INNOVATE 16 – Care closer article - Health Innovation Kent Surrey Sussex

Bringing care closer to home

By Des Holden | 21 July 2020

Des Holden, Clinical Director at KSS AHSN, looks at how COVID-19 has changed the healthcare landscape towards providing care closer to home.

It’s easy to throw descriptions around, but as the NHS comes out of the first wave of COVID-19 it will be grappling with greater change, uncertainty, learning, good will and scrutiny than perhaps at any time in memory.

It will be looking at re-establishing care for those who have been paused, building on changes that have been made, and thinking about autumn and winter, COVID-19, Flu and general seasonal demand.

Prior to COVID-19 the long term described moving care out of hospitals and into communities. Many of the changes made in March and April which created hospital bed and ventilator capacity can also be seen as moving care nearer to home, but closer to the spirit of the long term plan are some of the digital changes that have been made.

National focus, local delivery

Digital first in primary care has been introduced very rapidly, with huge numbers of people having remote consultation with their practice. Secondary care has also increased its remote out-patient use. These have been national programmes delivered locally.

In parallel with these changes innovation aimed at people with long term conditions, particularly for physical illness and supported care in the home, have been offered and taken up by some specialties and by some groups of patients.

ICS recovery boards are now grappling with how some of these leaps forward can be maintained, but also how deferred activity can be safely re-started.

The clearly articulated ‘single purpose’ of the early COVID-19 response has become much more complex and alliances made will come under strain.

There is worry about people who have come to harm through services being accessed less and ICSs are aware that while physical illness has been central stage, the already stretched services helping people living with mental and social health challenges have been even more seriously disrupted.

Impact on mental and social health

The first wave of COVID-19 infection may be ending but the wave of mental and social health need may be yet to come. Many commentators are saying this, but perhaps it will be worse if the wave doesn’t come and the morbidity remains below the radar, as perhaps it has for so long.

The NHS long term plan pledges funding and focus on prevention and on mental and social health. The All Party Parliamentary Group report on Longevity emphasised inequality of opportunity. Innovation generally and digital specifically have a role in moving care closer to home, but traditionally innovation has not closed the inequality gap.

Digital literacy, but not as we know it

The NHSE personalised care team worry about digital literacy and not just in the group we often talk about, the elderly, but in young people too. Charities working with children and young people report that the home may not give the privacy or safety needed to engage in virtual care.

Elderly people, whether cared for within their homes by family, or looked after in residential care, have also seen that services have not always been preserved or been able to meet their needs.

Providing better outcomes

Care closer to home has many advantages for citizens, and early research suggests the majority of people have preferred remote consultation with their GP. It has the potential to help reduce onward transmission of infectious disease if people can stay out of hospital, or a GP waiting room.

However, it is vital that it is inclusive and acceptable and gives at least as good, if not better, outcomes and opportunities to flourish than the models of care it replaces. It is vital it is a strong, thoughtful model allowing people to flourish, and not an out-of-sight, out-of-mind offering.

Case studies

e-wellbeing

A new e-wellbeing website launched during the COVID-19 pandemic is offering an innovative approach to providing mental health support direct to children and young people.

Created by YMCA Downslink and funded by Sussex Partnership NHS Foundation Trust, the website provides self-help information, handy toolkits, a directory of local services and COVID-19 advice.

Unlike other websites, e-wellbeing poses a series of questions to guide users to the appropriate content, and supports them to make the decision about whether they may need help from a professional service.

Dr Rick Fraser, Chief Medical Officer at Sussex Partnership NHS Foundation Trust, said that COVID-19 has led to unprecedented changes in all aspects of life, including access to sources of support and communication.

“For young people this can lead to feeling isolated, frightened and stressed which can lead to mental ill health problems,” he said.

“What I like about the digital platform for young people is that it provides a virtual place for young people to access good quality information and support, and link with others in a way that is safe and managed.

“This is an innovation that works in COVID-19 times but should also work well in times beyond. I look forward to seeing how this develops.”

Cat Pritchard, Wellbeing and Therapeutic Services Manager and Digital Lead, YMCA DownsLink Group, said that the site is crucially different to other ‘wellbeing’ websites.

“Mental health systems and pathways are often complicated and many young people, parents and carers, and professionals remark that they are difficult to navigate. This website works to simplify the process of accessing the right help, in the right place, at the right time,” she explained.

“Local services have worked incredibly hard to adapt their offers so they can continue to meet the needs of young people remotely. Now, more than ever, it’s so important that young people know there is support available to them and that there are lots of different ways they can help themselves and their peers.”

Digital solutions

The vast majority of GP practices in the South East now have the ability to have video consultations with patients, after a programme to introduce the technology was accelerated in response to COVID-19.

As part of the Long Term Plan for the NHS, NHS England and NHS Improvement’s Digital First programme was established to make use of technology to provide all patients with access to “digital first primary care”.

The rollout of video consultation in response to coronavirus has allowed patients to easily access advice, support and treatment they need using digital and online tools. This means patients can now book and cancel appointments, have a consultation with a healthcare professional, receive a referral and obtain a prescription.

Melissa Ream, Artificial Intelligence Adviser for Kent Surrey Sussex Academic Health Science Network and National AHSN, said: “We knew we had to respond to coronavirus rapidly, and very quickly had an understanding of the size of the challenge with how many GP Practices needed support with infrastructure, training, resources and workforce needs, and we were able to address any barriers promptly.

“The number of video appointments has risen each month since the social distancing guidelines across the South East came into effect.

