NHS Reset is an NHS Confederation campaign to help shape what the health and care system should look like in the aftermath of the pandemic.
In this blog, Dr Matt Kearney reflects on how COVID-19 has propelled changes to the way routine care is delivered.
The King’s Fund has published a report on technology and innovation for long-term conditions. The report reflects on the astonishing pace at which NHS services have moved online since the arrival of COVID-19 and describes some of the lessons learnt from recent case studies. Key among these is that ‘harnessing technology to deliver transformative change in healthcare is harder that it might initially appear.’
The pandemic has confronted us with an imperative to change the way we deliver routine care. Traditional NHS resistance to innovation has been replaced overnight by a hunger for new technologies, and primary care has transformed, with over 90 per cent of consultations now being delivered by phone, video or e-conversations. Such an extraordinary transition was inescapable given the existential threat posed to the NHS by COVID-19. But delivering high-quality comprehensive primary care in the new world will need much more than a switch to online consultations.
Management of long-term conditions illustrates the challenge. Maintaining good health and avoiding exacerbations in conditions such as diabetes, hypertension and COPD needs regular proactive review with assessment, monitoring and optimisation of treatment. COVID-19 has dramatically disrupted pathways of care with abrupt withdrawal of face-to-face appointments, cancelled referrals, limited access to diagnostic and monitoring tests and patient fear of contracting the virus if they report symptoms that might see them admitted to hospital.
These are some of the challenges that make it essential for us to do things differently in our approach to long-term conditions. But the sudden requirement to transform at scale also brings opportunities to address limitations and barriers in our traditional models of primary care, for example by using our workforce differently and by supporting a step change in self-management.
In response to the pandemic, at UCLPartners Academic Health Science Network we have developed a series of long-term condition frameworks (Type 2 diabetes, hypertension, COPD, asthma, with atrial fibrillation and lipids in preparation) to support this post-COVID-19 transformation in primary care. The frameworks are built on four key principles: virtual first, mobilising the wider workforce, a step change in self-management, and digital technologies to underpin the innovation. For each condition, the framework includes:
- Comprehensive SNOMED coded search tools for EMIS and SystmOne that risk-stratify patients based on clinical features, co-morbidity and ethnicity.
- Pathways that map interventions and staff roles to level of risk. For example, patients at high risk are prioritised to ‘see’ a clinician soon, and those at lowest risk can have virtual consultations with staff such as healthcare assistants (HCAs) or link workers to support education, self-management and lifestyle change. Where deployed, pathways will include local adaptation to ensure that people with poor digital access are not disadvantaged.
- A collection of digital and online resources that support remote management and self-management.
- Scripts and protocols to guide HCAs, link workers and others in their consultations.
- Bespoke training for staff to deliver self-management support and education for patients. Training includes health coaching, motivational interviewing and patient activation.
Using these frameworks, patients identified as high risk can be prioritised for early review by a GP, nurse or pharmacist with expertise in their condition. For those at low risk, such as patients with hypertension whose blood pressure is well controlled, the HCA or link worker will contact them by text to check if they have a BP monitor. If they don’t, they can be sent a link to the British Heart Foundation website that shows validated devices with information on cost and where to buy. If they do have a BP monitor, they will be sent a video link to demonstrate how to use it correctly, and the HCA or link worker can check technique with them in a single or group video consultation.
With their training in health coaching and prepared scripts to guide them, the staff member can then help the patient to understand what high blood pressure means and how to lower it and deliver brief interventions for smoking cessation, physical activity and weight loss as appropriate, drawing on a wide range of online resources. For patients with COPD, interventions would include teaching inhaler technique, use of apps such as MyCOPD, and how to recognise an exacerbation. And in diabetes, discussion would include checking feet and understanding red flags, and support to use apps such as Health.io for home monitoring of proteinuria.
A key message of the King’s Fund report is that just satisfying the understandable hunger for new technologies will not be enough to transform healthcare in the wake of COVID-19. Technology will be a key enabler, but clinical teams will need new pathways and new ways of working if we are to deliver high-quality proactive care to our patients with long-term conditions in this new world. The UCLPartners frameworks bring together some of the key components (searches, pathways, guides, training and digital) that are essential to support the NHS reset in primary care. The frameworks are now being rolled out in parts of London and elsewhere in England.
So as we work through the pandemic and mobilise technologies to help us do things differently, it is critical that we plan carefully for their use and identify the other building blocks that have to be in place if change is to be delivered at scale and in a sustainable way.
Dr Matt Kearney, GP and programme director at UCLPartners. Follow him on Twitter @DrMattKearney and connect on LinkedIn.
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