Report

Integration and innovation in action: virtual care

An in-depth look at how NHS organisations are using virtual care to improve outcomes for patients and local communities.

17 December 2021

Key points

  • NHS organisations and health and care systems moved quickly to implement virtual ways to deliver care in response to the pandemic. The shift precipitated innovative ways of working, a new relationship with the public and more integrated working within and between organisations, systems and professions.
  • Virtual care has proved a critical lifeline throughout the pandemic, enabling the health and care sector to care and support patients and communities.
  • As the NHS grapples with the arrival of a new COVID-19 variant, rolls out the booster programme and deals with rapidly rising demand, virtual care will be an important bulwark against a winter crisis.
  • This report outlines a range of examples where NHS organisations are using virtual care to improve outcomes for patients and local communities. Based on interviews with NHS leaders, it reflects on the opportunities and challenges of remote care.
  • NHS organisations have also started to think beyond the pandemic, and in the last 18 months more than 50 virtual wards have been established to deal with non-COVID-19 conditions. They are starting to embed the innovations they want to keep and simultaneously looking at how to adapt and introduce new ones to meet longer-term objectives.
  • However, while virtual care has several merits, it is not a silver bullet for all the challenges facing the NHS. Concerns have been raised over its potential to exacerbate health inequalities and widen the digital divide. These issues are now a core area of focus for healthcare leaders and their teams.

Background

Over the last 18 months the NHS and public have rapidly adapted to virtual modes of delivering and receiving care. A lifeline for clinicians and patients alike, virtual care has enabled the health service to reduce infection, manage increased demand and care for patients.

The rapid shift precipitated innovative ways of working and deepened integrated working within and between systems, teams and professions.

Yet the debate surrounding remote care has become polarised, catalysed by misconceptions that it has become a blanket (and, some argue, sub-standard) substitute for in-person care. The reality paints a different picture. Face-to-face appointments have continued throughout the pandemic and virtual approaches have suited many patients’ personal preferences and clinical needs. Some detractors have tended to oversimplify the issue, understate the benefits (to patients, the NHS and the environment) and gloss over the agency of patient choice.

Nonetheless, while virtual care has many merits, it is far from a silver bullet to the challenges facing the NHS. Concerns have been raised over its potential to exacerbate health inequalities and widen the digital divide. These issues are now a core area of focus for healthcare leaders and their teams.

In the last 18 months more than 50 virtual wards have been established to deal with non-COVID-19 conditions

While not a silver bullet, virtual care is an important bulwark against COVID-19. As the NHS confronts a challenging winter, grapples with the arrival of a new variant and rolls out the booster programme, this will be even more so.

The NHS has already begun to assess how digital technology might be used to support the road to recovery. This includes exploring its potential to help tackle the elective care backlog and workforce shortages, and how it might be applied to improve the quality of care and productivity.

NHS organisations have also started to think beyond the pandemic, and in the last 18 months more than 50 virtual wards have been established to deal with non-COVID-19 conditions. They are starting to embed the innovations they want to keep and simultaneously looking at how to adapt and introduce new ones to meet longer-term objectives.

There is acknowledgement that while the health service must seize one of the few positive legacies of the pandemic, there is still work to be done to evaluate the impact of these changes for patients and staff. Crucially, it must ensure that increased use of virtual care is not widening or creating new health inequalities. A blended approach of both remote and face-to-face provision will be needed in the immediate and long term.

This report outlines a range of examples where NHS organisations are using virtual care to improve outcomes for patients and local communities. Based on interviews with NHS leaders, it reflects on the opportunities and challenges of remote care and the lessons COVID-19 has highlighted for future practice.

Defining virtual care

Virtual care is a broad term that encompasses all the ways in which healthcare providers interact remotely with patients. For this report, we have used the term ‘virtual care’ due to its broad scope and the case studies referencing different types of digital tools being used in different ways.

We are grateful to the NHS leaders who have given their time to contribute to this report and our wider Integration and Innovation in Action series. Our hope is that the insights shared throughout the series will support you with the task ahead, shine a light on the changing way members are working, and connect you with a community of leaders across the health and care sector.  

