At AGFA HealthCare, we are transforming the delivery of care – supporting healthcare professionals across the globe with secure, effective, and sustainable imaging data management. Our focus on creating an exceptional experience through the power of technology has profiled us as an Empowerer in industry; we have reached the podium where we can radiate a life in flow to the market, and importantly, to our valued customers.

New for 2024, we are delighted to show true leverage of flow within our customer insights. Hosted by Chief Clinical Information Officer for AGFA HealthCare, Dr Nick Spencer, we have extracted some key insights from Enterprise Imaging users, illustrating how they find their life in flow in a series of videocasts.

In our first release, let us introduce you to Dr Matteo Fronza.

Dr Fronza is a Consultant Radiologist, specialising in Cardiovascular and Thoracic Imaging, based in the UK. Working for the NHS, the world’s largest single healthcare system, Dr Fronza is regular user of the Enterprise Imaging Platform. As a radiology professional for an enterprising healthcare provider, he is privy to seeing world-class technologies spanning across an entire hospital eco-system.

Speaking to Dr Spencer, Matteo gives his view on the day-to-day working practices of a Radiologist – a routine user of the AGFA HealthCare Enterprise Imaging Platform who, whilst working in the UK’s NHS sector, finds his life in flow.

See Dr Fronza’s My life in flow videocast below, find out more about the My life in flow campaign here, and explore our Enterprise Imaging Platform.

At HTN: Digital ICS, we were joined by Dr Shanker Vijayadeva (GP and clinical lead for NHS England – London region) and Dr Ishani Patel (GP and clinical co-founder of Lantum) for a discussion on building digital access hubs to increase patient access across primary care.

How do digital access hubs support GP practices?

Ishani: A few years ago, back in 2018, there were a couple of primary care networks (PCNs) in North West London who wanted to drive online consultations, but we recognised that not every practice across the two PCNs had the workforce to power it. We built what was called an e-hub at the time, but is now known as a digital access hub, and we developed a workforce team that was multi-professional, that would triage and process online consultations for the practices. That really prepared the PCNs for the arrival of the pandemic, when access needs and demand shot through the roof. That hasn’t died down, it’s forever increasing.

It provided a really good infrastructure for the practices to maintain and improve access, because the team had already been put together and nurtured, and quality standards had already been set. Since then, in North West London, we’ve seen seven or eight digital access hubs follow a similar model. They can help provide some stability and resilience for PCNs, especially when you’ve got surges and falls in workforce and things like winter pressures.

Shanker: I think a key point is the fact that there are lots of different angles we can take with digital access hubs; there are different dimensions, different approaches. Access is a key theme, and one of the biggest goals, but it’s not the only area that these hubs can support.

GP access recovery plan: how can digital access hubs support the goals?

Ishani: The three things that really stood struck me were tackling that 8am rush, the real drive towards working more collaboratively with our community pharmacies, and the plans for the NHS App.

For the 8am rush, from a digital access perspective, PCNs wanting to start their own hub could set up and use their additional roles to help manage that first two-to-three hour surge in demand at practice level. They could encourage patients with appropriate levels of digital literacy to submit an online consultation that can be rapidly triaged, which means a suitable action can then be taken according to the needs of the patient.

On the push for collaboration with community pharmacies, online consultations actually do fit into that very well. It obviously requires pathway working and potentially some training for the community pharmacy colleagues.

Finally, looking at all the fun stuff that is coming with the NHS App, I think there’s a key area of work in terms of how we can optimise the utilisation of the app to improve patient messaging and improve responsiveness to patients.

Shanker: I would echo what Ishani has said, but I’d add that if we look at the vision of the plan, there’s also a focus on making sure that patients get what they need on their first call. To achieve that, we need to route to the right team member, which is where you get the hub working – you can bring all of those different roles into the hub to try and deliver that.

There’s also the two week timeframe that we are trying to meet in terms of general practice. To deliver those timeframes, we need more at-scale working, and I think the hubs can bring real benefit there.

There’s the human element with regards to wellbeing as well; the new GP contract emphasises the importance of looking after our staff. If we are all really struggling with the pressures of our traditional ways of working, sometimes the access hubs could improve our staff wellbeing. We can implement ways to cope with the pressure better as a team. There could be interesting learnings around improvements in working relationships, from staff perspective, through digital access hubs.

What is required from a workforce perspective to make sure digital access hubs are a success?

Ishani: Fundamentally, whether it’s administrators, GP assistants, clinical pharmacists, paramedics, first contact physios, GPs – whoever is in the digital access hub workforce ecosystem – pathways need to be really clear. That is key in order to minimise harm and reduce significant events, and brings more clarity around patient expectations.

Supervision and support play an important role; where you’ve got co-location of a team, you need to have someone in place for staff to call if they are not sure. Online consultations are a good way in, but there are a lot of nuances. You’ve got access to the patient record so you know whether someone is a high priority, whether there are complexities, whether they are a carer, for example, and all of these factors affect the pathway that a clinician may choose. But where there is doubt, having someone there in real-time, on the phone or in person, is so helpful. That creates group learning for the team and gives them some confidence as well. A lot of clinicians do work in silo and feeling that you have someone to rely on for support is really important for setting up a workforce team for success in access hubs.

Shanker: I think we need to bring more understanding and flexibility into the workforce. I’m a great believer that whenever you put a change in, it always makes things worse at the beginning. You could plan for 10 years but as soon as you go live, a question will arise. There will be bumps with your digital access hubs – your IT might go down, for example. We have got to work together, learn together and share learning to improve.

When we present our hubs, we always present information on how well it’s doing – we’ve got to be open about what doesn’t go so well, and re-iterate that those bumps are normal. The important thing is that we are open, we learn, we’re flexible, and we work as a team. Then we’ll get there.

Learnings and challenges so far

Ishani: The learnings that really stick out are around practice expectations and their understanding of what the service can do for them, and understanding the individual cultures within each practice. I agree in standardising some things and having a uniform way of approaching certain tasks, but some practices have internal protocols that are quite different to the modelling you want to use for your digital access hub. Speaking to each of your membership practices and understanding what their expectations are is really important to minimise those bumps that Shanker mentioned. That then helps you understand patient expectations, because of what they experience in their own practice. Collecting that learning will then reduce the number of complaints and improve patient confidence.

It’s not something you can know from the beginning – you will learn by gathering feedback from practices and patients. It’s about having an open forum for practices about what’s going well, what they like, what patients like, and the flip side of that – what can we do differently, how can we try to accommodate as much of the asks from practices as possible? It’s not easy, especially with the variety in PCNs, you have to try and find some middle ground.

Shanker: Buy-in can be a challenge. The fact that primary care can be so tailored is both a plus and a weakness. There’s a journey to undertake to ensure that the team believes in the vision of the digital access hub. Then there’s work around communicating what the hub is doing, and everyone can perceive that differently – a patient might feel that they’re just being dumped onto the hub rather than seeing it as a positive, for example, rather than thinking that they are getting the right care in the right manner.

Lots of the bumps can happen around IT, which can be for a variety of reasons. It could be that staff haven’t been trained well enough on the different features of the hub, or the host IT platforms could lack functionality for what you need to do. Or you might have the functionality, but lack the capacity, or the financial resources to buy equipment.

The isolated nature can be a challenge, too – how do you get a new team bonded with remote working, how do you keep them engaged?

Practical steps for ICSs to make digital access hubs a success

Ishani: It comes back to targets; whilst an ICB does sit across commissioning and providing, the ICB is also accountable to NHS England.

ICBs can support digital access hubs with the technology, with the hardware, with providing contacts with other digital-first leads in other parts of the country to share learnings.

Lantum is working with ICBs where the ICB is partnering with us to provide the staff banks, so that’s a cost that a PCN doesn’t have to worry about. The ICB can set up a digital staff bank and then give access to its membership PCNs, and they can use that to help staff their digital access hub. Allowing them access to the full workforce pool across an ICB could be really helpful, especially for people who are hybrid working.

Shanker: Flexibility is key again. When we created our hub, we almost had an open book approach – from the start, how can we be open about the challenges, the finances, the flexibility of the model?

We’ve touched on workforce recruitment; that’s an issue in the NHS and it’s no different in the hubs. You might have a particular role you wanted for the hub, but the staff don’t want to engage or you can’t recruit them. You might have to change the model.

There’s no correct approach to how you start off or how you evolve, but I think because of these challenges, ICBs shouldn’t be rigid about it. It could just mean that the hub doesn’t evolve into what it needs to become.

Looking two years into the future, what would good look like?

Ishani: I would love digital access hubs to use technology platforms that also support the long-term conditions piece more. Historically, access hubs have been more for on-the-day demand; then enhanced access came out and there was a bit of a pivot to include more of that QOF (Quality and Outcomes Framework) element. It would be great to use access hubs as a way to bolt on things like proactive hypertension modelling, heart failure, COPD. It wouldn’t just be about digital consultations, it would be about using a number of digital modalities to help support the local population.

Shanker: When we think about access hubs, we tend to place a lot of the focus on their role in same-day access and routing patients away from urgent care centres. I think we’ve got that emphasis slightly wrong. The capacity is exactly the same as in a practice, the staff dealing with long-term conditions or chronic diseases are the same staff dealing with those same-day problems.

I think organically, primary care is facing an ever-increasing workload. If an access hub evolved naturally to meet the needs of primary care and becomes more sustainable because people see the value of it, it will benefit whatever form of access you want to measure. If we manage a diabetic patient more efficiently in terms of how they access their annual review, that could free up appointments for patients with a same-day need. Also, that patient who is potentially facing a lifetime of the same annual challenge around their diabetic review; they get a huge benefit from an improved access process.

How an ICS ensure that patients know about these resources?

Shanker: It’s all about communication and we’re not always good at that within the NHS.

Wouldn’t a sign of a good access hub mean that the patient experience is such that they don’t even necessarily realise that they’re in an access hub? To me, ‘good’ would be if your processes were built so well and the communication was so good that the patient, entering the hub, doesn’t even realise. There’s no need for queries because the communication would be in real-time about what is happening to them.

At top level, you obviously need to communicate on things like practice websites, you could do mailshots to the patients to explain things, but I think that can still land as jargon until you actually experience it. Until you use it, you don’t really understand it. How does a patient interpret what you mean by ‘hub’? There’s a risk of miscommunication, so I think the focus should land on getting the communication right whilst they are actually having the experience.

