Inpatient care and treatment - virtual capacity: interview findings

Findings: Qualitative Interviews

This chapter presents the findings from qualitative semi-structured interviews with representatives from each of the pathways. It begins by defining Virtual Capacity, before providing descriptions of each of the pathways in Scotland. Following this, wider contextual factors which were identified as affecting implementation are discussed.

What is Virtual Capacity?

Participants were firstly asked to provide a definition for Virtual Capacity. A number of key components were identified which included the provision of hospital level care in an alternative setting. This was identified as often being provided in people’s homes or in the wider community, but can also include outpatient appointments to enable people to remain at home:

“it’s [virtual capacity] creating additional space in which to manage patients who otherwise are required to remain in hospital. Not necessarily space but clinical services to manage those patients. So it’s an alternative to hospitalisation.” [Participant, OPAT].

Participants highlighted that people using VC have acute level needs, making it distinct from community nursing and primary care:

“they are multimorbid, they are elderly […] readmission at 30 days is particularly high for heart failure patients so a lot of this work is to reduce the readmission at 30 days” [Participant, Heart Failure]

“If you’re not seeing at least 20% readmissions then you’re probably not doing hospital at home right because you’re probably taking the more long-term conditions so there should be that level of acuity” [Participant, Hospital at Home].

The role of VC in alleviating pressure on inpatient wards was highlighted. One participant, for example, noted: “to me it’s about releasing capacity in acute beds” [Participant, Connect Me]. Others, including participants from the Hospital at Home, OPAT and Respiratory pathways focused on saving bed days, highlighting that their services had been successful in saving many bed days.

The Five Pathways

Although models of care vary within and between the different pathways, participants highlighted key components that crosscut the pathways: specialist, multidisciplinary and acute level care. However, the covid remote monitoring self-management pathway is the exception to this, which is explained in more depth below. The following section provides an overview of the five VC pathways, outlining their key aims, services, and how their development has progressed.

Hospital at Home

Participants highlighted that hospital at home (H@H) provides hospital level, time-limited, care “that is equivalent to an inpatient setting” [Participant, Hospital at Home]. It is currently provided to adults with a focus on older people in Scotland, though there is no lower age limit.

Its key components were identified as: a secondary care specialist and “a multi-disciplinary team approach” that provides “urgent access to hospital-level diagnostics and acute interventions” [Participant, Hospital at Home]. It was noted that models of care and interventions offered vary across services to suit local need, although they should encompass the key tenets identified above.

The staff responsible for delivering hospital at home were identified as predominantly nursing staff and Advanced Nurse Practitioners (ANPs), with support from a doctor “whether that is a consultant, [or] whether that is a GP with specialist interest” [Participant, Hospital at Home].

It was highlighted that Hospital at Home differs from other VC services in that there is not an overarching approach to treatment, but instead it involves diagnosing, assessing, and treating patients whose treatment plan may not be known at the point of referral:

“[Hospital at Home provides] secondary care level intervention overseen by a responsible medical officer, in the similar way to you would have in a hospital, it’s just bringing that assessment and acute intervention to the home” [Participant, Hospital at Home, 1].

Hospital at Home has been running in Scotland for around 10 years. It originated in Lanarkshire and national implementation has been iterative, although over the last three years the pace of change has accelerated. There are currently Hospital at Home services in 11 NHS Boards and 21 HSCPs. There was a 53% increase in the use of H@H services between 2021/22 and 2022/23 (Healthcare Improvement Scotland (HIS, 2023).

Recent statistics from HIS (2023) show a 20% reduction in length of treatment via Hospital at Home services between 2021/22 and 2022/23. An expert working group member attributed this to a combination of staff becoming more confident in managing risk resulting in earlier discharge, more efficient processes and procedures, and the potential changes in patient acuity linked to more supported discharges from acute sites.

Participants highlighted that broadening the criteria to accommodate wider populations and specialties was the focus of future development. The aim being to increase the number of people using services to ensure equity of access across Scotland:

“The key priority […] is to increase the number of people that are able to access hospital at home level care […] increase the established services capacity or throughput, ability to treat patients, but also to spread that geographically to treat patients in parts of Scotland where there were no hospital at home services.” [Participant, Hospital at Home].

