The Download: How virtual care can help hospitals free up beds

With covid-19 pressures in hospitals easing at glacial pace, the issue of discharging patients on time remains one of the biggest head-scratchers for managers this winter.

The problem of delayed discharges, which can have dangerous consequences during a pandemic, has been a source of immense frustration among hospital leaders — illustrated by a high-level wrangle between the NHS and Treasury over who is liable for care home indemnity.

Although a short-term fix for this appears to have been found, managers and clinicians are still scrabbling to find ways of discharging more patients faster and doing so safely.

Step forward the latest major digital transformation to be rolled out across the NHS.

The covid-19 virtual ward

Prior to the pandemic, discharge schemes usually focused on improving co-operation between hospitals and care homes or sending the patient home with follow-up care by other providers.

However, the overall reliance on technology to help the fight against covid-19 has encouraged health chiefs to rethink which mechanisms trusts can use to make the discharge process slicker.

The result is a focus on setting up “virtual wards” for covid-19 patients.

The concept is simple: Once covid-19 patients reach a certain point in their recovery, they are discharged to their home where they use remote monitoring equipment to send information to clinicians. This typically involved patients submitting daily readings of their oxygen saturation levels by using a device, and/or being contacted by doctors over the phone. While most patients would rather recover at home anyway, the scheme also offers hospitals the chance to free up more beds. 

Although NHS England/Improvement last month told all trusts to ramp up use of the covid-19 virtual ward, no data exists to show how many are doing it or what the outcomes are.

West Hertfordshire Hospitals Trust was among the first NHS trusts to create covid-19 virtual wards. Using a device called Medopad — provided by health tech firm Huma — the trust reported a 5 per cent readmission rate within four weeks of a covid patient’s first discharge to the virtual ward, compared to a rate of 8.4 per cent of covid patients discharged elsewhere.

Another trust, Northampton Healthcare Foundation Trust, set up a similar scheme last April after partnering with Swedish firm Doccla. The company reported a readmission rate of 14.5 per cent for patients on its virtual ward (including readmissions after 28 days of discharge).

Covid-19 readmission rates vary across the country so it is hard to compare data, but a study last month suggested as many as one in three patients are readmitted within four months — making West Herts and Northamptonshire Healthcare’s results encouraging despite the different metrics used.

NHSX’s role

Virtual wards were quickly identified by NHSX at the start of the pandemic as a policy to pursue.

Tara Donnelly, NHSX chief digital officer, told The Download the unit has helped 27 sites (usually acute or acute and community trust-led) create virtual wards for covid-19 patients, although many more are believed to run such wards without the help of the centre.

NHSX has also helped another 35 areas establish similar tech-led schemes within primary care, as part of the Covid Oximetry at Home programme.

The unit now hopes the progress made on virtual wards during covid will prompt a major shift towards remote monitoring more generally, at a time when hospitals desperately need to free up surgical and bed capacity to treat the alarming list of non-covid patients which has built up during the pandemic.

Ms Donnelly said: “This has been a terrific solution during the pandemic, but when things calm down we’ll see people appreciating this way of managing care — both clinicians and patients.”

And NHS England’s calculations suggest a package of interventions to speed up discharge, including virtual wards, avoided at least 5,000 beds’ worth of additional occupancy over winter — a substantial “opportunity cost” saving at a time when capacity was under such pressure. NHSE is also keen to maintain this gain to the system.

Breid O’Brien, who leads NHSX’s work on remote monitoring, said every trust is looking at how patients can be discharged earlier and that her team was “definitely seeing a growth in interest from people wanting to speak to us about technology enablement”.

How then can such tools be implemented and scaled up across the NHS?

The move towards remote monitoring

Last autumn, NHSX created — through the Crown Commercial Service — a framework of suppliers offering remote monitoring tools which all meet NHSX’s criteria. This framework has so far been used by three of England’s seven NHS regions (London, Midlands and South East) for buying software.

The unit has also funded software licences at a cost of £18m, which have enabled the NHS to use such tools, and it is currently providing support for 24 local projects, which have combined benefited more than 10,000 patients.

Ms Donnelly said: “We’ve worked with every region and backed their plans to scale remote monitoring.

“It can be for people in care homes, people with long-term condition management, or acute covid.”

She added: “There have been tremendous gains around remote consultations and I don’t want to take away from that, but where it gets really interesting is where digital becomes part of the pathway and we empower people with their own information to make their own choices.

“One example is home blood pressure monitoring, in which results are fed back to the clinicians and they then provide some medication changes and lifestyle advice to the patient. It keeps people well over a number of years, and we would love that sort of model to be part of mainstream medicine.”

But, according to others, it will take more than NHSX’s support to achieve an NHS-wide digital transformation.

Dag Larsson, who runs Doccla, which was the first company to agree a deal with a trust through the NHSX framework, said that while he applauded the “enormous progress” made – the implementation of remote monitoring in the NHS remained “fragmented” and that there was a “lack of widespread policy”, as well as few financial levers to incentivise the shift.

He pointed to USA, where both private insurers and the federal health insurance programme (Medicare) have started introducing codes for remote monitoring to automatically reimburse care providers treating patients in this way.

Adopting such best practice would be “the one thing that the NHS could probably do — at a central level — to facilitate widespread structural change and which would have the biggest impact,” he said.

Asked if a stronger policy shift was needed from the centre, Ms Donnelly said remote monitoring was “very firmly a top priority for us”.

She continued: “We’ve got more than 25 companies engaged in local work — that market is doing well. We are pleased with the pace of progress.”

Ms O’Brien added: “There are lots of products and innovators in the market. The pace of change with the innovators will be very significant, and the concept of remote monitoring is here to stay.”