Ishani: I would say, historically patient feedback wasn’t a big thing for the early versions of the access hubs, which we would probably think is a no-brainer. As different contracts have come in, I think we need to be surveying our patients a lot more to understand how they experienced the hub. The danger of that, as Shanker was saying, is that they may not have realised that they were being looked after by an extended member of the practice, so from an information governance perspective that is really important. The patients need to understand where their data is going, and the communication can then start once the online consultation has been acknowledged.

Many thanks to them both for taking the time to join us.

Babar Shafiq, national business development manager at Radar Healthcare, joined us at HTN Digital ICS to explore how Integrated Care Systems (ICSs) can harness machine learning and AI to drive governance automation and integrate health and social care.

During his presentation, Babar demonstrated Radar Healthcare, a leading solution of risk, quality, and compliance software, and how it can be used throughout an ICS to improve governance oversight, patient safety, and resident care quality. Having faced similar challenges as a commissioner for local authorities, CCGs, and NHSE, at regional and national levels, Babar could not only empathise but also highlight the significant benefits of integrating health and social care services, and what that might look like.

The drivers for change 

Babar evidenced a key challenge faced by commissioners by stating, “HIV is an example. Different commissioners at every level, each commissioning different parts of the pathway for the same group of patients, and historically, in my experience, not always talking to one another. Imagine all those key stakeholders sitting at the same table, working as part of one system and being able to commission the entire pathway together, with all their experience and knowledge.”

Babar then presented the findings of Radar Healthcare’s commissioned research on incident reporting in secondary care with 100 ward nurses, which identified some areas for improvement and key considerations.

According to the research:

• 92% of nurses log or report incidents immediately
• 64% want to improve their ward’s current reporting system
• 83% want more incident report training
• 40% believe their reports do not lead to better patient outcomes

The findings emphasised the need to support better health outcomes, boost staff engagement in incident reporting, and identify ways that suppliers might help this culture shift.

Click here to get your free copy of the ‘Incident reporting in secondary care,’ whitepaper.

Analytics dashboard at the ICS and acute trust levels 

“Radar Healthcare provides one system for all your key business functions instead of having to use multiple systems such as Excel spreadsheets, Word documents, paper records, and Teams meetings,” Babar explained. “The system automates the analysis while making the processes themselves simple and transparent, with clear lines of accountability.”

The session then moved to the accessibility of Radar Healthcare’s system, analysing data trends across multiple locations. “The data will be analysed and split by locality; it can even be split by staff member. At a regional level, the degree of oversight that you have concerning your various locations means you can observe performance and risk without having to make phone calls or send emails. All the crucial information you need is on your screen and at the touch of a button,” Babar added.

“The level of data granularity that you can achieve for each of your regions and site locations is an invaluable resource to have at your disposal.”

Babar showcased some of the analytic dashboard features in Radar Healthcare, including the Pulse, which detects any irregularities in your data set, or any potential unwarranted variation. When a certain threshold is breached, as the lead, you can receive an SMS text message or an email informing you that the threshold has been breached and you can begin investigating. “In some cases, these anomalies may not be detected by the human eye, so it’s reassuring to know that the system is constantly analysing the data and trying to identify these trends independently, and it’s not reliant on you to take the time to gather data and perform separate analysis in order to detect these types of trends.”

Babar then shared a testimonial from Somerset NHS Foundation Trust, which encapsulated his previous points.

“The analytical capabilities that Radar Healthcare offers really excites us. Detailed data that makes a big difference in terms of sharing information and understanding trends,” said Governance Systems Manager at Somerset NHS Foundation Trust.

“Sharing learning is the key thing here,” Babar noted, “and the impact they can have in terms of motivating staff to use the technology, as it provides real value.”

Babar then moved on to investigate the insights that are driving greater clinical outcomes and efficiencies. He demonstrated an acute trust dashboard followed by a performance dashboard, both of which are powered by local data-driven evidence that shows unwarranted variation. He continues, “This could really help to support the identification and prioritisation of transformation projects.”

Software in action 

Babar’s demonstration began with a user’s view of the dashboard, which displayed their entire caseload on a single screen, and the tasks they had been assigned, such as action plans, audits, documents, and events, to name a few, with corresponding deadline dates and progress and priority levels determined to each task.

He then showed a case of sepsis being reported on the Incident Management module at the service level and the path to how this is represented across an acute trust. Babar showed how, in less than 10 minutes, a sepsis case could be reported, with the relevant line manager notified and a workflow being created, outlining the next logical steps in terms of the investigation, and a relevant timeline for completion. This prompted the line manager to create an Action Plan which triggered an exploration and linking of other connected or unrelated cases of sepsis across the organisation.

The next step was to ensure that the most recent guidance or policy on sepsis management was available in the Documents library, identifying which version it was and viewing the timeline for when and by whom it will be reviewed. As a precaution, he linked the most recent guideline document using the Notices function and sent it to all employees to promote awareness of sepsis management. Finally, Babar, moved on to the Audit capability, scheduling a periodic audit and updating the Risk Register on how the trust was performing against the sepsis metrics.

This visualisation of an organisation’s entire multi-level risks, including corporate, departmental, and clinical was a powerful display of how risks can be monitored and mitigated through digital transformation. Babar noted the system’s intuitive nature, adding that when an incident is reported, “it knows there needs to be some consequential actions from that event.” This is beneficial because it no longer relies on staff to determine what the next steps are. The system makes it very clear and mandates the next steps. At this point, you could attach documents, create an action plan, link to another event or assign the case to someone else.”

Final thoughts

“It’s a way of demonstrating that if all the providers and stakeholders reported into one system – the level of oversight that you have is unmatched. You could go into ICS meetings with evidence and data to begin investigating with certainty, with your ICS partners, where the issues are, what the underlying causes are, and have those crucial discussions. The benefits that arise from being that one commissioner of a pathway and being able to see that pathway in its entirety with all the relevant stakeholders – it epitomises the collaboration we have all been talking about for some time.”

If you would like to learn more about Radar Healthcare, and how they can support with governance oversight of your ICS, book a free demo with one of their experts today at www.radarhealthcare.com

At HTN: Digital ICS, we hosted a discussion with Adrian Byrne, chief information officer of University Hospitals Southampton NHS Foundation Trust (UHSFT), on the integration challenges for an integrated care system.

The discussion focused on the successes and challenges experienced by the UHSFT in rolling out their digital strategy, covering areas including interoperability, coordination, innovation and environmental benefits.

Adrian began by explaining how the pandemic had forced rapid acceleration in areas which would not normally have been expected to see much progress for quite some time, such as in remote working for thousands of staff, remote multidisciplinary meetings and virtual outpatient consultations. He then highlighted the UHSFT digital strategy, which focuses on measures including patient safety and outcomes, innovation, the changing NHS landscape, efficiency and patient expectations.

“We definitely saw technology make a positive impact during that change,” Adrian said, “and it’s fair to say that we really couldn’t have operated at all as a unit in the way we did without the rapid deployment and change that was adopted.”

UHS digital Strategy and performance

Adrian spoke of the rollout of the UHS digital strategy and his insights into the challenges it had faced.

Another challenge discussed was the introduction of Capital Departmental Expenditure Limits (CDEL), and the impact that this had had on the ability for budget planning and project management. In particular, Adrian referred to the issues surrounding the loss of ability to carry unspent capital forward into the following year, noting the limits that this placed on projects and the ongoing injections of capital that had previously been relied upon to keep things ticking over.

Noting that it can feel as though there are often averse incentives in play, Adrian stated that “last year, for example, we outperformed compared to 2019, yet any extra income for that has not materialised.”

In addition, challenges related to the pressures of the pandemic and rapid rollout meant that often things were done in a sub-optimal way.

“There’s quite a bit of unpicking that now needs to be done, I think, and whether we have the time to do that will be an interesting challenge as people go forward and start to uncover things that were done during the pandemic.”

The danger, he said, is the temptation to slide into a not-fit-for-purpose way of working as a result of having to adapt so quickly to new ways of working during COVID-19. He noted that the implications of this could potentially be worsened by the need to work in the context of ‘less money, more work’.

“Maybe it’s about time we do reset our strategy drivers and think about what we can achieve,” he said, adding: “We’ve got the technology now that can help the service, and provided we can prove our case we can get the investment.”

Adrian also talked about the context in which the UHSFT’s digital strategy had emerged, stressing the impact of constraints such as having to work with technology that wasn’t quite ready, and working in some instances with legacy technology.

UHSFT has been relatively lucky, he said, as the trust had already begun to work toward integration and digitisation in some respects. He noed the launch of the Hospital Information Clinical Support System (HICSS) in 1998-2000; the HICSS Electronic Discharge Summary and eDocs in 2007; doctor’s work listing and electronic prescribing in 2011; and UHS Lifelines electronic patient record (EPR) system in 2012.

Adrian stated that transferring things over to digital working and EPR has not been as easy as simply rolling out a programme, but that it has been a part of an ongoing process whereby the trust has been building and buying functions over a period of many years. This work is still going on, and the rolling our of inpatient noting and other activities such as outpatient clinic letters, is something that Adrian feels particularly positive about. A KLAS study of approximately 2,500 respondents showed that clinicians at UHSFT spend less time outside of normal shift hours catching up on documentation compared with their peers.

Interoperability and innovation

This was an area that Adrian identified as requiring more effort, noting the need overall to do much better.

“When you look at what needs to be done, organisations need to get together to work out how to exchange documentation information,” he said.

Adrian spoke about the concept of semantic interoperability, noting that just because something is sent across to a different provider, that doesn’t mean that they understand it. In this way, it is important to bear in mind that the ways that information is exchanged within, and outside of, an organisation can be very different.

When discussing innovation at UHSFT, Adrian reflected on the challenges of working with a tertiary cohort of 3.9 million. He expressed that the trust is often waiting for the technology to emerge that can support the work it is doing and the local community it is part of.

“What we’re really hoping is that we can hang on until that emerges, until we can buy something that fits in with our local health community and the other people around us,” he said, “and do that integration and interoperability better.”

An area of innovation and success, thus far, can be found in UHSFT’s work in systems integration.

Adrian shared: “Sometimes people think that we’re a ‘best of breed’ site and that we’ve built hundreds of systems, but actually there’s quite a lot of what we do that’s in a single Oracle database.”