Heart failure

The Heart Failure pathway is a new pathway designed to support people with heart failure through four key services: 1) heart failure diagnostics; 2) inpatient heart failure reviews and early supported discharge; 3) ambulatory heart failure services; 4) remote monitoring.

Heart failure diagnostics aims to speed up the diagnosis process for people with heart failure to improve their prognosis. It was noted that people with heart failure are most commonly diagnosed at the point of presentation to acute care; the pathway is therefore designed to address this:

“our aim [...] is to get people diagnosed with heart failure quicker because what we know is if we diagnose people earlier on in their heart failure disease then their trajectory is much improved and their prognosis is much improved” [Participant, Heart Failure].

Although approaches vary, one model used in Greater Glasgow and Clyde that has been tested in a large clinical trial was described as follows:

“They got height, weight, ECG, blood pressure, echocardiogram, they were seen by a cariology ANP […]. And they were examined and given a diagnosis on the day. And they were treated on the day”. [Participant, Heart Failure].

Data on patients is entered onto a digital platform to improve information sharing across systems. The digital platform holds information on “key cardiac investigations, diagnosis and treatment” and is designed to “cut down on time to treat” by reducing the need to do “a manual trawl of notes” [Participant, Heart Failure]. This “markedly reduced the amount of clinic face to face cardiology appointments that were required”. The pathway is currently trying to nationally procure a heart failure digital diagnostics platform to further improve heart failure diagnostics and treatment.

Inpatient heart failure reviews and early supported discharge involve undertaking inpatient reviews with people with heart failure so that they can be referred to a specialist heart failure team. This is combined with virtual wards to support early discharge, and reduce hospital length of stay and readmissions:

“we can keep them on a virtual ward and know exactly where they are, go and visit them and keep an eye and make sure they’re not deteriorating from a heart failure point of view, which will reduce their hospital length of stay and ultimately readmission” [Participant, Heart Failure].

Ambulatory heart failure services were identified as aiming to reduce hospital length of stay by managing people as outpatients, providing required treatment, including IV diuretics, IV iron, and medication optimisation. Patients attend for treatment on a day case basis and are managed via a virtual ward.

Remote monitoring of heart failure is facilitated through the Connect Me service. Patients are provided with blood pressure monitors and weighing scales and use the Inhealthcare App for monitoring, which sends alerts to heart failure nurses when triggered by readings that indicate deterioration. This can be personalised to the individual to reflect their typical readings. This is used alongside a virtual ward to manage deterioration:

“quite often our heart failure patients run with very low blood pressure so if they were set at a standard pressure for example, they’d be alarming all the time. So, they can be very patient centred” [Participant, Heart Failure].

Two areas in Scotland currently have funding to deliver these services: Greater Glasgow and Clyde (GGC) and Forth Valley. GGC is further along in implementation and delivery, with most components of the service being delivered across the Health Board. The digital platform is being used in Forth Valley and funding has been secured to roll out the other components.

OPAT

Outpatient Parenteral Antibiotic Therapy (OPAT) is an infection specialist led service providing IV and complex oral antimicrobial treatment in the community as an alternative to inpatient hospital treatment (Scottish Antimicrobial Prescribing Group (SAPG), 2022). OPAT supports early hospital discharge and admission avoidance “primarily, stopping people coming in, and getting people out as quickly as possible” [Participant, OPAT]. The focus is not on reducing readmission due to exacerbations of chronic conditions:

“this is not a chronic disease management strategy, so not about reducing re-admission due to exacerbation of the chronic disease. OPAT is all about managing acute infections which inevitably is about an alternative to hospital care” [Participant, OPAT].

It is infection specialist led and multidisciplinary in nature. The key aim of OPAT is to provide care that is “expert, and it is safe and effective, and well governed” [Participant, OPAT]. This is demonstrated in studies showing that OPAT is generally safe, effective, and acceptable for treating a range of infections (Barr et al, 2012; Gilchrist et al, 2022; Seaton, 2005).

OPAT is available for anyone over 16 in Scotland, though the average age of people receiving OPAT was identified as being on “average late 50s, early 60s” [Participant, OPAT]. There are currently very limited paediatric OPAT services in Scotland.