“Bringing many different parts of the NHS together across the region, the NHS has delivered an objective planned for 2021 in just a couple of months.”

Video consultations are just a part of the digital offer available to patients. Patients can also use online consultations to ask questions, report symptoms and upload photos securely online and their GP practice can respond by phone or email or, in some cases, arrange a video consultation if the GP feels it is needed.

Verified baseline data from the beginning of April showed video consultations were available in 86% of GP practices in the South East, while 58% offered online consultations. As of the end of June, 99% had video consultation capability and 91% could offer online consultations.

KSS AHSN has also been working with partners the Design and Learning Centre, Medway Innovation Hub and Kent Integrated Care Alliance to support care homes on their digital journey. This work recognises the importance of care homes within the health and care system and the response to COVID-19, and aims to:

Improve the quality and increase the number of video of consultations between primary care and care homes.
Improve the digital skills of staff working at all levels in care homes.
Increase the number of care homes in Kent using NHSmail.

The partners have created a Connecting People to Improve Care guide, which outlines key ways that care homes can access and use technology to improve communications between residents and health and social care professionals.

Additional work is taking place around Improving Digital Tools in Care Homes: and builds on the KSS AHSN well connected care homes programme which achieved £756,144 in savings with eight care homes, by testing new digital health intervention that aims to enhance the appropriateness of healthcare received by care home residents and the skills of care home staff.

ECG monitoring

Following feedback from stakeholders over the challenges in providing remote ECG monitoring during COVID-19, KSS AHSN’s cardiovascular disease team has collaborated on a new approach that allows patients to be tested in their own home.

Traditionally ECG monitoring devices have been fitted to symptomatic patients when attending acute and community cardiology clinics, but due to COVID-19 reducing direct contact and reducing risk of infection is critical.

With reduced demand on routine NHS services during the peak of the pandemic and an anticipated surge post COVID-19, there is an increased risk of Atrial Fibrillation(AF)-related strokes and sudden death in those with undiagnosed arrhythmias. There are also issues around adding pressure to the system as it attempts to deal with the backlog in the months ahead.

The KSS AHSN proposal offers a solution to meet the need for ECG monitoring in the recovery phase of COVID-19 in any UK region. It has worked with three independent companies that deliver a range of courier service, safe, sanitised, 24hr to 14 days Holter ECG monitoring services and diagnostic quality ECG devices with fast results, reporting and e-consult options.

The diagnostic reports are delivered directly to the commissioning healthcare professional, allowing the patient to receive fast results and an individualised treatment plan from their GP or Cardiologist.

Data Dashboards

Working in collaboration with KSS AHSN, the three companies will submit monthly non-identifiable patient level data on all referrals they action through this project for all participating sites and run through a centralised web-based dashboard monthly.

A range of metrics will be captured including time to diagnosis and yield, with a quarterly report produced on high level impact on outcomes and cost modelling. The dashboard will be available to view monthly at AHSN, STP, Acute Trust / Community Service site levels.

Evaluation

KSS AHSN will produce a six-month evaluation report for each participating ICS, using quantitative data from the dashboards and qualitative data from patient and clinicians experience. The evaluation report will demonstrate if the demand for ECG services has been met and if the services provided a non-inferior service to the standard of care prior to COVID-19.

Jen Bayly, Cardiovascular Programme Lead at KSS AHSN, said that the work meets the challenge set out by Simon Stevens for the NHS to restore the provision of urgent clinical services around arrhythmias, heart attacks and stroke.

“The centralised data dashboard and evaluation report delivered at six months by KSS AHSN will be valuable to the commissioners and clinicians as they can then take a view on their longer-term plan on commissioning and delivering ECG monitoring services,” she said.

“We know that COVID-19 has created an immediate need to find new ways of working that will ensure patients have access to ECG monitoring, delivered with minimal direct contact and in a safe way. We believe this proposal will support the NHS recovery phase and the clinicians to meet the demand for monitoring patients at high risk of having a stroke, therefore offering optimal patient care.”

The ECG solutions on offer

▒ Technomed – is offering a fixed £99 incl price until April 1 2021 for each courier service ECG Holter test which includes 24hr, 48hr, 72hr and 7day sanitised monitors. Telephone support to patient to talk them through the fitting and turning it on. The ECG report will be sent to the GP or Cardiologist within 24hrs via nhs.net. If the GP is not confident with understanding the report and is looking for next step recommendations. An optional e-consultation with a cardiologist is available to the GP and included in the £99 price. (CQC registered)

▒ iRhythm – is offering to courier the Zio patch at a reduced price of £199 incl, until April 1 2021 (normal price £295). The Zio patch has a key benefit of a 14-day recording. No risk of cross infection as a new device sent to each patient, easy to fit adhesive patch with written, video and telephone support for patient self-fitting. Analysis and report competed within 1-4 days and posted on iRhythms web-based platform, as a PDF. (CQC registered)

▒ AliveCor – is offering discounted prices on lead 1 devices at £90 and 6 lead for £148 (pricing table in link). They are offering KardiaPro platform for free for six months to support the proposal of loaning or giving the patients devices to use at home. The clinician would give the patient a unique code to add in their Kardia app when they set-up the device, then every trace the patient takes is automatically captured on the KardiaPro platform and assigned to the clinician who authorised giving the device.

Des Holden

Des is Medical Director of KSS AHSN and Chief of Innovation at SASH. In addition to these two roles he is a non- executive director of the Southeast Health Technology Alliance (SEHTA).

Des Holden, Medical Director, KSS AHSN, des.holden@healthinnovation-kss.com