Whereas many organisations still have many small systems with their own, and in some cases, not interfaced data. UHSFT has managed to build an integrated environment through a mix of strategic platforms. The work in this regard is not done, however, as Adrian notes that there are still many different systems to be integrated. This will, he said, depend on creating the right investment and opportunity for integration, which is something that the trust is already working towards.

Something for other trusts to be aware of, Adrian stated, is that important programmes should be aligned in terms of resource allocation and priorities.

“One of the things I’m seeing is a tendency to put digital into the IT box,” he said, noting that people tend to think of it in the sense of “we’re just providing the rails, somebody else will provide the trains.”

Adrian’s take is that “digital transformation needs to be hooked up very closely with the whole concept of improvement, and we need to work hard with the prioritisation of the work that’s going on there.”

Across the ICS

As the discussion moved on to talk about the challenges in rollout across integrated care systems, Adrian reflected on some of the difficulties that may arise during this process, especially in areas like primary care, which may be steeped in existing systems already. In another example, he looked to community mental health activities; can it really be possible to converge an entire system across a whole ICS? As work continues to try and identify areas in which integration can, and should, occur, other factors are also likely to emerge.

“What happens when the private sector moves in to this is an interesting question, I think,” Adrian noted.

“We need to work on putting the patient at the centre, at the point of care. We need to do local integration between hospitals and regional and tertiary services. As you build out from that core, you tend to get into more ‘batch transfer’ type information, in terms of the type of information that flows between a patient handover and such.”

He commented that it will be interesting to see how rollout across ICSs will be possible in relation to the work of cancer networks, cardiac networks, and so on,. An example is UHSFT’s imaging network, which spans three counties and two to three ICSs, and presents an element of exchange which isn’t picked up solely within the integration process of a single ICS. He acknowledged that there are challenges to consider, such as how to deal with these types of networks and exchanges, as well as how to factor this into maintaining continuity and patient records.

Virtual wards

Adrian reflected on some of the groundwork put in place over the course of the pandemic, citing the development of virtual wards and virtual patient consultations. A challenge in this sphere, however, is having the teams in place to run them.

“Virtual environments can’t just translate to the ward team looking after 30 or 40 more patients,” he said.

Adrian discussed the success of UHSFT’s My Medical Record online portal, which provides patients with results and the opportunity to message with their clinical team, without having to visit the hospital. Efforts to measure the impact of this on the trust’s environmental output, through reduced travel, remain ongoing.

My Medical Record has been rolled out within a variety of hospital services, focusing on developing digital relationships with patients and providing benefits for clinicians in terms of information availability. Clinical teams can, for example, view information on patients, check compliance and see results. In heart failure patients, the success has been in enabling blood pressure readings to be remotely recorded and then viewed by Cardiologists.

Altogether, Adrian said, this is building toward a much more integrated patient health record. He called it “another thing where digital is providing some key enablers for real strategic change.”

ICS-wide maternity service

Adrian considered the possibility of convergence across-ICS in certain areas, citing the example of a common digital maternity system across four maternity units in the Hampshire and Isle of Wight region.

Launching in 2020/21, the system has run for three years, using the SWASH management service – an equal partners group – to enable work across multiple organisations. Although this was, as recognised by Adrian, an excellent opportunity for collaboration; it was difficult to keep everyone on board. Some of these challenges were mitigated by the use of the CleverMed self-referral portal to provide single point of access and BadgerNet Maternity for clinical records. However, Adrian feels that this does not completely mitigate the challenging nature of this type of convergence.

“When you start to channel that kind of interoperability across a single system, across an ICS, you might lose some of the close links that you have between systems that you had before within the hospital, and we’ve certainly found that. We had much more integrated reporting with things like order communications within our hospital than we do now, in fact.”

Closing thoughts and future directions

On one of his presentation’s closing slides, Adrian presented the following quote: “UHS Digital has proven that it can develop and implement successful digital solutions at scale with an innovative modular, yet integrated approach to clinical systems.”

Adrian added: “We need to work more across the community in future, but nonetheless, we’re progressing toward a high level of digital maturity using the existing methodologies for now.”

Speaking of how the digital systems at UHSFT were one of the main attractions for staff, he shared a final consideration: “if you don’t have good digital systems, how can you hope to attract the best and brightest minds to come and work for you?”

Many thanks to Adrian for taking the time to join us.

At HTN: AI and Data, we were joined by members of the NHS England Blueprinting Team for a discussion on the blueprinting programme, the NHS AI Lab Skunkworks programme, and a project from Gloucestershire Hospitals NHS Trust in partner with PolyGeist.

Joining us were Andrew Freeman (programme manager of the blueprinting programme at NHS England); Oludare Akinlolu (former data and technology lead at the NHS AI Lab,  NHS Transformation Directorate); Sarah Hammond (deputy CIO at Gloucestershire Hospitals NHS Foundation Trust); and Bradley Pearce, (director and co-founder of Polygeist).

The blueprinting programme

Andrew began by defining a blueprint is the step-by-step process that a trust or organisation goes through when deploying a particular product, system or process. It’s not the same for everyone, he pointed out; every organisation is different. “We like to think is that blueprints can offer a degree of support from a minimal level.”

As of last month, there were 3,346 users registered on the platform. There are different levels of blueprints available, including full blueprints outlining the full detail of the project supported by relevant artefacts; blueprints on a page (BPOAP) which provide key insights, benefits and an outline of the main activities and project journeys, and technical annexes, which provide a more detailed guide in implementing technical solutions and roll-out. At present the programme has published 204 blueprints and just under 3,000 artefacts which range from issue logs to business cases to project plans.

“The ultimate aim here is for us to start to work across ICSs and across the wider health and care system,” Andrew scared. “We are working with social care, so there will be new social care blueprints emerging soon and we have already got several primary care blueprints because that’s another new area in which we’re expanding.”

NHS AI Lab programmes

Joining the conversation next was Oludare Akinlolu. Oludare shared the work taking place at the NHS AI Lab.

Starting with the current structure of the lab, Oludare explained how the NHS AI Lab is divided into five functional programmes; AI imaging, the AI in Health and Care Award, AI regulation, AI ethics, and the AI Lab Skunkworks.

AI imaging looks after anything to do with imaging, Oludare said, including supporting the development of imaging tech. The AI in Health and Care Award tests and evaluates some of the most promising AI technologies  s. AI regulation convenes the key regulators to look at how we provide develop a robust and streamlined regulatory regime for AI products. , whilst AI ethics looks after the “ethical part of the life cycle of the solution, to make sure it is for good, useful purposes, and that it is ethical in terms of adoption across the whole system.”

Finally, looking at the AI Lab Skunkworks team, Oludare explained that his team helped organisations to test innovative ideas to see if they can scale or not, providing a research and development functionality for trusts to test functions before deciding their approach.

AI Lab Skunkworks 

The AI Skunkworks programme ran from 2020 to 2023 with a vision of  “creating an environment for organisations in health and care to test the possibilities of AI capabilities through practical experience, to potentially challenge what best meets their needs or fits their purpose.

The AI Skunkworks team  achieved this vision through three practical channels: experimentation, capability, and fostering community. They invited organisations to pitch potential problems and select the ones deemed most suitable for AI solutions to solve; provide scientific capability and outsource resources to equip organisations to explore a problem, and foster a community of AI practitioners by sharing knowledge. “Every project we have done in terms of proof of concept, we have always published our code as an open source for anyone and everyone,” Oludare shared.

Oludare then explained that AI falls into two broad families: narrow AI and general AI.

“Narrow AI is what we focus on in our Skunkworks team,” he said. “It is a goal-oriented system that performs one single task and does it extremely well – for example, facial recognition.” The AI solutions currently being developed by technologies companies and within the NHS for health and care are all narrow AI.

General AI, meanwhile, is where the system is human-like in terms of intelligence, can perform simple tasks simultaneously and is more aware of its own decisions, the consequences and the impacts on its environment. This type of AI currently doesn’t exist.

On the common issues around AI, Oludare said: “There are a lot of concerns around job security, and a lot of hype around AI replacing people or taking over the job market. But it’s meant to augment people, not to replace them.”

Other concerns include trust in AI’s decision-making capabilities. “We are engaging with patients and clinicians around this,” Oludare noted. “There is a clinical power with AI, but will clinicians have the confidence and trust to use it? Then from the patient’s side, will they trust the diagnosis that AI has given them? We are doing a lot in that space to build confidence here.”

Ultimately, Oludare said, it is about identifying areas where AI could speed up work processes. “It’s making things faster and better in such a way that it’s not going to replace anyone, but it’s taking the mundane parts out of their work. That means that the clinician can focus on caring for the patient.”

Implementing AI in Gloucestershire

Sarah Hammond from Gloucestershire Hospitals NHS Foundation Trust joined the discussion at this point to share a case study from the trust’s AI work.

Starting off their AI journey, she said, there was a lot of debate around what would make the most impact. “We got it down to a shortlist in terms of some of the big problems, both for Gloucestershire, but more importantly for the wider NHS,” she said.

Concerns around length of stay made the shortlist. “Length of stay would impact on hospital flow; if we had more beds available, more patients can get through the system in a more timely way. Our feeling was that it would impact on the big problem,” Sarah said.

On moving forward to apply for support from AI Skunkworks, Sarah noted: “What was important about our pitch was that we had senior clinical involvement from the beginning, and we had stats around the impact on patients.”

Gloucestershire was partnered with a company called PolyGeist, which Sarah called “a wonderful experience from start to finish. People were very generous, both PolyGeist and NHSE colleagues. They were really generous with their knowledge. Along the way we learned a lot, and actually it was a really easy process, although the subject was quite complicated.”

Polygeist’s support

Next Bradley Pearce came into the conversation to explain more about PolyGeist and how they helped Gloucestershire on their AI journey.

“We are primarily a defence company. We produce operational software for counter-terrorism, intelligence, law enforcement etcetera. This project was so successful that we’ve now branched into the healthcare market,” he shared.

The PolyGeist team wanted to predict a patient’s length of stay in absolute terms, and turn that prediction into a stratified risk score. “Scores were between one and give – one being patients that are probably not going to get admitted, all the way to five, where we are fairly certain that this patient is going to stay for 21 or more days,” Bradley explained. “There were many factors that contributed to that risk score, and we were able to build a reliable model that made those predictions.”