    This report draws on the following case studies:

    South West Yorkshire Partnership NHS Trust, which is exploring ways to overcome digital exclusion.

    Milton Keynes University Hospital NHS Foundation Trust, which is making extensive use of digital technology to enable patients to book their own appointments and see clinicians virtually.

    Suffolk and North East Essex Integrated Care System, which supported organisations across its footprint with the shift to virtual care and has been working with the public to co-produce principles on the use of digital.

    Warrington Innovation Network Primary Care Network, which is using digital triage triage to ensure that more patients go straight to the most appropriate person, reducing the workload for GPs.

    Norfolk and Norwich University Hospitals NHS Foundation Trust, which set up a virtual ward at speed at the start of the pandemic.

    We are grateful to the senior leaders who took the time to share their insights and learning to inform this report: 

    • Dr Dan Bunstone, GP Clinical Director, Warrington Innovation Network Primary Care Network
    • Professor Joe Harrison, Chief Executive, Milton Keynes University Hospital NHS Foundation Trust
    • Kate Walker, Digital Programme Director, Suffolk and North East Essex ICS
    • Emily Wells, Chief Nursing Information Officer, Norfolk and Norwich University Hospitals Foundation Trust
    • Salma Yasmeen, Director of Strategy, South West Yorkshire Partnership NHS Trust

    Taking a virtual leap forward

    Supportive systems

    With the rollout of virtual appointments, remote monitoring and electronic patient records, much of the focus on virtual care has been at an organisational level. But health and care systems have played an important role in driving adoption, facilitating collaboration and providing consistency at a pan-organisational level to support patients and staff.

    Suffolk and North East Essex ICS is a case in point.

    In four to five weeks, the ICS set up what would normally have taken two years

    The ICS had a digital care strategy in place when the pandemic struck, but capacity to deliver it was rapidly stepped up in response to COVID-19. One of its aims was to protect staff and patients from infection, so focus was placed on enabling staff to work at home, ensuring that services went ahead in some form and were easily accessible and resilient. “We were forced to become digitally literate overnight,” remarks Kate Walker, digital programme lead for the ICS.

    In four to five weeks, the ICS set up what would normally have taken two years. This included connecting hospital and GP records, enabling patient portals and apps so contact with the NHS could be done digitally, and improving remote staff access to hospital systems. It also provided tablets to care homes and wards to enable virtual appointments to take place. “The adoption rate was staggering,” says Ms Walker.

    The ICS:

    • helped 100 GP practices to set up online surgeries and made sure patients had the ability to access key information and order repeat prescriptions
    • mapped where patients with COVID-19-like symptoms were and established how they could be best supported
    • created a new app to allow medical staff to access records remotely
    • gave vulnerable people easy to use tablet devices, so they could connect with their family and friends
    • offered antibody testing to over 20,000 NHS staff in only five weeks, at two weeks notice, through the use of technology.

    The ICS has taken care to seek feedback from local communities on virtual care and has implemented improvements based on the findings.

    For the ICS’s digital lead, the use of shared care records will be key to greater use of technology by clinicians and others in an individual’s care. She is not alone in this view.

    Information sharing

    As organisations work more closely through provider collaboratives, integrated care systems and place-based partnerships, the ability to align technologically has become ever more important. Digital solutions will be a core pillar of the drive to deliver more integrated care, including the ability to share information across all partners in an individual’s care.

    Shared care records, for example, are enabling multi-disciplinary teams to provide patients with joined-up packages of care across providers. “We want staff to be able to work across boundaries,” says Salma Yasmeen, executive director of strategy and change at South West Yorkshire Partnership NHS Foundation Trust. “It is a really exciting time ahead, but we need to think about building this into operating models and clinical models.” The trust provides mental health, learning disability and community services in Barnsley, Calderdale, Kirklees and Wakefield.

    By enabling clinicians to access information and advice from other parts of their system, shared information is enhancing clinical decision-making. Milton Keynes University Hospital NHS Foundation Trust and its primary care and community partners, for example, can now access the same information on patients. And, with the help of an app, patients too can access information about their care, such as blood test results.

