations manager for two NCL homes.
They are joined in conversation by digital nurse leader and podcast host Anne Cooper.
Episode 15 transcript
Podcast transcript: Non-verbatim: Text adapted for improved readability
What happened next? Revisiting technology-enabled remote monitoring projects to explore the latest learning on challenges, outcomes and sustainability.
Anne Cooper: My name is Anne Cooper and I'm the lucky host of this podcast. I don't know about you, but I find the stories from people who've made exciting changes to the way we deliver care fascinating and compelling.
It is almost always about the people, how they've worked together and travelled on the journey to supporting people at home. Their stories, their successes, and things they might have done differently are shared in these conversations.
This episode focuses on the journey to launch and sustain digital support for people living in residential care. To find out more, I'm joined by two care professionals from North Central London, which supports people and staff across 265 residential care homes. The first thing I'm going to do is ask them to introduce themselves to you, and then we'll get into the detail of the work that they're doing.
First of all, Louise, would you like to tell everybody who you are and what you do?
Louise Keane: My name's Louise Keane, and I'm the nurse educator lead in North Central London, rolling out digital technology into adult social care.
Davison Chimenya: I'm Davison Chimenya, I'm the Operations Manager for Autumn Gardens and Anastasia Lodge Care Homes in Enfield.
Anne Cooper: So then I'm assuming that you two have been working together on a project that's about technology out there in care homes. Louise, do you want to tell me a little bit about how that all started?
Louise Keane: Yes, so it started two and a half years ago that in North Central London, we sadly had an excess of 522 deaths during Covid in adult social care.
And we realised at this time that staff were feeling very isolated and worried, and that clinicians weren't able to get into the care homes to see the residents. And so we wanted to develop some kind of technology that would support the care home staff to be able to get help quickly from primary care.
And so we started to use some technology and we were rolling that out into Care Homes and Davison's Care Home was one of the first care homes that agreed to come on board and try it out for us, and I'm glad to say he's still using it today.
Anne Cooper: That's lovely to hear. Davison, would you like to tell me a little bit about the technology and what happened when it first came into the care home?
Davison Chimenya: When it first came to the care home, I think Louise contacted me and said, we've got this lovely gadget that is going to help you, your staff and your residents. So of course, anything to help our staff and our residents, we always up for it. And we were part of the initial project, and we had training and support from Louise and her team.
And we then managed to roll it out to the GPs and the charge team that support us so that they're also able to log in and monitor our residents’ observations remotely.
Anne Cooper: Tell me a little bit about how the staff reacted to the gadget, as you call it, when it was first put into the care home.
Davison Chimenya: I think there was a lot of excitement from everybody.
I think nowadays everybody's gadget friendly, and it made their job easier because with the Whzan you get to calculate the new score automatically. They didn't have to worry about how to calculate it, so it helped them during their assessments and also when they contact a healthcare professional. When they mention that they're using Whzan and they're mentioning the NEWS2 score, that is easier for the healthcare professional to give advice and support.
Anne Cooper: Okay. And I suppose when times were more difficult in Covid, that type of information for the healthcare professional at the other end would be really quite instrumental to what happened next at a guess.
Davison Chimenya: That is true, yes.
Anne Cooper: Louise, it sounds like Davison's Care Home responded really positively to what happened. Was that the same everywhere?
Louise Keane: No different care homes had different views on it, and I think what was important and how the rollout has been so successful is that we didn't force anyone to come on board.
So, we brought the kit over to homes. We sat, we spoke to them, we asked them if it was the right time for them. And if it wasn't the right time for them, we've got a team of nurse educators and what we do is we'd support with other training that they might need. People have got to trust you and know who you are and know that you're going to be reliable and you're going to be there.
And so that's what we did. And so, we've got 80% of our homes that we've trained, which is now at 146. They've remained on the programme. I think that tells you that to put the support of a team of nurse educators around it, it works really well. And to do with not to was a big mantra of ours that we wanted people to feel they wanted to do this.