They took data from the trust and transferred it into a large spreadsheet that could be processed by their new model. “The system was crunching for a long time, to train a model to produce predictions,” Bradley noted. “We did that in isolation in our laboratories, and then we met up on a weekly basis to discuss the progress.”

Within 12 weeks, the system was not only operational but also integrated into the trust’s IT systems, producing results that could be seen within the EPR.

Bradley explained how it works: “Patients come in, we look at their record that is picked up by the systems at Gloucestershire, and we send that information to a machine learning system that is updated regularly. The features we identify are extracted, the model provides a prediction, and that in turn provides a risk score.” For example, if a patient got a risk score of four out a five, a patient is likely to stay between 10 and 15 days, and are at considerable risk of slipping over into 21 days, and the clinical staff can take action accordingly.

Bradley commented on the financial savings to be found for the trust if the system so much as affects a single day of bed occupancy, and added: “More importantly than that, patient outcomes are saved. Releasing people from hospital beds is a form of medicine.”

Lessons learnt

One of the key takeaways from the project from PolyGeist’s perspective was the importance of having a team inside the hospital that understands the clinical workflow and how data can drive decision-making and change behaviour. “That gave us a real ability to target particular areas in the patients’ stay where impact could be made, and build that into the technology,” Bradley said.

Reflecting on Gloucestershire’s lessons learnt, Sarah highlighted how AI can make a difference in the hospital. “It’s not a concept that people use behind closed doors and do something clever with, it can really have a difference.”

She added: “Although our project was successful, we didn’t know that until we got quite far into the 12 weeks. So it’s okay to fail. If you’ve got a good idea, it’s still okay to take it forward.” To underline her point, she commented that her team thought that they knew what the answers would be in terms of the main drivers for the algorithm, but they did not.

“Use the experience to gain knowledge for you and your team, and if appropriate and it’s related to clinical, make sure you’ve got a clinical sponsor, that’s really important,” she advised. “It’s so worth the time commitment. We made this commitment because we felt it was really important. And I’d also say, enjoy the journey, because it’s an exciting process.”

Many thanks to the team for joining us.

At HTN Now: Digital ICS, we hosted a panel discussion featuring Dr Tamara Everington (chief clinical information officer and haematology consultant at Hampshire Hospitals NHS), Dr Dan Alton (chief clinical information officer at Buckinghamshire, Oxfordshire and Berkshire West ICS); and Paula Ridd (strategy director, health and care at Civica).

Tamara, Dan and Paula shared their views on a variety of topics, including the role and opportunity of digital in integrated care systems, projects to date, learnings and approaches, technical considerations and hopes for the future.

Introductions

Tamara: As well as being CCIO and haematology consultant, I’m the associate medical director for change at HHFT, which means that I run the integrated improvement team. That involves transformation, project management, quality improvement and more. I’m also the Caldicott guardian; I steered the trust on a digital care journey as part of the national GDE programme to where we are now.

My role evolved because although we’d done a lot of digital change, we also had to focus on the work around change management. We now have a portfolio of over 150 change projects within the organisation and an even larger number of QI projects. The three biggest domains for us at present include getting real-time data from the frontline, from our EPR and the linked e-whiteboards, to inform our operational dashboards; focusing on elective improvement and recovery through outpatient transformation and surgical pathway transformation; and work in the virtual sphere, supporting people to avoid admissions.

Dan: I’m a GP by background alongside my role as CIO for BOB ICB. It’s an interesting role; as we know, ICBs are relatively embryonic, and alongside direct responsibilities we also have a role to support our constituent trusts, our partners in social care, the voluntary sector and wider communities to think about their digital journey, literacy and inclusion.

My particular interest is population health management – I’m also a national clinical advisor in population health management for NHS England, so I can bring the national perspective as well. For me, that’s all about data being an enabler for transformational change, to bring to life the whole concept of an integrated care system.

Paula: I’m lead strategy director for health and care at Civica. We’re a global govtech leader and we cover a wide range of software within the public sector across local and central government, education, health and housing.

Health and social care is a major focus for us, with approx. 20 capabilities spanning strategic themes, such as clinical care, financial management systems, people and workforce management, and optimisation. One example is our digital specialist pathway solution to compliment the large EPRs, working to support the convergence agenda for specialist systems such as cancer and endoscopy. We’re launching our next-generation rostering as a service in residential care homes, and we also have community scheduling. We’ve got multiple AI projects running and some carbon footprint calculations to tie in with the sustainability agenda.

On a personal level, I’ve worked within healthcare for 20 years, in an acute EPR and clinical setting.

The role of digital for an ICS, and where the priorities should lie

Tamara: Every ICS is in a different place, some are very mature and others – like ours – are really quite recently formed. I think there’s a struggle between the ICS balancing what it needs to do, with what provider organisations need to contribute. Sometimes, we fall into the trap of thinking that the ICS needs to do everything, and in my mind, the ICS should take the role of a coordinator to make sure that we are all working to the same objectives and outcomes. They are the things we really need to be focusing on: elective recovery, flow through our hospitals, and the system pressures. They are huge problems, and digital is potentially an enabler in this space.

I think it’s fair to say that it hasn’t always been an enabler, sometimes it gets in the way of us doing the right thing. We go out and buy shiny new digital toys but we don’t work out what we need or implement it in the right way. I think that’s another way in which the ICS can help, by linking regional and national teams and highlighting what we want to achieve, the frameworks that can help us achieve it, and the best way to coordinate so that we can move things forwards step-by-step.

Some of the things we will do will be all the same, everywhere; we’ve got pathology and maternity systems across the board, for example. But other things will be different and choice-dependent, such as patient engagement platforms. We might choose to go down a different way, but ultimately, we’ll harmonise around the NHS App.

Dan: In BOB ICS we have varying levels of maturity in terms of our providers; they’re at different stages in their digital journeys. One of the key priorities is going to have to be ensuring that we level up. I think the economies of scale offered by ICBs and ICSs forming can help with that. What we often find in meetings between our CIOs and CCIOs is that we have a particular organisation that is embarking on a journey that has already been completed by another. We can have mutual aid. That doesn’t necessarily mean transplanting a project team to another trust; sometimes it’s just having the contacts so you can pick up the phone or send an email to someone else in another organisation. By creating that wider community, we’ve taken isolated teams and made them part of a bigger team, and we can reap the benefits of that.

Another major priority is linked data. It is hugely advantageous for so many reasons. At the top of the list: tackling healthcare inequalities. We know that there are healthcare inequalities in this country and in some cases they are significantly embedded. In order to do something about that, we need to identify where they are and put in place interventions to turn the tide. Linking data across health and social care can give us a powerful tool to shine a light on this area, and there’s also all the other advantages of a population health management approach in terms of creating change through a very data-driven methodology. It helps us ensure that we are concentrating our transformation efforts in the right places for the right cohort, and of course, we should also be making sure that we involve patients and communities in that process of co-design and co-production.

The third priority that I’d point out would be the creation of a culture of innovation. Sometimes, historically, we have been almost reticent to try something because it might not work. The temptation is to carry on what you are doing, and just push harder. What ICSs need to do is instil a culture where we can try something innovative – often you’ll find that it’s already been done in some capacity elsewhere in the system. We need a culture where it’s okay not to get it 100 percent right at the first turn of the wheel. On this note, we have an innovation programme in place which is designed to help lots of innovative usages of digital and data to get started.

Challenges facing the ICS

Dan: As a clinician, often the biggest challenge to overcome is simply having the headspace for change. Often people agree to new ideas, but daily pressures get in the way. It’s worth trying to spend the time to create that headspace in order to allow clinicians to stop and take stock of where we are going in the longer term. That involves carving out time to bring together clinicians, clinical leaders, patients and community leaders, analysts, and finance leaders. When you get them in a room together, virtual or otherwise, and encourage them to think about where we are, what our problems are and what we are going to do about them, you begin to build that culture of innovation and you get past the initial resistance. It’s about creating a shared vision and winning trust, particularly of the wider clinical community. It should be irrespective of whether we are introducing a new solution or methodology.

Tamara: I think we forgot a lot of what we learned in COVID very quickly. In the pandemic, the first thing we had to do was stop. Stopping was necessary in order to start the joined-up, system-wide thinking that allowed us to do things differently. When we perceived that we were ‘moving on’ from the pandemic and closing those ways of working, all of those past issues came back, and virtual work actually exacerbated some of it and added pressure. Being able to connect virtually with colleagues on Teams, for example, can lead to people stuffing last-minute meetings in your calendar and just assuming that you can come. We’ve re-cluttered our world, which is taking away brain space for thinking about how to do things differently. So I’d say the first thing we need to do is actually stop doing things, because there’s way too much noise in the system.

Another key priority is to get the resourcing model for IT right. We’re still relying on cash drops from the centre, which often happens at the last minute and doesn’t always deliver what we want to deliver. There’s also a tendency to think about digital as a side project, rather than a key enabler.

The third priority is around supporting our IT team. They’re really struggling. What the NHS is prepared to pay for their expertise is very different to what these people can get paid in a private market. Recruiting and holding onto people in that space is therefore a major challenge.

Paula: As a supplier, we’re going through a similar transition. Dan mentioned the importance of taking time out and thinking about the art of the possible. We’re thinking like an ICS too – – how can we continue to join up our solutions and the data between our products, to help trusts solve more problems? As the ICSs are maturing and balancing different perspectives, suppliers have a call to arms to support with this agenda. We need to take the time to consider how best to do that.

The point has been raised about leveraging experience that has gone before – I think that’s partly our job as a supplier, to help broker some of that. We will be learning as we implement projects across the ICSs. We need to harness the insights that we can provide so that they become actionable, and we need to be at the table with the ICSs to help work through these challenges.

Culture change

Tamara: The principle of ‘everyone is an improver’ is core to what we do at Hampshire. That doesn’t mean that everyone needs to be hugely creative in their own space – it’s about all of us having an understanding of what we need to be achieving and how we can coordinate efforts to get the best possible results.

Creating the ‘everyone is an improver’ model really is about including everyone. At a conference last week, we heard about a whole range of projects and programme –  we had a porter talking about the change he has initiated in terms of making sure that oxygen cylinders are full enough during transfer of patients, we had the stroke team discussing their iterative improvement programme to help them gain an ‘outstanding’ rating, we also had the chief executive talking about how she worked on recovering the complaints process. We try to mesh digital in with everything else, so that when you bring in a digital change, you’re bringing it in the context of a whole system transformational change.