    “This is something which COVID-19 has done well - moving away from the paternalistic relationship with the NHS and instead engaging the individual with their own information,” explains the trust’s chief executive, Professor Joe Harrison.

    The trust is also using technology to reduce the need for clinicians to spend time gathering information about patients. Rather than giving details of their condition at a pre-assessment clinic, patients are now asked to fill in a digital form ahead of time. This improves the accuracy of the data collected, saves time and enables patients to do it at a time of their choosing.

    Demand management

    With the NHS under significant pressure, technology offers some potential to manage demand and enable clinicians to manage care differently. Dr Dan Bunstone, clinical director for Warrington Innovation Primary Care Network, suggests that 70 per cent of patients can be dealt with without a face-to-face appointment. This frees up time for GPs to spend with patients who really need that sort of consultation. By using technology, individual care providers can manage patient care in a way that reduces pressure elsewhere in their system.

    His PCN is embracing the potential for digital solutions to revolutionise the way patients are routed through general practices, helping patients to get the help they need from the right healthcare professional at the first contact.

    Workforce

    Dr Dan Bunstone says his PCN’s ‘digital first’ approach is partly by necessity and partly by design. The challenge of recruiting GPs has made the pressure on those who remain so intense that changes have to be made. While digital is not a solution to wider workforce problems, it does support existing staff, changing the way they engage and support patients.

    The ‘digital first’ approach that many in the NHS were adopting prior to the pandemic accelerated at a rapid pace due to COVID-19, bringing new ways of working for many. Milton Keynes University Hospital NHS Foundation Trust had already moved away from paper records, enabling staff who previously spent time managing paper records to move into other, potentially more satisfying, roles. The shift to electronic records enabled them to quickly move to different ways of working when the pandemic hit.

    The ability to work from home meant that staff could quickly step in to help when needed

    “We found that our clinicians were absolutely desperate to get involved – whether virtual ward rounds, discharge letters or virtual clinics,” says Prof Harrison. The ability for clinicians to work virtually enabled them to choose where they performed some of their work, improving their work-life balance, a key challenge for many in the NHS.

    This sentiment was echoed by Norfolk and Norwich NHS University Hospital NHS Foundation Trust, which found it could offer flexibility to staff who were shielding. The ability to work from home meant that staff could quickly step in to help when needed. “We are offering a new and flexible way of working, but we have also been able to redeploy staff who had been off sick,” says Kate Wells, the trust’s chief nurse information officer.

    The rapid roll out of virtual appointments wasn’t just new for patients but also for many staff. While the initial move to virtual came at a rapid pace, some trusts are now taking time to look at how they ‘lock in’ those changes in the long term. Salma Yasmeen, executive director of strategy and change at South West Yorkshire Partnership NHS Foundation Trust, says the trust is involving staff in their future, more integrated digital offer. But it comes at a price: “technology does not stand still and there are revenue implications of keeping on using and upgrading it.”

    Digital equity and inclusion

    Used well, virtual care has the potential to improve population health. It can allow for increased patient choice, better experience and broader access. But to capitalise on the potential, the NHS will need to better understand the impact of virtual care across different communities and groups of patients.

    An often-stated fear is that virtual care might exclude those who are not comfortable using technology or do not have easy access to it. However, Milton Keynes’ Prof Joe Harrison argues that offering patients a choice is not just beneficial to those who use technology in their everyday lives. For him, offering it to those that want it enables the trust to offer a better service to those who do not, to those who still want their outpatient appointments sent by post and who value face-to-face contact with health professionals. In essence, the use of virtual care may also improve the quality of traditional methods of care. “The use of technology enables the system to offer a choice which was not there before,” he says.

