Monday, September 26, 2022
HomeHeathWould you feel safe being treated on a 'virtual ward' in your...

Would you feel safe being treated on a 'virtual ward' in your home?


For anyone with a chronic condition, key challenges include the need for regular checks, unsuitable appointment times, costly parking and hours hanging about in hospital as clinics overrun — let alone the discomfort from their illness.

But technological advances mean many could have their health closely monitored in their own homes, rather than in hospital.

In fact, for some 280,000 NHS patients in England, home monitoring and ‘virtual wards’ (more frequent remote checks when patients need more intensive monitoring) are already a reality.

And by March 2023, a further 500,000 could be enrolled in home-monitoring programmes, with 25,000 at any one time being treated on virtual wards by 2024.

Technological advances mean many could have their health closely monitored in their own homes, rather than in hospital

Technological advances mean many could have their health closely monitored in their own homes, rather than in hospital

Launching the Plan for Digital Health and Social Care last month, then-Health Secretary Sajid Javid said the measures would allow patients to ‘take more control of their own care at home, picking up problems sooner and seeking help earlier’ and ensure ‘the NHS is set to meet the challenges of 2048 — not 1948’.

The idea is that, with kit such as blood pressure monitors and pulse oximeters (to log blood oxygen levels), plus training and support, patients can monitor their health at home and upload readings via an app on a smartphone or computer to an online ‘hub’.

The results are then monitored by a medical team or a computer programme. Any problem detected is flagged to a clinician, who may prescribe treatments such as antibiotics if they suspect a urinary tract infection or steroids for asthma — or, if necessary, recommend hospital admission.

Heart failure, lung conditions, stroke, urinary tract infections, arthritis, dementia and even cancer are among the illnesses that can be monitored, and in some cases treated, remotely.

Patients at risk of urinary tract infections may be asked to test their urine and take their temperature to check for signs of infection. Those with heart failure will check their blood pressure, pulse and weight (a sudden increase suggests water retention, a sign that the heart is not pumping effectively and medication may not be working). Those with asthma and lung conditions will check lung function with a spirometer (measuring the amount of air you exhale in a breath).

Meanwhile, cancer patients may be advised to send in temperature readings as a raised temperature can be a sign of an infection. Stroke patients may be asked to check their blood pressure and those with arthritis record symptoms daily via an app.

Heart failure, lung conditions, stroke, urinary tract infections, arthritis, dementia and even cancer are among the illnesses that can be monitored, and in some cases treated, remotely

Heart failure, lung conditions, stroke, urinary tract infections, arthritis, dementia and even cancer are among the illnesses that can be monitored, and in some cases treated, remotely

Home monitoring sounds appealing because, unlike in hospital, it means patients can eat, sleep and go out when they please, or have as many visitors as they like, while their health is kept under review.

The theory is that this allows patients to be discharged from hospital sooner or avoids them being admitted in the first place by picking up problems earlier.

For instance, if a patient with chronic obstructive pulmonary disease (COPD) — an umbrella term for chronic lung diseases — has abnormal temperature, oxygen and pulse readings, this suggests an infection.

Stepping in with treatments or medication ‘rescue packs’ given to patients in advance — in the case of COPD, antibiotics and steroids — could prevent the patient’s admission to hospital.

Avoiding unnecessary hospital stays also saves the NHS the £400 a day it costs to run a hospital bed and frees up beds and medical staff for other patients.

But is greater use of remote monitoring of patients in this way really the NHS magic bullet?

Some experts have reservations, as certain patients fear, or are unable to use, such technology.

‘Relying on smartphones and apps to provide healthcare immediately excludes millions, particularly older people — some of whom won’t have internet access and others who are not comfortable using the technology,’ says Dennis Reed, from the patients’ rights group Silver Voices.

‘This trend to digital-only as the fall-back position is worrying as it could make it difficult for some to access NHS services. We need to make sure there is an equally accessible alternative for those who find it difficult to work with apps, such as those with dexterity or eyesight problems.’

The Government is pinning its hopes on greater use of ‘telehealth’ technology to boost capacity in the NHS, which has been falling over the past decade. It wants to make a dent in its burgeoning waiting lists, currently standing at a record 6.48 million people.

Last month, NHS England chief executive Amanda Pritchard admitted that too many NHS beds had been cut. Some 25,000 have been lost since 2010/11, with fewer beds per head of population now than in comparable countries.

There is growing evidence that technology can allow patients to avoid hospital and be cared for effectively at home. However, the results are mixed.

In 2016, Cochrane — the independent body that reviews existing studies — looked at 16 trials involving more than 1,800 older people who were cared for at home rather than in hospital for conditions such as stroke or COPD.

It concluded that home monitoring ‘may provide an effective alternative to inpatient care for a select group of elderly patients requiring hospital admission’.