Dan: I think it’s interesting to point out that we’re half an hour into a discussion on digital health, and we haven’t actually spoken about tech much. I think that’s quite important and quite correct. It lets us place the emphasis on that culture change instead.

The work we are doing at BOB ICS broadly falls into three categories, in terms of creating a culture of innovation. It’s about trying to embed knowledge, skills and attitude. The knowledge requires an element of professional development, an offer to upskill.

The skills part can be achieved by giving people the opportunity to try, which sometimes will mean trying to carve out funding to put behind new projects. As I mentioned earlier, things might not always be a success, but at least we’re trying something new. For example recently managed to identify some funding for robotic process automation (RPA), to attempt to help general practice in reducing administrative burden. Some of our trusts have experience in RPA, so we’re able to connect practice leaders to have those conversations. We couldn’t have done that before we formed these links.

Attitude is the most difficult element. That comes back to the headspace; ensuring that we are creating a unified vision of what we are trying to achieve, having the time and space back to explore that with individuals, and instilling an attitude of innovation. It’s a bit more difficult to describe than the other two, and it can feel a bit nebulous. But it is key.

Paula: We are certainly seeing that piloting some of that innovative, cultural change using technology is really helping due to the ability to share the adoption perspective and the lessons learned. We worked in one of the cancer pathways, looking at how we can implement one single queue across the region. By taking one service and demonstrating a 42% reduction in waiting times, we can look at the experience and what was learned and then re-roll it out. Taking that small-scale step and then driving adoption from there can be beneficial and a helpful way of thinking.

What does digital ICS success look like?

Paula: Data is king. I would like to see a much more ubiquitous joining of data across all care settings. It comes back to providing actionable insights that consider all of the data in the system. Take our Civica portfolio – it would be great to use data management tools to bring together data from across the ecosystem – things like educational data as well as health records. If we can start to drive that collaborative approach, better our understanding of insights and increase our knowledge of how to action them, it would be a superb place to be – as a citizen within the ecosystem, not just as a supplier.

Dan: I think the easiest way to consider success is to look at it from different perspectives. From a patient perspective, the best case scenario in three years’ time would see us having made real inroads into tackling inequalities in terms of digital exclusion. Access to services would feel seamless, and they would be given the information that they need to take control of their health as much as possible. It needs to be meaningful – for example, if a patient has high blood pressure, they should be able to access information on their blood pressure, how best to manage it and local services that are available.

Success from a clinician’s perspective would see digital helping them to do their job as best they can. That includes a cyber secure, intuitive systems being used in order to rapidly support them with data.

From a wider population perspective, success means making better use of data – using population health management methodology in order to shift from reactive to proactive care at every level of the system, by identifying cohorts and co-designing interventions with that community to tackle disparities. It also means using data to better plan services, both now and in the future, through modelling.

Engaging through data

Paula: A really good set of examples from our portfolio is our artificial intelligence solutions. We’ve been using our AI to provide data insights that frankly would have been like looking for a needle in a haystack if we had been doing it manually. By honing in on those insights, we can very rapidly identify areas for further attention and we can look at two million episodes in a matter of minutes. We’ve been working with a number of regions on how they can use that data to look at clinical variation – in cataracts, for example, identifying variations has yielded about £300,000 in savings just by changing some work patterns, shifts and looking at allocations. Looking at practices across the region and sharing experiences has also supported that.

It involves a lot of stakeholder engagement and it comes back to time – we’ve seen the best outcomes when we’ve had time carved out for clinicians to get involved in these insights. The difficulty is the pace; using a tool like AI means we can build up those insights incredibly quickly, but being able to get stakeholders in the room to share the learnings happens at a slower pace. I think using these opportunities to think and plan for the future is really important.

To support ICSs, as suppliers we need to keep having those conversations with stakeholders, so we welcome opportunities to talk and find out how we can support them to work in faster, smarter ways.

Data for positive change

Dan: There are a huge number of examples, but I’ll pick out two. Firstly, there’s data for proactive care. We are using data in order to identify cohorts of the population who could benefit from a slightly different approach. Often, those cohorts of patients are not necessarily experiencing poor health outcomes today, but are likely to experience them in the future; for example, if their diabetes control gets a little worse year by year. We use population health management methodology to design interventions for the specific needs of that population, which will differ depending upon the local geography. For example, in central Reading, we have a large number of people of Nepalese background who may experience poor health outcomes in terms of diabetes. We are working with that community in order to design a specific intervention, with group consultations run by a Nepalese-speaking GP, and we can use this to adapt our approach to their needs. We wouldn’t be able to do that if we didn’t have the data to identify this problem in the first place.

Another huge advantage of linked data, at a wider level, is how we can use it to plan services. Traditionally, we’ve looked at a number of factors to decide where an urgent care setting should be located, for example, but we haven’t had all the granular data to make that decision. We’ve tended to design services based on what suits us, rather than what suits population need. It’s complicated, from an ICB perspective – taking BOB ICS as an example, we are an amalgamation of three CCGs each with its own data architecture. Linking them together involves an element of compromise, but it’s important that we have one system with one linked data source, to give us the power to help your population locally and at a wider level.

Our latest panel focused on developing a digital workforce and digital skills, and featured Jeffrey Wood, deputy director of ICT at The Princess Alexandra Hospital NHS Trust; Daniel Johnston, senior clinical workflow specialist at Imprivata and registered staff nurse at Cambridge University Hospitals NHS Foundation Trust; and Henrietta Mbeah-Bankas, head of blended learning and digital learning and development at NHS England.

To begin, our panelists introduced themselves to set the scene. Jeff got us started by sharing information about the different roles within his trust who are involved with digitisation.

The tech team at Princess Alexandra Hospital NFT

Jeff: We don’t have a ‘true’ digital team – like in most places, technology is just one aspect of our digital work. We try to embed digital across the trust as we go.

My technology team is quite large and covers a huge range of areas. We have a service department and an infrastructure team which includes security and technical design, applications support, and design and development. We also have an IT training team, a testing team, project management, transformation and business analysts, along with business partners and customer relationship officers. I also pick up the switchboard team as well as unified comms, which gives me a bit more insight into the communication side.

All of those teams have a specific digital association, whether it’s from the training side, through transformation and business analysis, or business partners connecting with the divisions throughout the trust.

From clinical perspective to health tech supplier

Dan: I’ve been a nurse for over 20 years now. I began my career within the NHS; I’ve worked in acute medicine, emergency care and telemedicine. Throughout that period time, I’ve taken on a variety of roles – clinical, operational and educational. I’ve also worked in research roles. It has all been very patient-focused and I’ve really picked up a passion for service improvement.

It has also given me an interest in clinical research and translational medicine. Over time, my work led to a US career; I’ve practiced out of Harvard ER, where I moved up into leadership and educational roles with a focus on methodologies around quality improvement, lean process design and co-design. At Harvard we had access to a whole range of technologies which we evaluated in the clinical setting. That led to working with things like predictive analytics, hand-held devices which were very innovative at the time, population health tools and decision support. My work focused on validating these tools in the clinical space, looking at how they could be adopted, what they could lead to.

I went onto an NIHR Research Fellowship, and from there onto the Florence Nightingale Global Scholarship.

My varied experiences really help me in challenging industry perceptions of what value is. What does it mean to interact with clinicians? What are clinician priorities? Ultimately, what does it mean to the patient, the healthcare system and our population?

Developing a digital workforce

Henrietta then shared her insights on developing a digital workforce from a national perspective.

Henrietta: From a national perspective, developing the digital skills of our workforce is critical. Along with developing the skills of our existing workforce, we are particularly keen on thinking about how we can support the future workforce. It’s about supporting everyone from those who haven’t yet started on their health and social care careers, to those at the highest level of their careers.

We’ve got various pieces of work underway which focus on developing a digital skills pathway with our further education colleges, universities and technical colleges. We want students on health and social care programmes to start the prerequisite digital skills that they need to either go straight into employment, apprenticeships or higher education. We’re also supporting digital students who might be thinking about careers within health and social care, particularly within the NHS, where we know we’ve got over 30 different digital careers available.

For both sets of students, there is support designed to help them such as the digital health leadership programme or the digital skills assessment tool. There’s plenty on offer from the NHS Digital Academy to really support the development of a digital workforce in the NHS.

How can we prepare people for digital roles?

Jeff: It’s really tough at the moment and there are a few main challenges. One is the fact that a lot of the funding for training is often delivered to clinical staff for healthcare, so it’s often a case of struggling by on the remainder, both for internal ICT staff and for digitally up-skilling other staff.

The NHS has been very slow, generally, to adopt technology, and therefore a lot of clinical staff have not had the opportunity to use cutting-edge tech in their working lives. Some use it at home, some don’t. It’s such a diverse requirement for our staff – we have some staff who are fresh out of university, so keen to use new tech, and can’t understand why it’s not available to them. On the other hand, we have some staff members who haven’t used much tech before and are struggling with the basics. For those people, the culture change can be really difficult.

Alongside, we also have our residents and patients, and we need to ensure that they are not digitally isolated or excluded. Again, there’s a wide variety of skills and attitudes; digitisation can be a boon or a curse.

We have a training team in place to try and train our organisation as best they can when it comes to the applications that we have, but wherever possible we try to use external free resources. There are a lot out there that you can use, and they’re about building the soft skills as well as the technology-specific ones. That helps a lot.

For us to get the best use out of technology and digital, we have to ensure that we procure intuitive systems. There are some systems that you might only use once a month – they have to be easy to use, otherwise people will stop using them.

We’ve invested in something called COPE – corporately owned, personally enabled devices – to encourage staff to take devices home and use them in their home life as well as their work life, because if they’re using them more often they will take more care of them and they will play with them, getting used to them. Then it’s less of a challenge to use them for work. That’s been good for us.

We record sessions where we can to make sure everyone has access to content such as training, because not everyone can join in live. That helps dramatically. It also allows people to return to a session and take it at their own pace.

Within our procurements, we’ve started to include support training. It’s not just about getting these applications in and supporting their use within the business, it’s about training the people that will be supporting others. That might mean our own technical support team or super users, for example. We ensure that training is included for them in a variety of ways, such as computer-based training or documentation, so that there’s different options available.