OPAT was first established in Tayside in the 1990s. There are currently services in both urban and rural areas, including Dumfries and Galloway, Grampian, Greater Glasgow and Clyde, Highland, Lanarkshire, Lothian, Fife, Forth Valley, Tayside, and the Western Isles. This expansion has resulted in an average of 250 people receiving OPAT per week in 2022 (Scottish Antimicrobial Prescribing Group (SAPG, 2022)).

Services are configured differently depending on local need and there are various models of OPAT. This includes teaching patients to prepare and administer antibiotics, including using pumps, receiving treatment in an OPAT clinic, the frequency of which will depend on the level of need, and community nurses treating people in their own homes.

A multidisciplinary team is responsible for delivery and can include infection specialists, nurse specialists, clinical pharmacists, and healthcare support workers. Referrals are made by GPs, hospital specialists, and relevant community professionals, including podiatrists.

Priorities for OPAT development are to ensure there is “the right governance, and the right guidance, and the right clinical practice in all of these services” [Participant, OPAT]. Having adequate workforce (skill mix and appropriate staffing) to meet population demands, and providing guidance to ensure consistency in practice and prevent the overuse of antibiotics due to rising antimicrobial resistance, was highlighted as priorities.

Respiratory

The respiratory pathway was described as aiming to safely manage people with respiratory conditions who have had an acute event through the support of a community respiratory team. This includes support from a specialist multidisciplinary team, and the use of medications not provided by primary care. It was highlighted that services provide:

“an alternative to hospital admission because the respiratory team then take over their care and then manage them at home until they recover from their acute event” [Participant, Respiratory].

The pathway predominantly treats people with COPD, though the intention is to expand this to include a range of respiratory conditions such as lung disease, asthma, lung cancer, and interstitial lung disease (ILD).

It was highlighted that a broader approach covering multiple respiratory conditions was taken in response to the Covid-19 pandemic. Services were redesigned in GGC to provide an emergency seven-day response service, which ran for one year. Respiratory nurse specialist and community respiratory services were amalgamated to reduce readmissions to hospital.

Services within the pathway exist in areas with high deprivation due to incidence of COPD being correlated with deprivation. Community respiratory teams are currently running in Glasgow City HSCP, all HSCPs in Lothian, and in some parts of Fife, Tayside, Lanarkshire, Ayrshire and Arran, and Dumfries and Galloway. Services are at various stages of implementation. It was noted that Lothian has been running for around fifteen years, Glasgow for ten, Dumfries and Galloway for around six or seven, Ayrshire and Arran for two years, while Lanarkshire is a new service.

Staffing and service models were described as varying depending on whether they narrowly focus on reducing admissions or have a more holistic focus:

“Everyone kind of looks at things from a slightly different angle. The physios and the nurses deal with the acute issues with the presentation. And the idea is the occupational therapists and pharmacist will come in later on, and the dietician, to work with patient to prevent further admissions. So not just preventing that admission but preventing subsequent admissions as well. So its whether you have a model that is purely stopping admissions and just being a surrogate for ED or whether you have a more holistic care model which tries to provide more overall care for the population group.” [Participant, Respiratory].

Referrals are made from primary care to community respiratory teams, or through early supported discharge from hospital. The future ambitions for the respiratory pathway are to expand capacity to meet demand and broaden the scope of services, building this into referral pathways, through:

“7 day working. We could link in with flow navigation centres. So people phone NHS 24, that gets diverted to the community teams rather than going through the weekend process” [Participant, Respiratory].

COVID Remote Health Monitoring

Covid remote health monitoring is part of the Connect Me service. Although a number of Connect Me services have been developed, this report is specifically focused on remote health monitoring for Covid-19. There are two strands within covid remote monitoring: clinically managed and self-management pathways. Covid remote monitoring was initially set up as a pilot in 2020 with a wider launch in January 2021. The service aimed to support early identification of deteriorating symptoms relating to Covid-19 including breathlessness and silent hypoxia (a rapid deterioration in oxygen levels). It was highlighted that:

“This was to try and offset that [deterioration] and to support patients where they weren’t displaying severe symptoms at the time. They could be managed at home, they chose to be at home and it was giving them the information they needed” [Participant, Connect Me].

If required, clinicians were able to check symptoms, such as oxygen levels, on the system and arrange a follow up call if concerned. Automated alerts were provided, and patients could use the system via telephone call, SMS, or an online app. This service was mainly used in Lanarkshire, Highland, and Grampian.