Anne Cooper: That's great to hear. Davison, how did it feel to be on the receiving end of the training, and what was the relationship like with the training team?
Davison Chimenya: Oh, the training team is excellent. Just knowing that you've got somebody at the end of the phone that you can just make a phone call and ask, because it was new to us. It was new to the team, but the support that we got from Louise and the team was very positive. It made everybody want to be part of it in our care home.
Anne Cooper: Did it mean you had to change the way things happened in the care home?
Davison Chimenya: We had to change some of our assessments and obviously being during the pandemic changing to electronic was a bit of a challenge, but it's eventually worked out quite well.
Anne Cooper: Good. And what do the residents think?
Davison Chimenya: It's brilliant. Cause obviously they know that their GP get to get the observations monitored straight away. And also, it's easier for the GP to prescribe promptly and if say they want to put somebody on a blood pressure tablet, they can monitor the previous results by just logging in. So, there won't be any delay.
Louise Keane: I was going to say it's great that you've brought up residents and relatives because they've been instrumental to help us do this. We really struggled during Covid to make contact with residents and relatives, but now we're going into residents and relatives meetings and we're showing residents and relatives the kits in action. And most in fact, all of them just say, what you waiting on? Just let's get this going. We love it. We want it to happen. We feel much safer that we know that we can ask for the staff to take observations if we are worried about mum or dad. And the great thing is because we're coming into the homes to do the training, that's these ladies and gentlemen's homes, so we encourage them to come into the training as well.
We just did some training the other day where residents were taking staff's blood pressure. We flipped it over the other side, so they were part of that as well. And we feel that's really important because this is for everybody. This is not just for the residents, it's also for staff, which is key to say that while we were doing observations, we came across an alarming amount of staff who had high blood pressure.
And who we had to encourage and support to get to their GPs or we've had to phone London Ambulance Service a couple of times to get people blue lighted into hospital because they were so poorly. The kit is there for everybody to make everybody better and well and spot long-term illnesses. I think that's not what we were expecting.
We hadn't thought about that, including relatives as well. We've supported quite a few relatives too.
Anne Cooper: I love that idea. I love the idea that the technology is pervasive and doesn't focus solely on one task, and that must be an asset Davison around helping you to support your staff as well, helping them and their wellbeing.
Have you done anything else as a result of some of this around wellbeing?
Davison Chimenya: Obviously looking at the, how we can support our staff's wellbeing and I'm in conversations with Louise to arrange the wellbeing bus. It's something that we are really looking forward to as well.
Anne Cooper: And tell me about the wellbeing bus Louise.
Louise Keane: So, we've got a bus and we realised quite quickly that we needed to support staff. Staff were struggling to get time off to go to GPs appointments. Or a lot of care staff already have caring responsibilities at home, whether it's children or older adults that they're looking after. We thought the best thing to do was to bring a bus to them.
We're doing a pilot, which is starting in April, and we're bringing a bus to care homes across North Central London. We're going to be doing blood pressure checks, diabetes checks. We're also going to have the wellbeing hub from North Central London on the bus who'll be able to speak to staff because we know lots of staff are suffering from trauma on the back of Covid and they'll be able to take referrals.
And we've also got some support around finances because people are really struggling at the moment. And we've also got our physio coming on who's going to be giving hands and back massages and we're hoping that makes the staff feel supported and looked after. And valued.
Anne Cooper: So, all of these things, as I'm hearing the story anyway, came about because you were trying to put a technology into care homes and you've got an education team who are out there understanding what's going on out in those communities.
And as a result, all of these green shoots of new things are starting to spring, which I think is absolutely amazing. Let's go back to some of the more practical things that sometimes get in the way of some of these things happening. What about sort of the commissioning arrangements and the contracting arrangements?
Were they set up to help you, and how did you navigate some of those things that might have got in the way? What about you, Louise?