Trying to free staff up to attend training has been difficult for us. We always have to highlight a compelling reason as to why you need to be more digital, why it’s important that you come along to training sessions and engage. Having our business partners and transformation teams helping to digitise processes and not forgetting that process change before they digitise it is really important.

We’ve also worked closely with our chief clinical information officer. It helps to have someone there who can talk to clinicians on their level and explain the benefits. In a similar way we’ve got a head of digital nursing who is helping us.

I think the real key is keeping in mind that everything that we do in terms of digitisation has to be the right product. It has to give the clinicians more time to spend with their patients instead of in front of a PC. Everything we do is about saving time, making something easy to use, making it fit for purpose, so that we can show the benefits and give clinicians the time back that they need. That’s when they really invest in the technology.

Dan: For digital in the future, I think staff involvement is key when it comes to design. I would say that there’s also a role for industry to have more clinicians in the trade, so that they can help translate and make things accessible.

As Jeff said, digital needs to be accessible and intuitive. We should have the same principles for health tech that we have in our personal lives – you don’t pick up a training manual to use an iPhone, and the same should be said for our systems.

We should also make sure that systems really make sense to the workflow of what people are trying to accomplish. I’ve had to use quite a lot of systems both from a clinical perspective and an industry perspective, and a lot of systems aren’t necessarily intuitive and communication around them is not always clear. There should be training, but that training has to be done closer to the frontline than we currently see.

The industry really is moving fast, and I think it’s about making sure that the products we get are consumable at the point of care. I think that’s something that is a challenge at the moment.

Learnings from national programmes

Henrietta: Culture is a huge issue, and there’s no one-size-fits-all solution. Jeff and Dan have already raised a lot of the learnings that we’ve found from national programmes around the need for accessible, intuitive systems.

Another learning is around how we can start to make digital part of people’s everyday language, rather than ‘the other thing’ that they don’t always want to engage with. It almost needs to be socialised into our professionals and our roles until we make digital the thing that enables people to effectively do what they need to do within their role. If we don’t do that, it will carry on becoming ‘the other thing’. That’s why, for us, it’s really important that we start investing in our future workforce, to embed this from the start.

There’s an assumption that young people are automatically digitally literate – we’ve found from our learnings that this is not always the case. They will have strong digital skills in some areas, for example, in communication and connecting; this tends to be around social media use. But there are other areas within our digital capability framework where we see young people with digital knowledge gaps. That said, their attitude to digital is positive.

On the topic of digital skills, there’s also something to be said for examining overall digital readiness. That looks at attitude as much as skills. Attitudes will only change if we make it a lot easier for people to access digital tools, for people to have training for the skills they need. That’s why our support is very much targeted at the person’s level of expertise or their level of skills, to ensure that we do not lose people who do not feel digitally confident.

The final point I’d make brings us back to the use of digital champions. We have found that this is one of the most effective ways of supporting staff who do not feel digitally confident to start developing their skills. As our medics often say: see one, do one, teach one. If people can see how something works and they learn to do it, in time they develop the confidence to teach others how to do it.

Measuring digital skills

Henrietta: There are a number of ways in which we can measure people’s digital skills. The digital skills assessment is an obvious one – it was developed by Health Education England, now under NHS England, and it provides opportunities for you to baseline staff. The data is owned by the DLS Learning Solution Centre. You can get your people to complete the assessment and from that data you can understand where your staff are at in terms of their digital abilities. You can look at it from a number of perspectives, from groups to whole departments, depending on how the registration has been handled. You can also repeat it periodically to see whether there has been a shift in people’s abilities and track progress in that way.

The move towards integrated care

Jeff: The key word is collaboration. We need to be talking to each other a lot more as we progress, and the way to do that is the use of technology. Within the trust we are doing a lot of work in terms of our training needs analysis going forward, to understand where our staff are, but ultimately the patient is at the heart of everything we do. Therefore everything we look at should be improving the lives of patients, whether that’s within the hospital or at home.

It’s key that all of the digitisation we put in place is accessible to the patients and also accessible to everybody that needs to be treating those patients. Integrated care systems are starting to bring those things in together – we’re procuring more systems that have joint use and we’re looking at ways in which services, people and roles can be shared across many organisations.

Dan: There needs to be a vision. If you’re going to make any of these technologies accessible, having a vision of what you’re looking to accomplish is key. It sounds basic, but because of the complexity I often find that the vision is either changed or it isn’t clearly defined or it’s sometimes even absent. In order for the technology to be available and consumable to staff, it’s got to have a real tangible benefit to it.

Digital identity

Dan: If you’re going to have digital systems, you need to be able to say who you are and what role you are – who, what, when, where and how, just the same as if you were documenting on paper. All of that is only really enabled if we are able to prove who we are within systems. It’s not acceptable in the analog world to complete note and orders and records using somebody else’s signature. So from a professional point of view, and in terms of security, there’s the accountability and clinical governance aspects to take into consideration.

The challenge is, with all of these checks and balances, it still needs to be accessible, consumable and fast. In addition, the focus needs to remain on the patient, as Jeff was saying.

When you’re looking at it from an ICS perspective, you’re obviously taking numerous organisations into account; and the power of digital means that more people have digital touch points and can access more data than ever before. It underlines the fact that it is paramount that we can evidence who we are. We would expect it if it was our own care or a loved one’s care – we’d want to know who did what, where, and why. It is the basis of a learning healthcare system.

I see digital identity as a cornerstone within a myriad of technologies that enable progression and digital maturity.

Culture change

Jeff: Everybody knows by now that COVID brought a big change in focus for everybody in the NHS. It’s been said that technology advances in leaps and bounds during war, and actually we were at war with COVID. It brought a massive change in terms of how NHS trusts looked at technology and what it could do. I also think that the funding available during that time and afterwards has helped significantly both in terms of being able to invest in the technology but also being able to demonstrate what it can do. There have been a lot of proof of concepts that have gone out, a lot of different hospitals have tried different things.

When I first joined the NHS about five years ago and we wanted to change a system, one of the first things I suggested was finding out what other people in our region were doing and going to talk to them about it to learn. Now, we’re all starting to talk to each other a lot more. We’re starting to run alongside each other and re-use what others have done to make improvements, and I think that has been a big culture change.

Henrietta: On the other hand, we have also got organisations that are not open to learning from failure. If people don’t feel confident with digital, they often don’t want to touch the tech because they think that if it goes wrong, it may have implications for their employment. For the culture to change, we need to foster openness for learning. It needs to be okay to learn, to not know something from the start.

Fostering change and innovation

Dan: It’s about being people-centric. As I mentioned before, you need a clearly defined vision; you need to know where you’re going. You’ve got to be really close to the frontline and understand the work that is being completed or the processes that are being used and the value within that.

Co-design is a must. I think we’re on the cusp of change in this area and COVID probably accelerated it, but there’s still a long way to go to make sure that the people who are going to be delivering innovation are part of the process of innovating. We’ve still got a long way to go though.

In terms of existing projects, I think there is further innovation that is yet to be realised, and there’s a lot of excitement about that.

Looking particularly at benchmarking within healthcare IT; if you’re going to innovate, you need to understand what your current state is and where you are going to. Sometimes, some of the best ideas come from those who aren’t especially digitally literate, because they’re more focused on their current state and where they would like to go. We’ll probably look back on this era and see it as health tech in the dark ages, and it’s only through benchmarking right now that we can understand where we can go. All too often, it’s not present and is still not a big enough topic of conversation.

Henrietta: People are already busy doing their day-to-day jobs. As a starting point, it’s always useful to highlight what people need, but also what’s in it for them. Why do I need to engage with this digital solution or gain digital skills? The conversation needs to change.

Advice for developing digital skills in an organisation

Henrietta: We need to utilise those champions to make the most of peer-to-peer learning. We have a user group who say ‘we don’t do digital’ – how do we target our interventions to engage them?

We’ve got our digitally positive group who embrace tech; we need to support them to develop their digital leadership skills so that they can support us in implementing strategies and interventions within organisations.

The third group are those who sit in the middle. They think digital is fine, they’ll try to use it, but they’re not really bothered. Based on our interventions, we can move this group to be either positive or negative towards tech, which is why it is so important that our interventions are targeted and considered.

The fourth group to consider includes people who are digitally excluded, irrespective of their digital skills. If they haven’t got access to the tech or access to connectivity, it’s highly unlikely that they will be able to utilise the skills they have developed.

In any organisation, to fully implement digital skills or digital strategies, you really need to think about the needs of these four groups independently, but also in terms of bringing them together to support each other.

Jeff: I’d agree with Henrietta. It’s key to make sure that you recognise each staff group and handle them in a different way.

It gives us a lot of benefits when we give our champions access to the new tech and let them play with it, and share proof of concepts with them. When others see these people using them, it creates a sense of ‘you’ve got that, I want it too’. It’s about trying to foster that want in people before you deliver it out. The worst thing you can do is just hand someone a device and tell them to use it because it will help their job. People are resistant to that. By building that want within the business, people are more likely to come to you and ask for a device because they’ve noticed a colleague using it and they want to try it.

It’s also important to be clear about evidencing the needs and requirements across the whole organisation, not just at exec level. We need to show people the art of the possible, because that then encourages them to want to try these things. It’s amazing what people come up with when they try tech as well – ways to use the device that we never would have thought of. If you can get that information out to the rest of the trust and it’s come from somebody outside the technology team, that’s really important.

Dan: In my own opinion, we need a bit less digital and a lot more focus on how we can use our digital systems to deliver benefits to patients or organisations. If we can be more outcome-driven, then I’d hope that digital will just become part of the overall healthcare matrix – one mode in which care is delivered or recorded. That would be welcome, because I think the word ‘digital’ can create boundaries in itself. We have to move past that word and focus on making these technologies available and understanding the barriers to their adoption.

Many thanks to Jeff, Dan and Henrietta for their time.

At HTN Now: April, were joined by Dr Gemma Donovan, head of behavioural insights at Generated Health, along with Dr Sabine Van Der Veer, senior lecturer in health informatics from the University of Manchester, for a discussion on the potential and pitfalls of digital health and behaviour change. In particular, Gemma focused on behaviour change for the Core20PLUS5 framework, the NHS England initiative aiming to drive down health inequalities by defining a target population and identifying five focus areas requiring accelerated improvement.