The self-management pathway was set up at pace in January 2022 to roll out the availability of pulse oximeters to help people with Covid-19 to safely stay at home. Patients were assessed by a clinician, and if deemed suitable for the service, issued with a pack and invited to register with the national call centre for two weeks of remote monitoring. Over 15,000 packs were distributed to clinical teams and included a pulse oximeter and guidance for use. This pathway did not offer any clinical oversight and people were required to call 111 or 999 depending on the nature of their symptoms (Alexander, 2021).

Packs were offered to all GP practices in Scotland, alongside out of hours GP services, respiratory services, the Scottish Ambulance Service, and some maternity services. Alexander (2021) highlights that between January and August 2021, 149 people used the service in NHS Boards in Lanarkshire, Grampian, Highland, Western Isles, Forth Valley, and Orkney.

The Connect Me representative explained that the omicron variant did not have the same respiratory impacts resulting in significantly less need than anticipated. Around 350 pulse oximeters were used and the self-management pathway has now ended, though the clinically managed pathway is still running, and the remaining pulse oximeters are available for respiratory and NEWS2 (National Early Warning Score) pathways.

As part of the national contract for the underlying Inhealthcare App, available to all Health Boards, a key focus for the Connect Me team has been the scale up of remote blood pressure monitoring. To date, over 75,000 people have registered on the hypertension pathway. It was highlighted that:

“Evidence has shown people who use telemonitoring maintain optimum blood pressure longer than those who may only attend for annual reviews” [Participant, Connect Me].

As part of the wider Hospital at Home programme, work is currently underway to develop a Vital Signs pathway. This will provide short term remote monitoring of blood pressure, SpO2 [oxygen saturation], heart rate, respiration and temperature, along with an option to calculate a NEWS2 early warning score.

Contexts

Macro (health system and wider structures), meso (organisational), and micro (individual) contexts shape implementation processes and outcomes (Harvey and Kitson, 2016). As such, the interviews examined barriers to implementation to elucidate what factors could be addressed to increase the chances of successful uptake. Core barriers to successful implementation and delivery are presented here alongside the mechanisms that helped to support delivery.

Outer contexts

Macro level, or outer contexts, are those within the wider health system and the wider structures surrounding the system (Harvey and Kitson, 2016). Participants specifically focused on how funding structures, workforce, and Covid-19 shaped delivery.

National Prioritisation and covid

In recent years there has been a national interest in VC. Prior to this, implementation was variable, and reflected the interests and endeavours of local clinicians. Participants highlighted that national policy interest, leadership, and funding has altered the pace of change, and has been an important catalyst that has helped to accelerate service development:

“the support from Scottish Government for hospital at home has been obviously really key […] I think the leadership from the Scottish Government has been a key enabler” [Participant, Hospital at Home, 2].

The Covid-19 pandemic was perceived to drive national interest. The covid remote health monitoring pathway was set up because “there was a concern that it [Covid-19] would overwhelm services” [Participant, Connect Me] and new ways of working were sought to help prevent the spread of infection:

“Covid was a major factor because everybody’s looking for […] different ways of managing admissions, and shielding patients, stopping them having to come into hospitals […] it kind of made everybody realise that you can’t just keep doing things the same way. You have to be a bit more agile and flexible in the way we manage patient pathways” [Participant, OPAT].

Funding structures

The national focus on VC was accompanied by central funding. Participants reflected that this enabled the recruitment of additional workforce to deliver services:

“we’ve used that [funding] to employ new nurses and a healthcare support worker. Got some consultant session[s] which we didn’t have before. And funding for a pharmacist” [Participant, OPAT).

However, participants talked about the need for further funding for expansion to ensure equity of access across the country. The Respiratory pathway for example, was described as being currently at capacity, and in need of additional funding to expand the workforce to increase service provision and meet demand. The potential to provide extra capacity to meet demand on the wider health system was reflected upon:

“we’re currently turning people away, on both a national level and local level, we’re turning away and we’re not expanding the service as much as we can. We’re holding back on implementing elements which could have a dramatic impact on ED, would have a dramatic impact on flow navigation centres because we don’t have the resources to do it.” [Participant, respiratory].