    Virtual care also has the potential to enable patients to see the right healthcare professional faster. Warrington Innovation Primary Care Network (PCN), which was using virtual care prior to the pandemic, directs patients through a “total triage” process before an appointment is made. Dr Dan Bunstone, clinical director for the PCN, says this has enabled them to direct patients to the right person prior to an appointment. Dr Bunstone’s own surgery – Chapelford Medical Centre – sees 30 to 50 patients each day who could be helped in other ways and do not need contact with a GP. “Now we are at the stage of looking to expand it. It is our raison d’être to get the right person in front of the right healthcare professional” says Dr Bunstone.

    Throughout our interviews, there was a recognition that the use of digital technologies will not be the right medium in every situation, even when no ‘hands-on’ care is needed. Salma Yasmeen gives the example of a mother with perinatal mental health issues - a face-to-face appointment may give vital contextual information that is not captured by a digital consultation. But she also acknowledges that asking a mother to visit trust premises can have its drawbacks. This is why the trust is guided by patients as far as possible and tries not to impose “solutions” on patients, instead thinking about virtual care in terms of “choice, preference and need”.

    Patients who might be most at risk from catching COVID-19 during a hospital admission may appear to be less likely to use technology or may struggle with hard-to-use digital solutions. The leaders interviewed believe that it is worth persevering, arguing that when technology is used intuitively, it can extend its use to patient groups who might otherwise not benefit from it.

    One way to tackle digital exclusion is to ensure that models of care are co-designed with patients

    Norfolk and Norwich University Hospitals NHS Foundation Trust has found that the technology it uses has been acceptable to most patients, especially as it has become smaller and easier to use. Emily Wells says that patients with dementia and learning disabilities at the trust have used technology successfully – and these are the groups often most at risk from COVID-19 should they acquire it during a hospital stay.

    For patients to harness the potential of digital technology, they need access to it in the first place. 17 per cent of those over 65 surveyed by The Health Foundation said they lacked a suitable device to download a COVID-19 contact tracing app (Health Foundation 2020). 1 One approach that is being used by South West Yorkshire Partnership NHS Foundation Trust to overcome digital exclusion is the gifting and loaning of equipment to patients who would not be able to supply their own. Additionally, Warrington Innovation PCN is putting in place mitigating actions for those patients who do not have digital access at home, including setting up access points in local pharmacies.

    One of the ways in which digital exclusion can be tackled is through ensuring that models of care are co-designed with patients, and patient feedback is built into the implementation and delivery. Suffolk and North East Essex ICS recognised that services worked differently across the system and realised the need to tailor to the local context in collaboration with local organisations and communities. As part of its learning, the ICS repeatedly sought feedback on patient experience through the local Healthwatch as it scaled up the use of virtual care. The feedback showed that there was some opposition to the use of digital technologies and concern about health inequalities being exacerbated by their adoption.

    While there is huge potential for virtual care to improve patient access and choice, the conversation is far from over. The recent media backlash over virtual care has highlighted that there is still a lot to do to build people’s digital skills, awareness, trust and confidence. As Suffolk and North East Essex ICS’ Kate Walker says, “Patients need to see the benefits – the usefulness of the NHS App, for example – or they won’t adopt technology willingly”.

    System working also enables an integrated approach to issues that affect all providers, such as digital exclusion, where a system-wide approach would enable the sharing of learning and for these issues to be addressed across the whole system.

    The importance of evaluation

    The speed of adoption meant there was little opportunity to bring service users and their families and carers along in the initial period, and to consider the impact for both patients and staff. 2 NHS services are only now able to deeply assess and evaluate these innovations. 

    The rapid adoption of virtual care models does not necessarily mean they have all been successful. Many will not have been co-produced with the patients that use them, and there will be aspects of implementation that need to be revisited to ensure they work well. Suffolk and North East Essex ICS acknowledges that the virtual models it adopted at the start of the pandemic “now need to evolve” to meet future need. “We need to sustain those things that we need for the future. The message we are getting is that we want these tools but we want to use them in a better way” says Kate Walker.

    Similarly, South Yorkshire’s Salma Yasmeen is concerned that after many years of talking about bringing care closer to home, digital can be seen as the antithesis to this – too remote, and users may become frustrated and believe they are being offered a lesser solution and/or service. 