What is a behaviour?

To begin, Gemma defined what a ‘behaviour’ is, from a behavioural science perspective. “It’s anything that somebody does in response to internal or external events,” she said. “An internal event is where we think about something that we want to do and then we do it, whilst an external event is where we do something that is prompted by the external environment. In terms of health behaviours, we’re generally thinking about things that people are choosing to do or choosing not to do which may affect their health. Importantly, behaviours are observable – we can watch somebody perform a behaviour.”

Behavioural science is not about controlling what somebody thinks, she added, but rather to influence the action that they take.

Looking at behaviours that could be important for somebody’s health, Gemma shared a few examples. Self-monitoring involves a series of behaviours, she said; for example, using a device to track blood pressure and filling the results in. Taking medication is another behaviour; so is the action of requesting help.

It can help to think about behaviours through a model, Gemma continued, such as the Capability, Opportunity and Motivation model for Behaviour (COM-B), available to view at 07:35. “This is part of the Behaviour Change Wheel that was developed by Susan Michie at UCL. There are three different components; capability, either psychological or physical; motivation, reflective or automatic; and opportunity, social or physical.”

Gemma pointed out that on the model, both capability and opportunity feed into motivation. “If somebody lacks capability or they have enhanced capability, that will affect their motivation to engage in a particular behaviour,” she explained. “Opportunity will similarly affect this.”

Gemma also noted that all three components are bi-directionally linked to the performance of the behaviour itself. “If you can get somebody to initiate a behavioural change, that alters their capability, motivation and opportunity,” she said. “We can get a positive loop going sometimes with behavioural change – the more we encourage people to perform the behaviour, the more capable and more motivated they will feel, and the more they will feel that they have the opportunity to perform it.”

Behaviours and Core20PLUS5

Next, Gemma examined the components of the Core20PLUS5 framework with a view to what they might mean for behaviours.

Firstly, she provided a refresher on the framework, focusing firstly on Core20. “The core 20 are the most deprived 20 percent of the national population, as identified by the national Index of Multiple Deprivation. The domains of deprivation within this are income deprivation; employment deprivation; education, skills and training deprivation; health deprivation and disability; crime; barriers to housing and services; and living environment deprivation.”

“There’s a range of things, when you look deeper into Core20PLUS5, which could be potentially affecting people’s ability to engage in health behaviours,” Gemma said.

The PLUS part of the framework is recommended by NHS England to be defined at a local level, she continued, though they have identified some populations which they would expect to see in most areas, including ethnic minority communities; people with learning disabilities; people with autism; people with multiple long-term health conditions; groups with protected characteristics; coastal communities; and groups experiencing social exclusion, such as people experiencing homelessness, vulnerable migrants and sex workers.

The 5 part of the framework, meanwhile, focuses on five clinical areas of focus which require accelerated improvement: maternity, severe mental illness, chronic respiratory illness, early cancer diagnosis and hypertension.

“All of these areas can involve a range of behaviours; there are a lot of self-monitoring behaviours around chronic respiratory illness, and early cancer diagnosis involves a lot of detecting of symptoms. Blood pressure monitoring, for example, might be relevant for pregnancy-induced hypertension as well as hypertension case finding, and it’s also helpful in supporting clinicians to make decisions about treatment around hypertension management.”

Moving on to explore how this ties into the COM-B model, Gemma shared some example questions to detect behavioural influences from ‘The Behaviour Change Wheel: A Guide to Designing Interventions’ by S. Michie, L. Atkins and R. West. “These questions are designed to tease out the kind of things that might be getting in the way of people’s ability to change their behaviours,” Gemma explained. “They’re helpful to ask when thinking about digital health interventions, to help us understand people’s actions.”

The authors provide a range of prompts: “To change my behaviour, I would have to: know more about why it is important, know more about how to do it, overcome physical limitations, overcome mental obstacles, have more money, have it more easily accessible, have more people around me doing it, have more support from others, feel that I want to do it, feel that I need to do it, or believe that it would be a good thing to do.”

The questions, therefore, link into each of these prompts; are people not changing their behaviours because of physical limitations, mental obstacles, lack of money, lack of access?

“As you can see, there may well be things in the Core20PLUS5 populations where more barriers might exist,” Gemma commented.

Digital health equity

Sabine took over at this point to discuss digital health equity.

Firstly, Sabine clarified the difference between health equity – “the absence of unfair and avoidable or remediable differences in health among population groups” – and digital health equity: equity in design of digital health solutions, equitable access to digital healthcare, and equitable outcomes from digital healthcare and/or equitable experiences with it.

Sabine moved on to examine the digital determinants of health, sharing a framework illustrating the domains of influence over someone’s life in comparison to levels of influence. Domains of influence include the digital environment along with other influences such as biology or the sociocultural environment, whilst levels of influence range from individual to interpersonal to community to societal. The graph can be viewed at 22:12.

“It’s often about the individual level,” Sabine commented. “Do people have the skills, the knowledge and the confidence to use digital technology in a way that allows them to benefit? Not everyone has access to a smartphone, or maybe some people do have access but they don’t have an up-to-date version that allows them to use certain apps, for example, or they don’t have mobile data.

“At an interpersonal level, you see the influence of the clinician as the gatekeeper, giving people access to digital services. I see that factor quite a lot in my own research. That ties into implicit tech bias, which is another interpersonal influence; the clinician makes a judgement call on whether the person in front of them is willing and able to use digital services. There’s also interdependence, related to technology access as the individual level; some people might have access as a household to a device but share it among themselves, which can create barriers for using digital services.”

At community level, Sabine noted the importance of infrastructure; some communities, for example, may not have access to broadband or high-speed internet which means that they cannot have a virtual consultation with their clinician. “People living in an urban area might have a community centre around the corner that provides digital skills training,” Sabine said, “or they might have a technology walk-in clinic. People in more remote areas tend to have less access to that kind of infrastructure.” Community attitudes can also be significant, she added; if there’s distrust towards technology in the community, then they will be less likely to engage.

Finally, at societal level, Sabine said: “This is about how we organise digital technology as a society. Are there nationally-accepted design standards for developing accessible technology, to make sure that people with sight or hearing impairments or dexterity issues can still use them? Algorithmic bias is another factor; we know that people from certain communities are not represented in the datasets that we use to create algorithms, and we use those algorithms to help us make decisions or predict certain risks. If those people are not represented in the data in the first place, it’s very likely that the algorithm won’t work as well for them.”

So what is the link between these digital determinants of health and Core20PLUS5? Sabine displayed each of the domains the Core20PLUS5 framework and ran through the impact the domains can have on digital determinants.

Income and employment deprivation can affect technology access to devices and data, along with interdependence (sharing devices).

Education, training and skills deprivation can impact digital literacy, digital self-efficacy and attitudes to use.

Health deprivation and disability can affect the patient-tech-clinician relationship, healthcare infrastructure (including lack of integration of digital services) and design standards (with regards to accessibility in particular).

Barriers to housing and services can impact community infrastructure (such as internet) and community support (for example, accessing a local service for assistance).

Living environment deprivation and risk of crime can have an affect on people’s ability to access a private, safe space, and can lead to lack of representation in data sets through algorithmic bias.

“Gemma already explained that having certain deprivation characteristics means that you have additional barriers to behaviour change,” Sabine said. “This shows that if you are trying to implement digital behaviour change interventions, you have to take care not to create an additional barrier, because people from those groups have digital determinants of health that can make it even harder for them to engage with the technology effectively.”

Managing the impact of digital health equity 

Next, Sabine shared a multi-stakeholder process to identify potential impacts of digital interventions and how to manage them called the Health Equity Impact Assessment.

“It’s not a checklist, although you could use it in that way,” Sabine explained. “The most benefit comes from going through the list together with stakeholders – the end users of your digital health interventions, but also the people developing it, the healthcare professionals who will be offering it to people, experts in the area. Put them together in a room and go through these steps.”

The process includes five steps:

1. Scoping: consider social and digital determinants of health, start from initial testing results and published research and reports
2. Potential impacts: explore positive and negative unintended impacts
3. Mitigation: consider strategies to tackle negative and harness positive unintended impacts
4. Monitoring: create a plan for the evaluation of the effect of mitigation strategies
5. Dissemination: create a plan for sharing outputs and findings with stakeholders

Florence and behavioural change

Gemma moved on to discuss the role of Florence Intelligent Health Messaging, Generated Health’s platform, as an inclusive digital health tool for behavioural change.

“I don’t claim to have all the answers for how we tackle this,” Gemma remarked. “At Generated Health we’re also on a journey in terms of thinking about how best to do this – we’ve always been really interested in how we can be more inclusive. We’re purposefully an SMS-messaging solution because we feel that SMS is the most accessible form of digital health, and that comes with a couple of benefits from a behavioural change and inclusion point of view.” The SMS messaging delivery can also be adapted into other languages to try and improve inclusivity.

There is no cost for patients to use Florence, Gemma explained, as the cost of messages are recharged, which means there is no requirement for patients to have any credit on their phone. There is no need to access the internet and they can take part using any type of mobile phone handset. Standard adaptations on handsets which can be used to increase accessibility, such as increasing font size, do not affect how Florence is used.

“When we onboard our customers, we do a process of co-designing our content,” Gemma continued. “We have a completely adaptable solution. We use this a lot to try and improve our inclusivity. We’re used to working with particular populations in order to make sure that content delivered by Florence is suitable for that population. This means that we can adapt our content around the behavioural insights that we receive. When we work with our customers to understand their challenges, the likely behaviours that need to change, the best way to support patients to engage in that behavioural change, all of that can potentially be adapted to a very specific population if that is what is required.”

The project that Generated Health is currently working on with Sabine and the University of Manchester is taking that one step forwards, Gemma added, exploring how this co-design and personalisation can be developed further.

“We also make sure that our content follows clinical care processes,” she said, “and that it maps with what is happening in real life in the clinical setting. We hope that this means we’re less likely to exclude people on the way, in terms of who is being offered the technology, because it should be fitting around what is already there and hopefully enhancing existing care.”

An example of one of the ways in which Florence can support patients is the hypertension pathway; Gemma shared how the platform can assist patients in collecting blood pressure readings by sending them reminders, providing them with an easy way in which to record readings, and sending immediate feedback. This feedback could be instructions on what to do if a reading falls within a certain range, or it could be simple confirmation that all is well.