Louise Keane: We got our funding from NHSX as it was then. I have got to say that the team were absolutely supportive. They set up London wide meetings for us all to meet together to share and learn from each other. That made a huge difference. Funding, like everything, it can be challenging, but they were brilliant to give us the money to start with, to set us up. I can't fault that. And that means that all the care homes received the kit for free and all the training for free. And the licensing for free, and that made a huge difference to enable everybody to come on board. Maybe not just the homes that had more money than others. It was open to everybody.
Anne Cooper: What type of impact have you seen in terms of benefits?
Louise Keane: For us, we've seen benefits across the system, so we've looked at as a lens across the system to see what we can pull related to data. We've seen a reduction in London Ambulance call outs of 28% for homes that have Whzan, homes that don't have Whzan it's a 14% reduction. And we've also seen 12% reduction when we've done training. For example, we've done some urine UTI training recently, and we saw 12% reduction in urine infections by training up staff, which is brilliant news. So that's spotting early deterioration and acting on it.
Anne Cooper: Davison have you seen any consequences of this in terms of staff turnover or how people are talking about their work in the care home?
Davison Chimenya: I think in terms of staff turnover, it's always been a challenge. Especially recently. The team that we initially started with, we still managed to retain half of them, but the new staff that came on board was also encouraged to use the Whzan.
We were able to teach them and support them on how to use the Whzan and to tell them the good stories that we've been having with the Whzan.
Anne Cooper: That's great. I think that what you're both pointing out is how relationships matter. It strikes me that you two actually know each other and your collaboration between the education team and the care home has been fairly instrumental to this work. Is that right? Davison?
Davison Chimenya: Yes, that's right. I'm on Louise's phone call every time. She calls me, there's something coming. I say, Louise, I've got a question here. So we've got that relationship, and especially when it comes to education, you always want to try and ensure that your staff get the very best. And Louise has always been looking out for it, for us.
Anne Cooper: Louise, I know a bit of a secret about how you manage some of the, to increase some of the relationships through the pandemic. Do you want to tell everybody about the sunflowers?
Louise Keane: Oh yes. So, during the pandemic we were really worried about our residents and our staff, and we wanted to bring some joy.
We posted out sunflowers to as many homes as we possibly could. I'm not sure if Davison's was one of them. And then we did some gardening groups where we grew sunflowers, and we met once a week to show us how we'd planted up the sunflowers and how they were growing. We had huge response And we went from people who were really struggling to use technology because we went on Teams. And one of the reasons to do that was to try and help our residents and our staff to be more digitally savvy, because some of them were really struggling with that. And so by having fun and planting sunflowers and going out into gardens and measuring our sunflowers, using our rulers and using our hands and everything we were able to get people used to using Teams and comfortable, but most importantly, we were able to help the residents get comfortable with using Teams. And on the back of that, we learned that people started to talk to their friends and families via Teams. And they also started to have some doctor's appointments via Teams.
And they were very comfortable because we'd had fun on Teams, so it wasn't seen as something threatening at all.
Anne Cooper: That's really interesting to see. I really do believe this is a pervasive project, Davison looking back to before all of this started, what's the difference between how the home views technology in it's all its different guises and how it views it now.
Davison Chimenya: Well, I can imagine life before Teams, before Zooms. They were there, but I think that's one of the positives that the pandemic brought and having to be able to provide training from wherever you are. So our staff are able to attend the training. They don't have to worry about public transport.
Whenever there's a training that's suitable for us to have it, on Zoom or Teams, we always encourage staff to attend. It's actually improved on our staff attending the trainings.
Anne Cooper: That's great to hear as well. Okay, so let's go back in time. Louise, if you were to start right at the very beginning or somebody else was to start right at the very beginning, what three pieces of advice would you give them?
Louise Keane: I would say it's good to, it's important that you understand the layout of the area that you're working in. So, you understand who's there and who they are and build up those relationships. The second thing I would say is you need a team to support the homes so that they know that they've got long-term support, and it's not just for two months or three months, they're going to be there.
