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4th October 2024
More patients are experiencing delayed discharges from hospitals, but integrated care boards (ICBs) are working with system partners to develop new and innovative ways to address this. In the first of four case studies, Kathy Oxtoby reports on how Central London Community Healthcare Trust is approaching this longstanding issue via virtual ward and Quick Start initiatives.
To reduce unnecessary delays to discharge and needless admissions to hospital, Central London Community Healthcare NHS Trust‘s (CLCH’s) Hospital at Home Service in Wandsworth and Merton operates as a virtual ward.
One of the first community trust-led virtual wards in the country, it combines technology and face-to-face visits to allow hospital-level care, including diagnostics and treatment, to be carried out in a patient’s own home.
Through on-the-spot blood testing, remote monitoring and face-to-face visits from advanced nurses at CLCH, frailty patients receive the hospital-level care they need safely and conveniently and closer to their support networks, the trust says.
Since its launch in December 2021, the trust estimates the initiative has saved approximately 4,836 hospital bed days in Wandsworth and Merton (as of August 2024).
This approach helps to ease urgent and emergency care capacity pressures by improving patient discharge rates, or avoiding admission.
The trust’s Quick Start initiative brings together CLCH’s Hospital at Home and discharge services to provide ‘the right care to patients at home’, the trust says. Patients can be provided with therapy, medical or social care support dependent on their needs, preventing admission to hospital and supporting earlier discharge from hospital.
CLCH works with acute services at the point of admission to ensure that the package of care a patient needs at home will be ready for them as soon as they are well enough to leave hospital, preventing delays due to the absence of safeguarding support or equipment to help their recovery, the trust says.
Dr John Rochford, deputy chief medical officer at Central London Community Healthcare NHS Trust says: ‘In collaboration with South West London Integrated Care System – our partners in acute, primary and social care – we provide tailored support to care for our communities at home.’
He says CLCH and the South West London ICB are ‘enhancing patient care through the use of virtual wards with a focus on ensuring seamless integration of services, pre-hospital care to help patient flow and improving patient outcomes through prevention and early interventions’.
‘The partnership around virtual wards exemplifies a shared commitment to delivering high-quality healthcare in many areas, such as digital solutions to support clinicians to make quicker and safe bedside decisions, to meet the needs of the community,’ he says.
‘This innovative way of working means that we are able to support more patients to get better in their own homes, helping them to avoid unnecessary and lengthy admissions to hospital, which can have a detrimental impact on their health,’ says Dr Rochford.
‘Patients fare better in familiar surroundings, when they can sleep in their own bed, eat the food they like and have friends, family and pets around them whenever they wish,’ says Dr Rochford.
Mark Creelman, Merton and Wandsworth place lead at South West London ICB, says: ‘Across South West London, there are four virtual ward – hospital at home – services covering our six boroughs, all with face to face and remote monitoring capabilities to provide hospital level care for patients who would otherwise be on a ward, in the comfort of their own home where it is safe to do so.
‘We now have 415 “beds” with a central remote monitoring hub operating 24 hours a day, seven days a week to support patients’ own monitoring, and we continue developing our virtual wards to improve services, help ease pressures on urgent and emergency care and contribute to reducing avoidable admissions.’
Read more about tackling delayed hospital discharge and improving patient flow in this analysis, and discover some of the other inspirational work being done across England in the other case studies in this series:
This case study was originally published by our sister publication Healthcare Leader.
More patients are experiencing delayed discharges from hospitals, but integrated care boards are working with system partners to develop new and innovative ways to address this. Kathy Oxtoby reports.
Patient discharge is a well-documented pinch point for the NHS.
According to The King’s Fund, delayed discharges from hospital are ‘a widespread and longstanding problem that can have a significant impact on both patients’ recovery and the efficiency and effectiveness of health and care services’.
And the Nuffield Trust says a huge challenge facing the NHS is that more patients are experiencing delayed discharges. ‘Reversing this trend is a major system priority given rising waiting lists, overstretched A&E services, and the risks that unnecessary long stays in hospital pose to patients,’ it says.
Analysis by the think tank found that the total number of patients in acute hospitals who were ready to leave but were delayed has increased by 43% from an average of 8,545 patients per day in June 2021 to 12,223 patients per day in June 2024. At its peak, in January 2024, there were 14,096 patients delayed in hospital.
The fall and rise of delayed discharges observed this year may be indicative of winter pressures. ‘Every winter sees an increase in A&E admissions and a reduction of staff due to sickness absence that can hinder effective discharge processes within hospitals,’ it says.