“Florence can respond to patients supplying word-based messages as well as figures,” Gemma explained. “For example, a patient can tell Florence about a symptom they are experiencing and Florence will record this and generate further action as needed. She can also pick up on trends to help identify whether patients are getting better, worse or staying the same, therefore helping clinicians to identify when an intervention is needed.”

Although SMS is very simple and easy to use for patients, the data is transformed into meaningful information on a data dashboard from the clinician perspective, summarised for ease of access.

Florence and the University of Manchester

Sabine shared some more information about the collaborative project taking place between Florence and the University of Manchester, which aims to explore how Florence can support hypertension self-management in people from South-Asian backgrounds.

“We’re going to do a focus group using the process I described earlier; so we’ll invite a group of people from the different stakeholder groups, involving lots of South Asian people with hypertension, and we’ll go through the process to work out the potential positive and negative impacts, and the strategies that we can think about for addressing them,” Sabine explained.

A second focus group will then hone in on the findings from the first group, with the aim of prioritising the actions that are most feasible whilst having the highest impact.

After that, the project will pick out the high-priority strategies selected through these groups and start co-designing them with stakeholders.

An expected outcome from this project might include altering the language of Florence messaging for this patient population, Sabine said. “But I think that we’ve learned so far is that understanding and reading English is often not the problem. It’s the way that you frame certain things which can mean different things to different populations. It’s especially important when you think about behaviour change. For example, if we’re trying to increase people’s physical activity, you might be working with a population who go to the mosque several times a day. Why not develop some culturally-adapted messaging prompts which take this into account?

“The other thing we’re hoping to get from this is to learn whether there’s anything to be done around how Florence is offered to people,” Sabine concluded. “We’re working with clinicians to think about their implicit biases, and how that can be tackled so it can be offered to everybody.”

Many thanks to Gemma and Sabine for sharing their time and experiences.

Last week at HTN Now, we held a series of webinars focusing on different health tech topics. In one of our sessions, we were joined by Rachel Binks, nurse consultant and clinical lead for digital and acute care at NHS Airedale Hub, for a presentation on digital innovations and remote monitoring at scale.

The session shared the work Airedale NHS Foundation Trust has undertaken in order to deliver digital and acute care, touching on their progress and the positive outcomes they have made so far in their journey.

Airedale’s digital journey

Rachel began her session by sharing a timeline of the digital process made by the trust.

“In 2006, we started digitising patient services and started to deliver outpatient consultations to prisoners who either didn’t want to come out of the prison for health assessments, or where it was preferable to assess them remotely due to their high security risk,” Rachel said.

Over the next years, they worked on a range of small-scale pilots. “Some of them were evaluated extremely well, but getting the funding to continue them and to commission those services across the board – or even just across our patch – was really quite difficult,” she noted. “In 2010, with the support of higher management, we opened our Digital Care Hub. I was nurse consultant for critical care and carried this role on alongside my work with the hub for many years.”

In 2014, Rachel said, the trust started their 24/7 Goldmine service which provides support for people in their last year of life. “It began as primarily a telephone service but we can also use video. The point of this service is that we can safely support people who want to be at home. We arrange for care to come to them and their families, rather than them having to travel to the hospital or a GP practice.”

As part of this, the trust supports the patient and their family to ensure that the individual can die in their preferred location. “When we look at our Goldline data, we can see that by successfully monitoring patients in their last year of life at home, 93 percent of people remain at home. These are people who don’t want to go to hospital – through out services and digital tools, we do everything we can to keep them out and where they want to be.” Rachel shared a video on Goldline which can be viewed here.

“The service is still going ten years on and is really well evaluated by patients, who love the fact that they can stay at home,” Rachel shared. “Their families and carers often tell us that we gave them the confidence to be able to support their loved one at home, and that has been invaluable for them. It makes the experience more bearable for somebody who is caring for someone in their last year of life.”

As the service continued, the trust had the idea of expanding the service beyond people in the last year of life, so that it could support people who are in their own homes with long-term conditions too.

“And so, MyCare 24 was born,” Rachel concluded. “In 2023, went into a joint venture with a tech company, who supported us and helped us to spread the services much further and we became adept at marketing and selling our services across the country.”

MyCare24 and the Digital Care Hub 

Rachel described how the trust continued with MyCare24 through the pandemic, as it evolved into virtual wards and a service called CO@H. “It’s getting to a point where we’re now looking in on 6,000 people with COPD, frailty, diabetes and so on in their own homes,” Rachel said, “and we’re also looking at a tech-enabled virtual respiratory ward.

“We care for people using video and telephone services to support carers who may not be registered nurses to keep people at home – whether that’s a care home, their own home, or somewhere else. We use electronic patient records and we have registered practitioners to deliver clinical assessments, as well as band three healthcare support workers to handle calls.”

There is the capacity to participate in remote monitoring via an app along with a paper alternative as needed, though Rachel noted that most people tend to use the digital option. “Users can input all sorts of information and access services from COPD, Parkinson’s, heart disease – there are lots of different modes and modules within this app that we can use. They put their observations in and it alerts to us on a dashboard in the hub – we can then process that alert and make a plan of what we’re going to do. That’s all documented in SystmOne, so everybody can see that this person has alerted and what we’ve done about it. Sometimes we call them, sometimes we video call them – in other situations, we just message them to say ‘how are you doing?’, depending on what the alert is. We are able to identify very early if they’re beginning to deteriorate or veer from their normal state, meaning we can intervene very quickly.”

Essentially, Rachel said, “We offer 24/7 access to a qualified health care professional for patients living in their own homes with a long-term condition… We want to improve patient experience and flow, keeping them out of hospitals if we possibly can and thereby reducing costs.”

Touching again on offender health, she described how the service covers around 44 prisons and young offender institutes, offering a mix of consultant, therapy and specialist nursing services. Rachel shared some data on appointments and waiting times, commenting: “Waiting times are quite low which is great in terms of accessibility for these vulnerable people. It is truly amazing how many different services and patient consultations you can deliver remotely.”

Looking care care homes, Rachel shared how the hub uses ‘wall boards’ which “act as a live core management system. It shows us how many calls are coming in, how long people are waiting and if they are abandoning the calls if the wait is too long. Our KPI is for 80 percent of calls to be answered within five minutes.”

Data from the service also enables the team to analyse calls by hour and track which times of day they are most busy, enabling them to alternate staff accordingly.

The impact of digital on care homes

The trust is particularly proud of the hub’s work to support care homes, Rachel said; she shared some stats showing how it has supported 90 percent of patients to remain in their place of residence, with 4000 calls per month handled in 2020/21. 50 percent of those required no onward referral.

At 9:28, she showed a graph demonstrating the number of calls received from care homes and the percentage of residents who were conveyed to hospital as a result, peaking at around 30 percent in 2018.

“We do not convey people to hospital if we can help it, if we can keep that person safe in their own home or care home. The last thing we want is for people to be carried into hospitals on trolleys, sitting there for hours and hours,” she said. “Importantly, the kind of monitoring that we would do in terms of their neurological observations, such as blurred vision, feeling drowsy or confused, can all be done in the care home. Staff can reach us within a few minutes, we can go through how to monitor the patient to make sure that they are not deteriorating, and then we call back after a couple of hours and after six hours to check in.”

The team can also support care homes with things like falls and medication, which could include advising GPs on whether a resident is due a medication review. “We have consultant pharmacists working in the hub now, which has been a brilliant addition in the last year.”

The service has helped the trust get conveyance rates down to 10-15 percent, she said, and 50 percent requiring no onward referral “is fantastic.”

As well as keeping patients safe at home, Rachel added, it’s about changing the flow of patients into hospital, and the associated benefits that come with that.

“We can now electronically prescribe which is brilliant for people in their own homes as well as in care homes,” Rachel continued. “We are spreading this from our local area towards Dorset, Devon and Liverpool. Electronic prescribing is great in terms of governance as we can keep an eye on things, what staff members are prescribing, and look at their scope of practice.”

72-hour service 

Moving onto the 72-hour service offered by the hub, Rachel said: “This is a service that we started off right at the very beginning, for people who are coming into A&E who have been confirmed as low risk by us or by the hospital. They can either go home or they will potentially be kept in for a day for observation. We then come in and tell the hospital to get them stable and send them home, and we will keep an eye on them for the next three days.”

This entails making calls a few times a day, making sure that the patient still stable and that they are feeling well enough to remain at home. Rachel noted that “nearly all of them want to be, and if there are any questions that they have or any worries, we can support them by telephone or video to manage those issues at home.” As the hub is based in an acute trust, Rachel continued, they can also get their specialists and nurses to make a telephone or video call if required.

“People don’t have to go to A&E to be referred – our urgent care response team can also visit people at home to assess whether they need our help.” The stats show that 86 percent of these cases have no onward referral.

Ambitions and future goals 

“In our Digital Care Hub, we have put all these services together as a means to empower patients and carers to manager their conditions at home with support from us. We’re trying to build system resilience because as  a system, we cannot sustainably cope with all the work the way things are going at the minute,” Rachel said.

“Our other key goal is to protect our environment, which is crucially important. If we can decrease the amount of people having to travel to hospital, not only does it protect us in terms of our physical and mental state, but it also protects our environment and our patients as well.”

Over the next three to five years, she said, she would “love to see everybody with a long-term condition being able to be managed or supported like this in their own homes. We do it in our places, there’s no reason that we can’t spread across other systems so other places can do it too. The whole point is to support people to help themselves, to proactively manage their condition keeping them happy and healthy at home.”

A few years ago, Rachel acknowledged, she would have thought that they would “never be able to get people to use apps to support them, but actually having introduced it, it works really well. I think one of the few things we can say about COVID is that it did make people realise that you didn’t necessarily have to be face-to-face to deliver a really good service.”

The other ongoing objective of MyCare24 is to “reduce dependence on stretched healthcare services. I think sometimes in the community, people go to see their patient at home just in case, because they’re a bit worried. We can do that assessment remotely now and reassure those healthcare professionals that their patient is absolutely fine and does not need a member of the community service team or the virtual ward team to go and see them in person. We are realising the patient and system benefits of this and we want to do this at scale – the whole point of doing this is to do it big.”