Themes:
- Admission avoidance and early supported discharge
- Collaborating across systems
- Tackling health inequalities
Background
Central London Community Healthcare NHS Trust (CLCH) is one of the largest community providers in the country, spanning four integrated care systems (ICSs) which between them include 11 London boroughs plus West Hertfordshire. CLCH covers a large geographic area, operating out of 650 sites, employing 4,500 staff and delivering care to around two million patients a year.
Virtual wards: national policy
Virtual wards allow patients to receive care they need at home, supported by a mix of new technology (for example, rapid diagnostic tests), remote monitoring and in-person visits.
The model existed before Covid-19 but was used in response to the pandemic. Covid-19 virtual wards were rolled out across the country, and since then, NHS England has sought to significantly expand the care delivered in this way. NHS England has asked ICSs to deliver 40 to 50 virtual wards 'beds' per 100,000 of the population by December 2023, with £200m of funding available nationally for 2022/23, and £250m on a match funded basis for 2023/24.
Building on progress made during Covid-19
1. The CLCH team as a partner in the South and West Hertfordshire Health and Care partnership (SWHHCP), which includes West Hertfordshire Teaching Hospitals Trust (WHTH), have built on progress made during the pandemic to deliver two different virtual wards models for Heart failure and chronic obstructive pulmonary disease
(COPD) patients.
2. Older and frail patients, operating in South West London, provided by CLCH.
After launching in December 2021, by August 2022, 280 patients had been treated in the COPD and heart failure virtual ward, and 211 in the frailty virtual ward.
Both virtual wards started with a focus on early supported discharge, because, Dr John Rochford, complex care GP and clinical director at CLCH, says: "This is where the energy was." Both teams have now extended their work to include admission avoidance.
Delivering two different virtual wards models
The two models share aims to reduce length of stays, prevent avoidable admissions, and improve patient experience and outcomes.
In South West Hertfordshire, the mean length of stay for heart failure patients in the virtual ward is less than two thirds the length of the mean hospital stay for heart failure. For COPD, the number of non-elective admissions to WHHT has fallen from 131 in 2019 to 62 in May 2022. In South West London, the mean length of stay for all patients at the local St George's Hospital is 11 days, while for the frailty virtual ward it is 6.5 days. The frailty virtual ward has supported 63 patients to avoid hospital admission since December 2021.
Importantly, both virtual wards have received excellent feedback from patients. For the frailty virtual ward, 100% of patient feedback in the initial six-month evaluation was positive. COPD patients score the WHHT virtual ward an average of 8.5/10 for patient experience, and heart failure patients score it 9/10.
Tackling inequalities
Both virtual ward models have a strong in-person element. John says: "We deliver an equitable amount of care as people would receive in hospital."
Dr Niall Keenan, cardiology consultant and clinical lead for the South West Hertfordshire virtual ward, explains: "There is a concern that virtual pathways could increase readmissions, but this is not happening," partly because "patients are getting comprehensive in-person care" through the virtual ward.
Tackling health inequalities and digital exclusion is also a key consideration for both teams. John explains: "A comparison of the population health of the boroughs and our caseload mix shows we are not selecting less complex patients and creating an inequality here. We take nearly all referrals, and where technology is a challenge, we find a solution."
For the COPD and heart failure virtual ward, Niall says: "At first, we were going to ask people to use their phones, but realised some people didn't have one, so we give everyone the devices needed." However, Niall reflects: "Exclusion is not as obvious as you would think – there are more affluent patients who are more socially isolated and less digitally confident than others."
Collaborating across systems
Shared planning, leadership and governance across systems is essential. Over the course of 2021/22 the SWHHCP worked collaboratively to understand the benefits and costs of virtual wards, agree clinical pathways, and develop a joint business case.
The South West Hertfordshire model is driven by a multi-disciplinary team that meets several times a week, and includes acute, community and primary care clinicians. They also work with voluntary sector partners.
Niall reflects: "We are working more closely with community and primary care partners than ever before."
John also talks about the importance of shared governance, and says: "Clinical governance must be considered at the start, and be the driving force behind delivery."
Ashwin Anenden, complex care GP, CLCH, says: "Good relationships, trust, and integration with secondary care colleagues has been essential." Partnership working has supported the discharge of more complex patients to the virtual ward, and Ashwin says: "We recently supported a patient to go home five days earlier than planned, which was important as this was where she felt she would recover best."
Unlocking further potential
Niall says national ambitions to further scale up virtual wards will need new resources and will not be delivered "on a wing and prayer." John hopes the new statutory ICSs will be able to build on work begun in response to the pandemic and will support collaboration ahead of competition.
But to achieve that, he says systems will need to move beyond "short-term thinking" encouraged by time-limited national funding, which has created barriers to recruitment by discouraging trusts from creating permanent roles running virtual wards. Adequate numbers of staff, with the right skills and experience, is crucial. John considers the scale of the national ask, and says, "a target of 40 to 50 virtual ward beds per 100,000 of the population is basically a district general hospital – you can't have 11 staff running 10 wards."
Niall says: "Most patients need to be spoken to every day, otherwise they wouldn't be in a hospital bed. If you don't have the right staff to patient ratio, you won't be diverting people from hospital beds – you will be hitting key performance indicators but not maximising value."
Looking to the future
Niall and the team in South West Hertfordshire are now looking to develop a virtual wards dashboard and enhance their understanding of any inequalities in service provision. They are also developing other virtual care models, including for diabetes, frailty and pneumonia, with other pathways at earlier stages of exploration.
At CLCH, John and colleagues are now looking into expanding into an anticipatory care model. They are keenly aware of growing older and frail populations and the need to develop their approach to meet these changing demands.
Both teams are keen to continue learning from each other, and from other colleagues across the country who are delivering virtual wards.