Changes in the total number of delayed patients are mainly attributed to increases in delayed patients who have been in hospital for up to 21 days or longer, this analysis shows. These patients are more likely to experience delays in discharge because often their needs are more complex and their care needs outside of hospital are greater, and organising that care takes more time and resources, says Emma Dodsworth, a researcher at the Nuffield Trust.
Prolonged stays in hospital are ‘bad for patients, especially for those who are frail or elderly’, NHS England says. ‘Spending a long time in hospital can lead to an increased risk of falling, sleep deprivation, catching infections and sometimes mental and physical deconditioning.’
Delays to patient discharge impact the wider health system. ‘We know that hospitals are struggling to manage the flow of patients because of the high volume of beds being occupied by people who might be better cared for elsewhere,’ says Ms Dodsworth. ‘When people are struggling to get out of the system it is more difficult to get people into the system – so we tend to see pressures on entry points to health services such as on ambulance services and A&E departments,’ she says.
Delays to patient discharge are also having an increasing impact on community health services and social care, says Ms Dodsworth. She says often, there is a desire to get people out of acute settings and quickly into community settings in the form of a step-down intermediary care package. ‘But you risk putting them into an additional setting that also faces delays with discharge and risk pushing the bottleneck further down the patient pathway,’ she says.
A lack of capacity in social care settings is often cited as a reason for delayed discharge, says Ms Dodsworth. The most common reason for discharge delays experienced by patients who have been in hospital between seven and twenty days is that they are waiting for some form of home care – and this could be due to staff shortages within the sector, says Ms Dodsworth.
And the most common reason for delayed discharges for patients who have been in hospital 21 days or more is waiting for a bed in a nursing or care home – and there is ‘a shortage of places in council-run care homes’, says Ms Dodsworth.
However, the reasons for delayed discharge are also ‘complex and varied’, she says. These can include hospital processes delaying discharge, for example, a discharge summary that needs to be written up or a final assessment or agreement on what further care the patient might need. Delays to these processes could be due to a shortage of healthcare staff, says Ms Dodsworth.
Funding given to help tackle discharge delays can also bring problems.
To reduce delays every winter, in England, it has become normal practice for the Government to provide additional one-off funding.
Last year, researchers at The King’s Fund interviewed commissioners and service providers in six local areas who said that while they welcomed extra funding, it came with ‘insufficient advance notice for effective planning, sometimes having to be spent on residential care that was available at short notice rather than developing more services to support people at home’.
Commissioners and service providers also wanted to be able to use the funds to prevent avoidable hospital admissions and ‘strongly criticised burdensome monitoring requirements’, researchers found.
Some areas did manage to use the funding to put services in place and support the social care workforce but were ‘not confident they were spending funding as effectively as possible’.
Researchers found varying depths of partnership working and that not all have a shared understanding of local causes of delayed discharges and priorities for action. ‘This, together with fragmented and inconsistent data, could hinder their ability to use additional funding effectively,’ the report found.
Key partners – including ICBs and the local authorities – ‘are all trying to work together, but because of different accountabilities don’t always have a depth of partnership’, says Alex Baylis, acting director of policy, events and partnerships at The King’s Fund, and one of the report’s authors.
Affecting these partnerships is a culture of ‘who is to blame for discharge delays’, with some hospitals blaming social care and vice versa, says Mr Baylis.
This year, the money to reduce discharge delays in winter was rolled into the Better Care Fund ‘so we’ll need to see whether there is a better sense of partnership’, says Mr Baylis.
Some £1.6bn has been allocated to social care services for 2023-25 as part of the Better Care Fund, which will include a focus on reducing delayed discharges, says Ms Dodsworth.
And ICSs have put in place initiatives to better handle winter pressures and the delayed discharges that come about during this time, she says.
Initiatives include virtual wards, allowing people to receive hospital care in their own homes, and transfer of care hubs which bring together system partners to better coordinate services to support timely discharge, says Ms Dodsworth.
Mr Baylis says there are examples of good practice around the country, rooted in local organisations – particularly across the NHS and local authorities – having a shared understanding of their specific local issues and the same shared data and plan.
There are also widespread examples of initiatives using the voluntary and community sectors to support people at home after discharge, he says.
In some areas, work is being done around discharge lounges, ‘which are staffed a bit like wards, may have beds, and can help get people off the wards into a lower intensity environment and free up a bed for someone who is acutely unwell’, he says.
Asked how the primary/secondary or social care/secondary care interface are working to better manage the flow of patients, Mr Baylis says: ‘Each general practice is unique, and each care home is independent, so it’s difficult to generalise how they work with hospitals.’