The intersection of the funding landscape and VC’s position in the wider health system was discussed. Whilst some national funding has been made available, participants noted that local funding provided directly through Health Boards (HBs) or Health and Social Care Partnerships (HSCPs) is also required^[5]:

“because it’s acute care but it’s delivered in the community, so for certain parts of the workforce, partnership might fund it because it’s community, but for some services, the consultant-input might be Board funds and even though there was government funding, each year that wasn’t enough to fund a whole service” [Participant, Hospital at Home].

Another participant talked about how one off, non-recurrent funding can result in risk aversion from HB’s, who can be reluctant to fund services that may not have sustained central funding:

“the Boards won’t give recurrent funding because they, the risk might be too much. So who does the risk lie with? Should it lie with the Scottish Government, or should it lie with the Boards? And the Boards are like, but we don’t know if the Scottish Government will give us the money the following year.” [Participant, Heart Failure].

Despite requiring additional funding to develop services, participants were conscious of challenges with the current economic climate, reflecting: “money is tight just now” [Respiratory], “the major issue is funding obviously” [OPAT], and “there’s no spare cash at the moment” [Participant, Heart Failure].

Workforce challenges

Participants reflected that workforce issues impacted the delivery of VC. Some pathways secured funding but were struggling to recruit and retain the required staff to deliver services:

“a lot of times they plan a workforce that they can’t recruit and so they need to rethink it. There’s a lot of staff turnover, it’s like service development at the moment, a lot of staff turnover.” [Participant, Hospital at Home].

The wider context was reflected upon, with VC complementing acute services, rather than replacing inpatient beds. As a result, increased numbers are required from the same pool of staff:

“Hospital at Home doesn’t mean you’re shutting anything else; you’re not shutting wards or anything like that because Hospital at Home exists” [Participant, Hospital at Home, 2].

Recruitment challenges were perceived to be exacerbated by the way that funding systems are structured. The non-recurrent nature of the funding means that posts are often advertised as fixed term contracts or secondments, which acts as a barrier to recruiting talented, skilled staff:

“because of the funding availability, then often contracts tend to be short term or fixed term at the very least and […] you’ve also not always got contracts which are that appealing, so it’s tricky to attract people. [Participant, Hospital at Home].

Difficulties recruiting staff members was also linked to limited access to training and development. Implementation of the Heart Failure pathway, for example, has been delayed by a sho’rtage of trained cardiac physiologists and Clinical Nurse Specialists (CNSs), who play an important role in diagnosing and treating heart failure:

“we’re somewhat off having enough people trained to such a level to deliver all this properly. Although we are getting there and we’re in a much better position than we were three/four years ago” [Participant, Heart Failure].

This was perceived to be a consequence of a commitment to provide 500 Advanced Nurse Practitioners (ANP’s) by 2021, which resulted in funding and training being directed to ANP’s instead of CNSs. Although it was noted that this has now been addressed, posts are often being undertaken as training posts.

Another participant reflected that employing people on a trainee basis resulted in services not running at full capacity:

“they might undertake the training while they’re in the role, so it’s challenging for a service to reach its full potential quickly, as people are then undertaking training and they can’t take on the level of responsibility that they can when they’ve completed that” [Participant, Hospital at Home].

Inner level contexts

Inner level micro (local/individual) and meso (organisational) contexts impact the success of delivery (Rycroft-Malone et al, 2013; Harvey and Kitson, 2015). The following section focuses on culture and buy-in, local innovators and engaged communities, and access and equity.

Culture and buy-in

Participants talked about the importance of culture in shaping implementation progress, and the difficulties involved in changing embedded ways of working. Transferring people to hospital when an acute need is identified is the norm and changing engrained clinical practices and referral pathways can be difficult:

“one of the hardest things they did when setting up the service was getting the Consultant to trust that they could look after their patient. And you’re changing that culture, and think her words exactly were ‘...fixing the patient 100%, to just making sure they’re alright to be at home’, so that’s been a real challenge as well.” [Participant, Hospital at Home].

As well as culture impacting on people delivering services, the importance of having engagement of those in leadership positions was also mentioned. Business cases must be produced to secure funding, however, the success of this is impacted by having adequate buy-in and being considered a priority by Board’s. This was reinforced by the Heart failure representative who said: “if you’re not on the Boards priorities […] then the business case isn’t going to go through”.