Those treated at home were more likely still to be living in their own homes after six months and seemed ‘more satisfied than those who are in hospital’, it found.

The review noted that home care may be cheaper than that in hospital, although it failed to take into account the cost of family and friends providing care at home.

More recently, ‘virtual wards’ were introduced during the pandemic, using pulse oximeters to monitor Covid patients.

The infection can lead to low blood oxygen levels, which can be fatal if not identified and treated. But some Covid sufferers were arriving in hospital too late as low blood oxygen levels don’t always cause warning symptoms.

To address this problem, remote home monitoring using pulse oximeters was introduced on the NHS for clinically vulnerable patients diagnosed with Covid.

An analysis of data from 37 local health authorities in England that offered the service between November 2020 and February 2021 found that it had ‘no significant impact on outcomes’, reported the journal eClinicalMedicine in March this year.

However, when more than 3,500 patients with COPD, heart failure and type 2 diabetes from 89 GP practices in Liverpool had their health monitored at home, there was a 22 per cent reduction in the number of emergency hospital admissions compared with a matched group who did not receive the care, a 2019 study in the journal BMJ Open found.

The patients were given a tablet computer wirelessly connected to weight scales, a blood pressure device, glucose monitor and pulse oximeter and they submitted daily readings for at least nine weeks. They also received advice from clinical staff.

Doctors checked on my heart without me leaving the house 

Gavin Redhead, 57, a retired council advocate for vulnerable young people, lives with his wife Julie, 51, a local government officer, in Lancashire. He has heart failure and benefits from NHS remote monitoring. He says:

I was born with a hole in my heart and grew up being told there could be no running, no overexertion.

Still, I became a Sea Cadet, left school and met my wife Julie and worked for the local authority for years. But my heart problem was always there. I saw consultants every six months for monitoring but it was an arduous two-hour journey each way into Manchester.

In 2009 I developed arrhythmia — an irregular heartbeat. I was fitted with an implantable cardioverter-defibrillator (ICD) which monitors the heart’s rhythm, paces it and shocks the heart back into normal rhythm if it stops.

It monitors remotely and data is sent to consultants while I carry on with my life. The small matchbox-shaped device implanted under the skin by my heart is linked wirelessly to a handset with which I can trigger a download of information to send on. Doctors can access it, too.

I saw the consultant every 12 months instead of six. In 2016, he told me that the device had picked up an erratic heartbeat and the ICD had prepared to shock me but went back to a normal rhythm before it fired. I had no recollection of it — but it could have saved my life.

Sadly my heart condition worsened. One night, I got to bed and felt very unwell. I couldn’t even call for Julie so I texted her. She called 999.

In hospital I was told I had irreversible damage and my heart would eventually fail. I was given about eight tablets, including ACE inhibitors that relax blood vessels and ease the pressure on the heart; beta blockers, which block adrenaline, as well as MRAs to stop the build-up of fluid, linked with heart failure.

Doctors feared I’d need a heart transplant but decided that, thanks to my ICD, I could carry on living normally as the remote monitoring would reveal when more urgent help was needed.

I gave up work in 2019 due to fatigue. Now I’m a patient advocate with the Pumping Marvellous charity, helping others with heart failure.

I may still need a heart transplant one day. But remote monitoring has saved my life. Without it, I’d be terrified wondering when my heart might stop, or start beating irregularly. Instead I can enjoy the time I have with my family.

Interview by JULIE COOK

 

The readings were monitored by a computer programme that spots health changes — and any alerts were then sent to a clinical team. On average, each patient triggered an alert nine days a month.

The study, however, found home monitoring was more beneficial for some conditions than others.

The 171 heart failure patients in the study who had home monitoring saw the biggest drop in emergency admissions, probably because the condition has ‘the worst performance in terms of hospital admissions and readmissions in the NHS’, says Nick Hartshorne-Evans, chief executive of heart failure charity Pumping Marvellous.

Heart failure, which affects some 900,000 people in the UK, means the heart is not pumping as effectively as it should, often due to damage from a heart attack or ageing. It can cause breathlessness, swollen ankles and exhaustion.

‘With the average heart failure hospital admission being ten days, on the basis of such findings monitoring or treating patients at home would not only be a massive benefit to the patients but would also save the NHS £4,000 per patient stay,’ says NickHartshorne-Evans.

Chris Gale, a consultant cardiologist and a professor of cardiovascular medicine at the University of Leeds, agrees.

‘Home monitoring of heart failure can help patients to manage their own condition and means fewer hospital visits,’ he says. ‘It allows appropriate care in the appropriate place.’

In May, a virtual heart failure ward — only the second in the country — was set up by Mersey Care NHS Foundation Trust and Liverpool University Hospitals NHS Foundation Trust.

