22 - Care in the home

As the coronavirus response has consumed the lion’s share of NHS resources, the need to enable non-COVID-19 patients to take more responsibility for their health has never been greater, particularly for those with long-term conditions.

The Long Term Plan acknowledged that ‘for many health conditions, people are already taking control themselves, supplemented with expert advice and peer support in the community and online’. However, COVID-19 has forced more fundamental change in service delivery, as face-to-face contact with clinicians has been dramatically reduced in recent months and patients have been managed remotely where possible.
This article will explore how patients will be cared for during the remainder of the pandemic and beyond, with regards to managing exacerbations, providing ongoing monitoring and educational support.

Prompt treatment is important for managing exacerbations in patients with long-term conditions. As such, the NHS has been at pains to try to convince people to seek urgent help for potentially life-threatening symptoms during the coronavirus pandemic, and ‘safe hubs’ have been created in hospitals for non-COVID-19 patients to reduce their risk of contracting the virus.

However, data suggests that although A&E attendance is now rising, it is going to take a while to fully restore patient confidence. Weekly data from Public Health England shows that overall A&E attendances increased to around 105,000 in the last week of May, which was an increase from 98,813 over the previous seven days.

Data from the 77 A&E departments included in the research suggests that overall attendances are up to an average of 15,000 a day, compared to around 10,000 at the peak of the pandemic and the long-term trend of just under 20,000. However, attendances for bronchitis, acute respiratory infections, respiratory, pneumonia, asthma and gastroenteritis are still far below their normal levels.

Going forward, it is likely that we will see three distinct hospital settings with a ring-fenced, red ward for COVID-19 patients and separate safe areas for emergency outpatients and elective work.
However, efforts to keep people out of hospitals, where possible, and provide more care in the community, as outlined in the Long Term Plan, will continue to be a priority. This was underlined in new guidance issued on May 19 regarding: ‘Changes to COVID-19 finance reporting and approval processes as we move into the second phase of the NHS response’.

It shows, for example, that support for the remote management of patients through the provision of telephone-based or digital/video-based consultations and advice for outpatients, the NHS 111 service and also primary care will increase. Support for stay-at-home models is also likely to increase, while plans to release bed capacity should decrease/be replaced by hospital discharge programmes.

The COVID-19 pandemic has expedited digital NHS service delivery with, for example, digital triaging swiftly becoming the norm in primary care and patients turning to online services, such as NHS 111, in droves. Enabling patients to access such services is a key aspiration of the Long Term Plan, which promised that the NHS would ramp-up support for people to manage their own health over the next five years, with diabetes prevention and management and asthma and respiratory conditions among the priorities.

Remote monitoring is key to enabling more people to successfully manage their conditions at home. One area in which it can be successfully deployed is in respiratory diseases, where the Long Term Plan states that hospital admissions for lung disease have risen over the past seven years at three times the rate of all admissions generally.

A key resource in this field is myCOPD. The specialist self-care app is designed and built by COPD experts, and externally peer-reviewed by leading NHS consultants. Users can learn how to manage their COPD from world experts and complete online pulmonary rehabilitation classes from the comfort of their own home. They can also access help with perfecting their inhaler technique, which is a critical task given that 90% of people use their inhaler incorrectly, according to the NHS.

In common with many other long-term condition patients, people with respiratory diseases may have been having conversations with clinicians about managing their illness during the coronavirus pandemic. They may have been moved onto treatments that are easier to manage at home and do not need as much intervention from a healthcare professional, eg subcutaneous or oral drugs rather than ones administered via infusion.

If more patients are taking medications at home, rather than in hospital, there will be an increased need for digital devices that can monitor adherence, from pill bottles equipped with caps that provide a date and time record of each time the cap was removed, to smart inhalers, which link to an app, helping both the patient and his or her doctor manage the condition better.

Mobilising the wider healthcare workforce will be important for enabling self-care, as the burden of management shifts away from hospitals, particularly outpatients and acute care consultants, and into the community. Here a multidisciplinary team of GPs, clinical pharmacists, district nurses, specialist community nurses and health advisors will be responsible for supporting and managing patients.
Among these key stakeholders, we may see clinical pharmacists become a particularly important stakeholder group for pharma and take on a more prominent role in primary care.

As patients become more closely involved in making decisions about their treatment and take on more responsibility for managing their conditions at home, it will be interesting to see how the traditional patient/clinician relationship changes. For example, will patients begin to actively request certain drugs that they have researched themselves, rather than simply accept the first, or second-line treatments that a clinician would routinely prescribe? Will there be more patient-led conversations with clinicians about the safety profile of certain treatments?

It is too early to say what the longer-term impact of empowering patients might be in this regard. But certainly, as patients are required to take more responsibility for their health, there will be a clear need for access to educational resources and supporting information. We may also see greater patient participation in online forum debates about treatments and a growing interest in online support groups and other group activities, such as specially designed exercise classes, where patients can meet.

This demand is likely to be met by healthcare charities which will play an increasingly important role in providing information and advice via channels such as telephone support lines, website resources and apps. Indeed, some charities have already been proactive in offering support to patients via GP surgeries during the coronavirus pandemic.

It is possible that some charities might have direct access to information on the latest treatments that are being recommended nationally within their specialism and so they could become a useful conduit of information for GPs as well as patients. This may be particularly welcome at the moment, given that GPs’ abilities to refer patients may be somewhat compromised by the difficulty in holding face-to-face consultations and the reduced number of outpatients’ slots available.

In addition, it may also be difficult for GPs to put questions to specialists in acute care, while data sharing on new treatments and developments in specific disease areas may be slower as resources are diverted to coronavirus cases. This situation presents key opportunities for pharma to work proactively with both charities and GPs to provide educational information on specific conditions and drugs both during the coronavirus pandemic and beyond.

The Long Term Plan made it clear that the paternalistic relationship between patients and clinicians needed to change and this has been precipitated by coronavirus, which has required patients with long-term conditions to get more involved in decision-making and given them a taste of how many NHS services can be provided remotely.

However, the road to increased independence is likely to be fraught with challenges for many patients, hence educational resources and ongoing monitoring will be vital to help them acquire the knowledge, confidence and skills required for self-care.

There is a valuable role for pharma to play in working with charities and clinicians to provide educational resources on specific conditions and drugs. Industry can also lead the way in supporting adherence and providing the treatments and tools required to empower patients and help the NHS make a seismic shift in service design and delivery.