‘We found the involvement of general practice in local planning around winter discharge was quite variable, partly because it’s difficult to engage all of the GPs because they are independent. But GPs need to know if they are going to have patients discharged with higher levels of acuity and complexity,’ he says.
‘And in social care, the same happens – they are all independent businesses and charities, so different local authorities have different levels of ability to really engage across the whole social care market.
‘They all want the best thing for the individual patient, but they are not always organised to make it easy to deliver that,’ says Mr Baylis.
As for the role ICBs play in supporting the system in terms of patient discharge, he says they are ‘possibly the most interesting part of the entire health and care system at the moment, because they face in two directions’. ‘They support the local providers and services, but at the same time, they answer back up to NHS England,’ he says.
‘If NHS England puts pressure on ICBs to just get people out of hospital, that can undermine their role in supporting the development of the system as a whole because they are skewed towards those priorities.
‘So ICBs have a really important role to keep the focus on facilitating whole system approaches, and not to withdraw into the priorities that NHS England has specifically for hospital performance. It’s a balancing act,’ he says.
‘ICBs are in a tricky position because the short-term priority is to get people out of hospital. But the long-term solutions will only come from the whole system having a shared understanding, plan and way of working,’ he says.
To help address issues with patient discharge, the Nuffield Trust is calling for the government to ‘stop allocating funding to support discharge via short-term emergency pots that make planning impossible’, says Ms Dodsworth.
‘It means that ICS leaders and local authorities are reluctant to commit to commissioning new services because they don’t necessarily have long-term funding to support their ambitions,’ she says.
‘Needs are becoming increasingly more complex, and so we need system leaders to think about how to ensure the right care is available,’ she says. ‘Sometimes when we’re focused so much on getting people out of hospital, we’re not always thinking about whether we’re getting the patients into the best place that meets their care needs.’
Long-term sustainable approaches need to be rooted in prevention, she says. ‘Often, unpaid carers will feel that emergency admission of their loved ones could have been prevented in the first place if there was better access to support in the community. It’s about reframing prevention as a precursor to good care for people,’ says Ms Dodsworth.
Mr Baylis says there is ‘a good potential to reduce admissions to hospital in the first place’. He highlights NHS England’s Enhanced Health and Care Homes framework, ‘where GPs regularly visit care homes and check up on what can be done to keep people well’. He says this has been shown to reduce hospital admissions, particularly emergency admissions.
There’s also a role for ICB leaders to ‘get under the skin of how to make whole system working effective for reducing discharge’, he says. ‘ICB leaders have great potential to really work as system facilitators and support that partnership approach, which is driven by shared understanding and close working approaches that are fundamental to long-term solutions to discharge problems.
‘And when they do that, the benefits for individuals, staff pressures, and budgets are big. It is skilful work that is all about leadership across systems. And it’s not easy,’ he says.
‘Every area has unique challenges with patient discharge, and there is no “one size fits all” solution,’ says Mr Baylis. ‘That’s why it’s so important to have a shared understanding of the specific local issues, a shared plan, shared data, really close working and a shared view of what good looks like.’
Read more about the inspirational work being done across England to support the smooth and timely discharge of patients from hospital in these case studies:
This feature was originally published by our sister publication Healthcare Leader.
26th October 2023
Virtual wards should be expanded to include heart failure patients to help reduce recovery times and ease pressure on hospital beds during the winter season, new NHS clinical guidance has outlined.
NHS England has now pushed for integrated care boards to work with cardiac clinical networks to better understand their heart failure population needs and workforce competencies.
The expansion is set to build on the use of and learning from virtual wards for acute respiratory infection and frailty.
It comes after the NHS met its target last month to deliver 10,000 virtual ward beds, through which more than 240,000 patients treated successfully since April 2022.
There are currently a dozen heart failure virtual wards up and running, NHS England said. This includes Liverpool University Hospitals NHS Foundation Trust and Mersey Care NHS Foundation Trust, which together have supported more than 500 people on virtual wards for heart failure.
According to the guidance, as a minimum requirement the new virtual wards should ensure people with heart failure have access to rapid specialist advice and guidance, including via video or telephone, where necessary.
ICBs must also make sure these digital wards feature a daily virtual review with the heart failure team or a multidisciplinary team, with robust processes for escalating concerns.
NHS England also advised an ICB’s approach support ‘seamless patient care’, which may include:
NHS England’s national clinical director for heart disease Professor Sir Stephen Powis said: ‘More than 240,000 patients have already benefitted from virtual wards, and now we are growing this service to patients with heart failure.
