Hospital at Home across the globe

Fepulea‘i Margie Apa is the head of a relatively new health organisation - Te Whatu Ora, or Health New Zealand. It was created just under two years ago having merged twenty District Health Boards and a further seven shared service agencies into one organisation that is responsible for health care across the whole country.?

Employing around 80,000 staff, as CEO of Te Whatu Ora, Margie Apa seeks to make more of technology, to provide healthcare closer to home for New Zealanders, and was keen to learn more about our experience in the NHS of scaling Virtual Wards. Thanks to an intro from Professor Mark Britnell we had a great Zoom call and were able to then meet up in person as she as wove in a visit to a leading Virtual Ward as part of a trip to London recently.?

Margie is one impressive health care leader, and for all her expertise and wisdom, tremendously down to earth. For more about her, see here -?

Introducing Margie Apa, the new Chief Executive of Te Whatu Ora Health New Zealand

I took her to visit the Virtual Ward at Chelsea and Westminster NHS Foundation Trust - a leading London teaching hospital group that operates out of two main sites, the one in Chelsea that we visited and the West Middlesex Hospital in Isleworth. The team at Chelsea and Westminster have put real thought into how their services are designed to maximise patient uptake and this included creating and recruiting to the role of On-boarding Nurse, which I was keen to share with Margie.?The scale of service is great, having cared for 5,500 patients since they first established tech-enabled home care during the pandemic.??

Chelsea & Westminster's website

The Trust is part of the North West London Integrated Care Board (ICB), covering eight boroughs of London, a population of around 2.5 million people. The ICB has strong and mature Virtual Ward provision, with a single Virtual Hospital Hub for the sector, based at St Charles Hospital in Ladbroke Grove, supporting all 12 acute hospitals, which awarded its contract for Virtual Ward technology partner last year to Doccla, one of my clients.?

Chief Medical Officer Dr Roger Chinn led the visit and explained the North West London patch to Margie, a densely populated and diverse region.?

The Virtual Wards support patients who would otherwise require care in a hospital bed in one of the 12 acute hospitals across the geography, run by four Trusts, all of which use the Hub. These are Imperial College Healthcare NHS Trust, across St Mary’s Hospital, Charing Cross and the Hammersmith, Chelsea and Westminster Hospital NHS Foundation Trust, across the Chelsea and West Middlesex sites, London North West University Health Care NHS Trust, covering Northwick Park, Ealing and Central Middlesex hospitals and the Hillingdon Hospitals NHS Foundation Trust.?

About NWL ICB

The visit?

Roger then took us through some valuable context about the Trust and its values, summarised by the acronym PROUD. The U stands for being unfailingly kind. He explained that it is often easy to be kind, but ChelWest staff pride themselves on being kind even when the pressure is on and they are up against it; as that is when it matters most. He added that there was a great deal to be proud of at the Trust including having the lowest mortality rate in the NHS, delivering strong performance and being a place staff want to work.?

He said, at ChelWest -

“We are proud of our outcomes, our people and our innovation”?

and that the Trust wants to continue to be at the vanguard of innovation in the NHS, seeing these tech-enabled care models at home as very much part of that. He concluded the Trust description by outlining that there were 1,000 physical inpatient beds across the two sites and specialist services include children’s surgery, burns, sexual health and HIV.??

Dr Grant McQueen PhD then took the reins and told us the story of how Virtual Wards had developed, initially with Covid@Home services, where the Trust looked after 1,000 people with Covid at home through remote monitoring, right up to the present day. It is an impressive story; they now have a large service, with a high degree of tech enablement, strong outcomes and happy patients and families. ?

He explained a focus on Cardiac, Respiratory and IBD services had come from significant clinical enthusiasm in those specialties and commended the work of Cardiologist Sadia Khan as being an early innovator whose drive had helped establish these services locally.?

“Our team at Chelsea and Westminster have developed a virtual ward programme that serves the needs of patients and staff. Our emerging outcome data and feedback support this and we are really excited to see how this continues to develop."

– Dr Sadia Khan?

The Clinical Team

We then heard from the clinical team - first from two of the three On-boarding Nurses. We heard how this role had been created in the past year and that the team members rotate, with three months spent working in the Virtual Hospital Hub, three months at West Middlesex hospital onboarding patients and three months at Chelsea. In this way, they know each of the sites well and have a deep understanding of the Hub and how remote monitoring is provided, to answer any questions that patients and their families may have.?

Patricia Gutierrez and Dianne De La Cruz explained how the On-boarding Nursing role works - they give patients their Doccla Box - with sim enabled tablet and medical devices - and patients do a practice run of taking their measurements in hospital to be confident of how to do it once at home. It was clear that the nurses really enjoy this way of working and found helping people return to the comfort of home much earlier in their hospital stay rewarding.?

The COPD team were up next, starting with Charmaine Bvute the Respiratory Specialist Nurse who explained how part of her role was case finding suitable patients and passing them to the onboarding nursing team at the right point in their care.?