    The trust is developing gifting and loaning schemes to overcome the issue of some patients who may not have access to the technology needed for virtual appointments. Addressing digital exclusion is something which may need a system wide approach, she says. The trust works across two integrated care systems – West Yorkshire, and South Yorkshire and Bassetlaw – and both are keen to address these issues and share learning. One solution may be taking existing kit and repurposing it to allow for re-use within the community, but access to data and connectivity might need additional funding, she says. 

    The need for investment

    There is huge potential for virtual care to support the NHS as it recovers from the pandemic. Norfolk and Norwich University Hospital, for example, has found that virtual monitoring at home is 82 per cent cheaper than having someone in an acute trust bed. With 501 patients on the virtual ward at some point during the pandemic, 3,548 bed days were saved. 

    While this is positive, if the NHS is to embed recent digital innovations, capital spending will need to keep pace, and long-term targeted funding will be needed to support the workforce and the evaluation of virtual models of care. 3

    Chapter footnotes

    1. 1. Health Foundation (2020), Public perceptions of health and social care in light of COVID-19 https://www.health.org.uk/publications/reports/public-perceptions-of-health-and-social-care-in-light-of-covid-19-may-2020
    2. 2. Health Foundation (2021), Securing a positive health care technology legacy from COVID-19 https://www.health.org.uk/publications/long-reads/securing-a-positive-health-care-technology-legacy-from-covid-19
    3. 3. NHS Confederation (2021), Beyond bricks and mortar: capital funding for the NHS https://www.nhsconfed.org/publications/beyond-bricks-and-mortar-capital-funding-NHS

    Virtual care: what we have learned

    • The pandemic meant that both clinicians and patients had strong reasons for switching to virtual consultations – avoiding infections – and ensured buy-in. This was an exceptional situation and may not reoccur.
    • Because of the need for speedy implementation, there was little initial opportunity to consult staff and patient about the technology which was to be used. Some organisations have done this afterwards, as part of evaluations.
    • ICSs can help to drive adoption and provide consistency at a pan-organisational level. They have a key role in identifying and addressing barriers to adoption, and to avoid ‘hitting the target but missing the point’. This enables organisations to derive greater value from their individual and collective investments.
    • The delivery of care in the aftermath of COVID-19 will not just be about the way individual organisations interact with their patients but also how they interact with each other, how they work together to connect with patients and how they use technology to support their staff to work across a system, providing greater flexibility and opportunity.
    • Evaluations of impact and benefits can help to cement clinical support for continued use of technology which was introduced as an emergency measure. Concerns that were muted during the pandemic may start to arise as we return to ‘business as usual.’
    • Technology does not stand still and some of the solutions adopted at the start of the pandemic have developed further since then. While most interviewees were not planning to decommission technology they had used during the pandemic, it might be used in slightly different ways or enhanced to give extra functionality.
    • To be widely adopted by both patients and staff, technology needs to be easy to use and require a minimum of training, if at all.
    • Some of the groups who would benefit most from staying out of hospital – minimising their risk of catching COVID-19 – will also struggle with hard-to-use digital solutions. Intuitive technology can extend its use to patient groups who might otherwise not benefit from it.
    • Some solutions will need to be at a level above the individual organisation – especially around shared information. Integrated care systems are often well placed to push these forward.
    • Some of the big wins come from being able to make use of clinicians who would not otherwise be able to work – for example, because they are shielding or have been deemed to be at high risk from COVID-19 if they continue in frontline positions. It may also suit those with other caring commitments.
    • Remote monitoring can mean staff do not need to come into a workplace to ‘log on’ which can make filling rota gaps easier.

    Join our Virtual Care Forum

    The adoption and spread of virtual tools to provide care has been at the heart of the NHS’s response to coronavirus. But how can we build on these new service innovations and ways of working to aid recovery and improve care?

    If you’re interested in or work in virtual care, join this learning set to share your views and experience.

    To join, please email Kelley Ireland.

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    Integration and Innovation in Action is a new series that showcases how local services are working in partnership to address the biggest challenges facing health and care. Head to the web section to find out more, register for events and join the conversation on social #IntegrationInAction