Whilst participants reflected on person-centred care being the key driver for VC, it was noted that strategic decision-makers are often interested in cost savings. As highlighted, VC is designed to be an alternative, complementary service, as opposed to being intended to replace acute beds. However, a culture focused on addressing short term immediate needs was perceived to hinder the ability to invest in alternative options for sustainability in the longer term:

“the health service has been preoccupied with firefighting […] opening up winter beds and increasing capacity […] So, that’s the biggest barrier is the kind of, the process, the mentality within the health service. I’ve had many many meetings over the years where the manager’s just put up their hands and say there’s no money. There’s no money to invest.” [Participant, OPAT]

Local innovators and engaged communities

The development of VC in Scotland has happened “completely naturally or organically” [Participant, Hospital at Home] according to a number of participants, being shaped by local innovators and a “network of enthusiastic” clinicians [Participant, Heart Failure]. Participants talked about the positive impact that committed clinicians have had in progressing VC, creating and testing new ways of working, building evidence, sharing learning and best practice, and communicating and raising awareness of its benefits. This includes collecting data on the effectiveness of VC, such as how many bed days it saves:

“all our OPAT leads around Scotland are voluntarily collecting the data […] it does serve as a sort of stimulus for more development” [Participant, OPAT].

When the national pathways commenced, there was already an existing community of dedicated practitioners to influence and drive the agenda for change. Participants talked about how the qualities of individual ‘enthusiasts’ has provided a strong foundation to progress the rollout of VC in Scotland:

“because of their personality, they’re innovators. Because they did it without a national drive to do it, so they got it […] They want to kind of explain its benefits, they’re quite evangelical about its benefits” [Participant, Hospital at Home].

Access and Equity

The fragmented nature of implementation has resulted in significant variation in the numbers and locations of VC services, as reflected in the pathway descriptions. Participants highlighted the need for greater equity of access, particularly in relation to geographical spread and socioeconomic status, and emphasised the need for further funding to expand:

“It needs a bit more investment and ultimately it needs to become business as usual... if you’re denying somebody a service because of where they live, that’s not really right.” [Participant, OPAT].

The ways in which VC intersects with socioeconomic status was highlighted. Some of the pathways had a specific focus on supporting people from lower socioeconomic backgrounds. For example, covid remote health monitoring aimed to provide equity of access to pulse oximeters for people who could not afford to buy their own device. Furthermore, COPD services are located in areas with higher levels of socioeconomic deprivation:

“COPD is a condition of deprivation so in Glasgow if you live in a deprived area, you are seven times more likely to get the condition than if you live in the most affluent quintiles. So, incidence of COPD is associated with deprivation” [Participant, Respiratory].

However, other pathways reflected that those from higher socioeconomic groups may be more likely to access services due to the inverse care law^[6]. The OPAT representative, for example, noted that referrer bias and transportation costs can act as a barrier to equity of access, though highlighted steps that were being taken to address this:

“we’re all trying to make sure that transport to and from the hospital is free. But sometimes, for example, at weekends it can be difficult, and people can’t afford to, or nobody’s got a car, not well enough to use public transport and can’t afford a taxi. So that’s an issue as well but we’re all trying to address that because the whole issue of access and equity is all on our minds”.

Another participant noted that equality impact assessments are conducted locally to try and mitigate against this, building in processes from the outset to ensure that services are available in areas with mixed socio-economic indices to prevent further inequities. They said: “it would be very easy to end up actually creating an even wider gap, so each service does an impact assessment and considers those things” [Participant, Hospital at Home].

Conclusion

The interviews provide an overview of what VC is and how the pathways have developed. Virtual Capacity was identified as providing acute level care outwith inpatient wards, supporting people with acute level needs, and alleviating pressure on hospitals by providing a complementary service.

Until recently, implementation had been driven by local innovators who have established new ways of working, shared learning, and garnered support and evidence. As a result, the availability of services is variable and there is a lack of equity of access to VC across the country.

The recent national focus has helped to accelerate change, with funding being made available to expand services, although questions remain about the sustainability of funding. Workforce issues have also impacted delivery, with some pathways experiencing difficulties recruiting adequately skilled staff.

Participants underlined the need for sustainable funding to develop the pace and scale of change, as well as a culture that fosters new ways of working, a skilled workforce, and buy-in from strategic decision-makers and other key stakeholders.