Dr Liz Starren who is the Service Director for Respiratory Medicine and a Consultant Respiratory Physician herself, is a big fan of the service they have set up -

“I think we have been able to elevate care with this model. We are now able to consider a much wider range of patients in our specialist multidisciplinary reviews, including all those on the virtual ward, which means that more people living with COPD are getting expert input from the full MDT - that’s expert pharmacists, nurses, physios and doctors - into their care.”

She goes on to say that the impact is measurable

“We have seen the difference in outcomes too, with our evaluation demonstrating a reduction in readmissions in the cohort supported at home, of 6% compared to those receiving usual care.”?

She explained that SOPs are developed by clinical teams and harmonised across the ICB so it is the same standard of care across the virtual wards for the 12 acute hospitals.??

Liz closed by saying that achieving seamless, integrated care between hospital and community teams was a key aspect of their success and what enabled the delivery of very personalised care to patients, at home.?

We then heard from Natasha King, about the Virtual Ward for children known as PATCH and how in its first year it had prevented over 400 admissions to A&E of babies and children through jaundice monitoring and home IV therapy alone. The service looks after children with viral induced wheeze, bronchiolitis, gastroenteritis, croup, UTIs, jaundice and antibiotics that are IV or IM, providing care at home with their family.?

Looking at the feedback from patients cared for at one of the Chelsea and Westminster virtual wards, it really is glowing.

When asked

“Would you recommend the virtual ward to your family and friends?”

100% respondents on the COPD and Chest Pain at home service said “Yes”.?

On the question

“Was being looked after on the virtual ward better for you than being in hospital?”

the comments from those on the COPD home pathway included -

“Much better - particularly with my mobility and breathing difficulties managing my condition on line saves me energy and concerns in travel. I am very impressed with the Team’s care and follow up, thank you”?

One patient wrote -?

“Much better than hospital, they looked after me very well”

and another simply said?

“I feel more at ease at home.”??

For those on the Heart Failure at home service 100% patients rated the service as either much better (73%) or a bit better (27%) than being in hospital. The types of comments left by those ranking it “much better” include?

“It has enabled me to be with my family at a critical time and I am able to feel confident that I am still being looked after”?

and?

“Much better - comfort of your own home and not taking up a hospital bed”?

For those on the Chest Pain at home service, comments included -?

“Much better - able to sleep in own bed and much quieter than hospital. Still have the reassurance of being monitored”?

and?

“Much better - I’m more relaxed at home.”?

Overwhelmingly, when asked about call frequency - if patients found that calls from the remote monitoring team were too often or not enough, across all pathways over 90% replied “about right”.?

Similarly, in terms of ease of using the remote monitoring technology 88%-92% patients across all pathways found it either “very easy” or “easy”, 38 patients in total. Just five patients found it “a little difficult” with no patients at all reporting finding it “very difficult”. One comment was?

“Very easy - straightforward and well guided”.?

Another was?

“Easy - and I am not good technically!”?

About Doccla?

We heard very positive feedback from the visit team about finding Doccla a good partner, as well as their patients finding the system intuitive to use. Will Turner, Regional Delivery Lead for London at Doccla was delighted to hear this.

In London, residents in 22 of the London boroughs have access to a Doccla Virtual Ward, with Trusts selecting including Guys and St Thomas' NHS Foundation Trust and Barts Health NHS Trust as well as all of NW London.?In fact, Doccla is now the leading provider of virtual ward technology in the NHS, in most ICBs in England and has recently been awarded the whole country contract for Wales. We heard that Doccla sites have now monitored over 200,000 patient bed days between them and that the company has developed a strong implementation offer to clients where it offers support for all aspects of the deployment.?

For more on Doccla see here

Final reflections?

After a good discussion about the service and comparing notes between health care systems in the UK and New Zealand, we then had a chance to see more of the hospital with a tour including the Sky Garden accessible to patients in ITU.

Many thanks to Roger and the whole team we met, including a quick bump into Chair Matthew Swindells. It really was a fantastic visit and great to have a really detailed look into the service.?

Fepulea‘i Margie Apa’s reflections were:

“Thank you so much to the team at Chelsea and Westminster for hosting this visit, and to the wider team across North West London who have set up such an impressive home care service at scale, using technology to extend their reach to patients.?

My takeaways are that there are three aspects that have made this service so successful - the Hub model is critical for scale, the strong Clinical leadership in pathway design and the key role of Onboarding Nurses - and these would be aspects I would be keen to emulate in New Zealand.”?

Margie gave us this wonderful book to say thank you for the visit. Written by Maori Psychiatrist Dr Hinemoa Elder, it provides whakatauki or ancient Maori proverbs in a form that are helpful for understanding modern life, or as she puts it "nuggets of wisdom that provide life lessons [..] that stem from the great story-telling traditions of Maori culture".

It is particularly apt then, that a theme often returned to in the whakatauki is the intimate connection to the lands of our ancestors, or homeland.

The world over, there really seems to be "no place like home".

Roger Chinn Grant McQueen Elizabeth Starren Charmaine Bvute Sadia Khan Matthew Swindells Penny Dash NHS North West London ICB Caroline Clarke chris streather Luke Readman