Continuing our series on innovation, Maggie Ioannou looks at the lessons learned from delivering virtual ward.
In 2006, the virtual wards in Croydon won an unprecedented four categories at the HSJ Awards. This started a cascade of presentations, workshops and conference appearances as what started as a small idea spread across the country as a model for managing complex long term conditions.
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In 2004 NHS Croydon was facing significant growth in accident and emergency attendances and emergency admissions for people with acute exacerbations of long term conditions. The experience of these patients was poor and the system was letting them down.
Two initiatives for change began in Croydon.
First, the Department of Health funded the development of a predictive risk tool for early identification of patients at high risk of readmission to hospital. These patients were the caseload for the newly established role of community matron.
The second phase of the modelling produced a far more sophisticated tool now known as the predictive risk model (Resource Centre, page 20, 27 May). Its sophistication was provided by the multiple data sources used: all hospital data, prescribing data and most importantly the rich data from GP registers for a whole population.
In the second initiative, Croydon’s nurse consultants produced a piece of work based on analysis of patients’ diaries, identifying why they continued to call emergency services. These included:
- loss of faith in services outside of hospital;
- poor access to primary care
- lack of understanding of their disease(s);
- no clear care planning that addressed individual anxieties;
- the perception that a hospital ward was safe;
- the perception that there was always someone to call when in hospital;
- the perception that the ward round would ensure the right people were there to discuss and treat their symptoms in a coordinated way.
From these the “virtual ward” was created, for vulnerable patients who live at home but have the highest risk of unplanned admission. Patients are cared for using similar organisation and staffing as a real ward
The virtual ward has 80 “beds” and a patient can only be admitted to the ward by identification from the predictive risk modelling; not by clinician referral. The ward is led by a community matron and each one has a named ward clerk too. All other care is provided by the community staff already in place.
The community nursing teams and the therapy teams are aligned to the wards, creating ownership and local identity for the public. Each ward relates to a defined group of GPs and has an identified local social worker and voluntary sector link. The hub for communication with professionals and patients is the ward clerk.
Creating 10 wards to cover the population of Croydon has taken two years, and refinement of community nursing services another year.
There was, unsurprisingly, resistance from local medical colleagues who disputed the evidence that clinician referral was not the best way to identify at-risk patients. Personal contact and debate proved the most effective way to allay some of this but it took time before GPs felt ownership.
Most powerful of all were the early case studies which showed the difference the model was making to the quality of patients’ lives. As one GP commented, “I never realised how the system was creating this truly awful existence for our patients. We must try to radically change it”. Patient stories are consistently the most powerful form of communication to both engage clinicians and lever change.
The other lesson is the need for leadership at all levels. As director of nursing I had some of the most difficult discussions with colleagues. But the leadership was more pervasive than that. It was in every conversation the nurse consultants and community matrons had with any health or social care professional; the public discussions that also grew in number; the written briefings, and in the conviction of those creating a service to match the wishes of the patients.
This model provides an excellent example of clinician engagement. It builds on the values of frontline clinicians to seek improvement but challenges traditional development processes - here patient experience is the strongest consideration and then the evidence and technology to support the patient’s vision.
This approach could be transferable to many other redesign projects.