And I would suggest as well as you work with, not do to. You encourage people to come on board when they're ready and don't force any one.
Anne Cooper: Just to come back on the end of that. You said earlier that you, not all care homes that started out have stared with you. Do you know why they might not have continued on the programme?
Louise Keane: Yeah, so we've got homes that have closed. So in North Central London we have got the highest level of bed closures across London and we have done since 2014. We've had a lot of care home closures. We've also had homes that didn't want to come on board because they didn't want to upset their GP because the GP didn't want to take part. The last one being is that new providers have come and taken over the homes and they have a different agenda and they didn't want to use the technology at that time when they took over the home.
Anne Cooper: That's lovely. And the same first question to you, Davison. So you've come to the home and somebody's knocking on your door and saying, would you like to start The Whzan Project with us?
What advice would you give them in that situation?
Davison Chimenya: I always say, be open. There's no fear. And always look for new things or innovation to improve the life of your staff and your residents and families.
Anne Cooper: Okay, so let's just talk a little bit about sustainability. What does the future look like from here onwards?
Louise, do you know what the future of the service is?
Louise Keane: Yes. The future is that we want the technology to link into as many different services as possible. At the moment, we're doing a piece of work with our tissue viability nurses. To look at how the technology can enable the tissue viability nurses to be looking at wounds and to give real time feedback and support quickly because we don't have enough tissue viability nurses and we have to think, we need to think cleverly so that we can support our homes.
So that's the first thing. The second thing is that we've now got our technology linked in with 111 and that homes who are using the technology can get a call back within 15 minutes if they've a new score of four or above. So that is a real game changer. That's the care home managers and staff's words not mine, that this makes a huge difference.
Because sometimes they have to wait an awful long time and that causes distress and problems in the home to the resident and also to the family. And we're trying our best to connect the system so that the technology is seen as benefiting and not just doing one thing. It does many things. We're also doing some work around falls at the moment, and we're using some acoustic monitoring and we've managed to get the acoustic monitoring linking in with the technology.
And if someone starts to cough in a night that wouldn't normally cough, we get an alert so that they can go and take some observations as well, because potentially we might be developing a chest infection or something's happening.
Anne Cooper: That all sounds really exciting. Davison in addition to that, is there anything in the home that you've got your eyes on for some of this work?
Davison Chimenya: I think it's just continuing managing our residents health and obviously improving their lives.
Anne Cooper: Good. And finally, just a question about your relationship with the supplier. How's your relationship with the supplier been Louise?
Louise Keane: It's been really good. So we've worked really well together.
They've been really open about areas that we found that we think would help everyone. So for example, we've developed a red person alert on the side of the person's name that says that the person either isn't able to take a full set of observations or the person is on an end of life pathway and we wouldn't be taking observations.
And that really helps the care homes to have a relationship with professionals. Because often professionals were calling and saying, why have you not taken a full set of observations? And actually that was setting off that conversation on the wrong foods. And we need these conversations to be really positive.
And that we're listening to each other and respecting each other. So having the red man, now, the clinician can see the red man and know straight away. Actually, hang on a minute. There's a problem here that we can't have a full set of observations. Let me have a look and they can have a look and they can see it.
And we're getting told that the relationships are changing between health professionals because we've got our care home staff, which what should have always been, but much more on a footing with our NHS colleagues and most importantly, talking the same language and that they're being listened to much better now, which is great.
Anne Cooper: That's from my point of view wonderful to hear. I think this project is a wonderful thing to see and hear about, and I wish you every success with all of your plans for the future. It just reinforces for me this, that technology is really about people. The technology has not been the core subject of the conversation that we've had today.
It's the relationships between you all and the impact that you're having on the residents and the relationships between the professionals. So thank you both for your time today.
Louise Keane: Thank you.
Davison Chimenya: Thank you.
Anne Cooper: These stories add to the evidence base about the impact of digitally enabled care. If you would like to hear more about the Innovation Collaborative, you can find them on the future NHS platform.
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