So far about 40 patients have been managed on the ward, each of whom was ‘admitted’ when their condition worsened; normally they would have gone to hospital.

During their ‘stay’ of about 14 days, in the comfort of their own homes, the patients have observations taken three times a day including temperature checks, blood pressure, oxygen levels and ECGs of their heart to see how well it is pumping — and whether they need to attend hospital as an outpatient for intravenous diuretics to remove excess fluid which may be worsening their condition.

There is also a daily virtual ward round with a consultant heart specialist (including at weekends).

The aim is to recruit 200 patients in Cheshire and Merseyside by November, which it is estimated could save about 1,500 bed days in hospitals and £540,000 in costs.

However, Professor Gale says, patients with complex health problems will still need to be seen in hospital and more scientific research is required to show that home monitoring ‘improves care, outcomes and is cost effective’.

Relying on technology in health monitoring, though, is not without risks. Accuracy of the readings depends on the quality of the devices used. Equipment can fail or patients can make mistakes using it, and not seeing a patient face-to-face means that subtle visual cues that suggest changes in their health may be missed.

For example, pulse oximeters work less well on patients with darker skin. The devices measure how much light is absorbed by the tissue of the finger: dark skin absorbs more light than fair skin, giving a false high reading when the patient’s blood oxygen levels may be actually perilously low.

Some fear inaccurate readings may have contributed to the high death rate from Covid among black and Asian people at the height of the pandemic. Meanwhile, a UK survey of 1,500 arthritis patients and their doctors, published in the journal Rheumatology last month, revealed 93 per cent of doctors and 86 per cent of patients ‘rated telemedicine as worse than face-to-face for assessment accuracy’.

‘Misdiagnoses and other inaccuracies were frequently reported and often attributed to the absence of examinations and visual cues,’ researchers said.

When it comes to dementia, which can be monitored with routine health observations, such as pulse and temperature, plus sensors in the house to show how often a patient leaves it, Kirstie Kalonji, policy manage at the Alzheimer’s Society, agrees that telemedicine is not ideal.

She says: ‘Technology alone cannot address the lack of post-diagnostic support faced by too many people with dementia.

‘It can play an important part in helping people with dementia live well with the condition for as long as possible but it must be accompanied by improved specialist support.’ Lung patients also remain sceptical.

‘Eighty per cent of people with asthma want their annual asthma review to be carried out in person and 55 per cent of people with COPD prefer to receive face-to-face pulmonary rehab (a physical exercise and advice programme for people with the condition),’ says Harriet Edwards, head of policy and external affairs at the charity Asthma + Lung UK.

She points out that some aspects of care, such as checking someone is using their inhaler properly, are more effective face-to-face.

And one big question is: who is going to staff this NHS digital revolution? Data submitted from patients monitored at home is often initially assessed by a computer programme, designed to spot unusual results. This then sends an alert to medical staff for assessment.

But ‘you don’t need highly-trained medical professionals to run the home monitoring,’ says Nigel Edwards, former head of the NHS Confederation and chief executive of the think tank the Nuffield Trust. ‘You just need an experienced clinician who can step in where needs be.’

The Government has announced it will create 10,500 data and technology roles by 2025 plus increase training for new and existing staff to roll out the programme. However, Pritesh Mistry, a policy fellow at the King’s Fund think tank, warns that staffing is an issue.

‘You need staff for both virtual and hospital care, and the question is, how are we going to go full-steam ahead introducing more technology when we already have significant workforce shortages?’ he says.

‘The people best placed to be introducing these changes are the people who are delivering services to others.’

The other question is whether home monitoring will actually free up beds.

‘The beds that home monitoring free up are generally not surgical beds, staffed by medical teams who could do then more operations, but general medical beds,’ admits Nigel Edwards.

‘Where it could make a difference is getting people into hospital from ambulances, which is currently a problem because of bed shortages.’

But the technology is not popular with everyone.

In the previously mentioned 2019 BMJ Open study of GP patients, only 22 per cent of patients taking part asked if they wanted to take part in remote monitoring ultimately agreed.

And within four weeks 7 per cent of these patients had asked for the technology to be uninstalled.

‘In my experience, there seems to be a 50:50 split among patients,’ says Nick Hartshorne-Evans. ‘Half of patients embrace the technology and the other half are sceptical, phobic about technology and worried they are just being palmed off.’

Digital inequality is also a glaring issue, with older people, low-income families and disabled people more likely to be affected. Some don’t have internet access, others may not have the skills and confidence to use the technology.

But there is another point.

‘Telehealth is generally perceived as a good thing as long as patients have the choice,’ says Pritesh Mistry. ‘It’s not a magic bullet and it won’t work for everyone.

‘There is a concern that this will become the default approach rather than an option for patients, so we must ensure that for those who don’t want to use technology to monitor their health there is a suitable, well-funded alternative.’

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