‘This is a positive development in how the NHS can treat patients, and testament to the hard work of our staff after hitting our target of 10,000 virtual ward beds last month.
‘The expansion has been implemented at a key time just before winter, when there will be a lot more pressure on our hospitals and will free up beds for those who need them the most.’
Around 200,000 people a year are diagnosed with heart failure and often require significant NHS support, including long or frequent hospital stays. Some 5% of all emergency hospital admissions in the UK are attributed to the condition.
A version of this story was originally published by our sister publication Healthcare Leader.
1st August 2023
A lack of understanding of what virtual wards actually are ‘may be holding back’ progress and uptake of the model in the UK, despite evidence of the public being largely supportive of the concept, researchers have suggested.
According to a survey led by The Health Foundation, 45% of the UK public is ‘very‘ or ‘quite‘ supportive of virtual wards, with over a third (36%) saying they were ‘not very‘ or ‘not at all‘ supportive. Some 19% responded that they didn’t know.
However, when asked if they would be happy to monitor their own health at home using technologies, instead of in a hospital – a similar scenario that avoided the term ‘virtual ward’ – support shot up to as many as four in five (78%), compared to just 13% rejecting the idea.
This indicated that a lack of knowledge about virtual wards was ‘stymying support for the policy’, risking slowing the uptake for the model of care, The Health Foundation said.
NHS England is aiming to introduce more than 10,000 virtual ward beds ahead of this winter, including an announcement last month to expand the services to cover children’s care.
Current NHS England guidance is also driving the digitisation of virtual wards, with plans to enhance them through the use of technologies, such as remote monitoring. Similar commitments are also in place in Scotland, Wales and Northern Ireland.
The Health Foundation’s research also found that:
The research also included 1,251 NHS staff. Of these, almost two thirds (63%) were either ‘very‘ or ‘quite‘ supportive of virtual wards, while 31% were ‘not very‘ or ‘not at all‘ supportive. When asked what will matter for making sure virtual wards work well, their top two factors were the ability to admit people to hospital quickly if their condition changes, and the ability for people to talk to a health professional if they need help.
Director of innovation and improvement at The Health Foundation, Dr Malte Gerhold, said: ‘It is encouraging to see support for virtual wards is higher among those more likely to require healthcare, such as older people, disabled people and those with a carer. As virtual wards are rolled out, the NHS will need to consider the barriers that households can face and make sure they have the right support available.
‘In the face of unprecedented pressures, the NHS won’t be sustainable in future without greater use of new technologies, so ensuring new ways of delivering care have the backing of patients and the public will be critical if they are to become part of business-as-usual. As well as evaluating virtual wards to ensure they are delivering high-quality care in practice, policymakers need to engage more with the public about how to maximise the potential of better tech-enabled care at home.’
A version of this article was originally published by our sister publication Healthcare Leader.
5th July 2023
Hospital-level care at home will reach children in every region of England with the expansion of the NHS virtual wards services this month, NHS England has announced.
NHS chief executive Amanda Pritchard will announce the expansion today (5 July) to mark the 75th anniversary of the NHS.
The virtual wards service will treat conditions like respiratory illness and heart conditions, with children able to receive care in familiar surroundings, intended to speed up their recovery and free-up hospital beds.
In the last year, more than 6,400 children have been successfully treated during trials, including in Blackpool, Dudley and Dorset.
More than 160,000 adult patients have been successfully treated on virtual wards since April last year.
The rollout comes as part of the NHS’ plan to create 10,000 extra virtual beds by winter.
Announcing the expansion, Ms Pritchard said: ‘As the NHS celebrates its 75th anniversary today, it is amazing to see how services have changed since our foundation. Virtual wards are already providing excellent care to families when their children are sick, and this expansion will enable thousands more to receive high-quality care from home.
‘Being treated at home can have a hugely positive impact on patients – it means they receive hospital-level care, but it also means they are not separated from their families – providing peace of mind for loved ones.’
The NHS’ national clinical director for children and young people, Professor Simon Kenny, said: ‘The introduction of paediatric virtual wards means children can receive clinical care from home, surrounded by family and an environment they and their parents would rather they be – with nurses and doctors just a call away.
‘More than 6,400 children have already been treated on a virtual ward, which also means they spend less time in hospital and that paediatric beds are there for the children that need them most, when they need them.’
Patients on a virtual ward are called for by a multi-disciplinary team providing a range of tests and treatments, with patients reviewed daily by the clinical team.
This story was originally published by our sister publication Healthcare Leader.
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