Behind the scenes at Dorset’s virtual hospital ward – where the inpatients are outpatients
Back in March, Brian Neale, a retired accountant with type 2 diabetes, began to feel unwell as he wandered around the home.
As well as needing to visit the lavatory regularly, the 82-year-old was also losing a lot of feeling in his feet and legs and he struggled to maintain his balance.
Matters came to a head one weekend, explains his wife Christine, when he fell six times at their village home near Bridport, Dorset. The most serious tumble left him trapped in the downstairs bathroom. “It was just the most awful experience,” she says. “Really. It was hell.”
Later, their daughter visited the local GP to discover what could be done and Mr Neale was referred to what is known as Dorset’s “virtual ward” – one of 10 such schemes being piloted nationwide designed to help elderly patients stay out of hospital.
The next day a member of the local community rehabilitation team visited his home to assess him. The following day another rehabilitation worker arrived and fitted numerous items of equipment around the house to help Mr Neale with his balance.
The worker, Caroline Cooke, also drew up a diary of regular home visits, and gave the family her phone number to call if there were any problems – so far there haven’t been.
“I can’t believe how quickly things happened,” says Christine. “Our lives have been transformed.”
In many ways Dorset should be at the sharp end of the social care crisis that is currently draining the NHS’S resources. Exacerbated by austeritydriven local authority cuts, there are fears that there could be a nationwide shortfall of £2.5billion within two years.
A demographic survey of Dorset this year shows 28 per cent of the residents are over 65 (compared to 18 per cent nationally). In 2016, Dorset calculated that a “do nothing” scenario would create an annual financial gap in the local health system of almost £230million by 2020-21.
But over the past year in west Dorset, with its virtual ward, unplanned hospital admissions among the over-75s has fallen by 4.9 per cent. That compares with an overall rise for the whole of the county at 1.4 per cent, although a further 11 virtual wards are in various stages of development. The length of time patients stay in acute hospitals is also falling.
These may sound slim margins but replicated across the country they could have a major impact on one of the greatest strains upon the NHS.
Hospital bed numbers have been cut by half over 30 years, increasing the pressure to limit admissions.
In January, the latest figures available, the NHS had more than 150,000 “delayed days”, with patients having to remain in hospital despite being fit enough for discharge.
At the same time a report published by the Nuffield Trust this week revealed a 40 per cent rise in urgent readmissions to hospital for patients suffering from potentially avoidable conditions, such as pressure sores and pneumonia.
The virtual ward – known in NHS parlance as an “integrated care system” – is designed to address these flaws in the system and break down the “silos” into which patient care is usually divided.
Meetings take place twice a week at Bridport Community Hospital and include those involved in patient care: the community rehabilitation team, matrons, nurses, carers and mental health practitioners.
They are led by Riaz Dharamshi, a community geriatrician who has worked for the Dorset NHS Trust for four years and who was integral in the creation of the virtual ward.
Details of a dozen patients of concern are put up on a screen and the team discusses each case and what steps to take.
Issues range from a patient who needs to be persuaded to leave his home for supported care to one who has started acting inappropriately around his young nurses.
The trust uses an electronic clinical record system called Systmone, meaning details of patients’ medication and admissions are instantly available and can even be updated during the meeting.
“What we do a lot here is deal with patients where there isn’t necessarily a right answer,” Dr Dharamshi explains. “It doesn’t work if you are fussy about who you accept.”
Eavesdropping on the meeting, what soon becomes clear is the depth of knowledge such health and social care professionals have about each case. At any one time the virtual ward can have between 10 and 25 patients on its books. Fine perhaps, for a rural area such as West Dorset, but would this work in Birmingham or London – cities with a high density and a transient population
Dr Dharamshi, who previously worked in healthcare in London, insists the same principles could be applied, although he says the maximum population for a similar service to still function well would probably be around 100,000. The West Dorset virtual ward draws from around 30,000 patients.
“It’s about taking the time to understand who your frail patients are, what their needs are and then planning their care,” he says, “then collaborating your existing services to support and seek help with the most difficult patients. That is not particularly revolutionary. It’s a simple thing to implement but it does require the willingness to be flexible in how you work.”
Dr Dharamshi says the Dorset virtual ward has been introduced with no additional funding by shifting around the duties and priorities of existing staff.
“I’ve had to work differently,” says Beverley De Lisle, community matron for Bridport and Portersham, who has been with the trust for three years.
“To be able to share and learn from colleagues makes a big difference. The patients really appreciate it and it gives patients and families more confidence to be at home,” – as it is for John Kemp, an 82-year-old Dorset “landscape poet”, who was recently referred to the virtual ward.
Sitting in his flat surrounded by books, Cheryl O’halloran, the community matron, describes how she was asked to visit two months ago and found him “quiet, dehydrated, with swollen legs; generally unwell”.
She discovered he had been sleeping in a chair rather than in bed and was eating poorly. A GP was called and Mr Kemp was referred to the ward at Bridport Community Hospital where he was introduced to a case worker from social services and presented with a care package.
Now his flat has been decluttered, medication adjusted and he receives visits three times a week. He has been persuaded to buy a washing machine and has become well enough to go to local poetry readings again.
“It has given me an opportunity to mend and recover,” Mr Kemp says.
“Unfortunately I’ve had to spend quite a lot of time under their care, but they have been marvellous.”
‘It’s about taking the time to understand who your frail patients are, what their needs are and then planning their care’
‘The patients really appreciate it and it gives the patients and their families much more confidence to be at home’