Digital transformation in community nursing

The phrase ‘digital transformation’ has become synonymous with healthcare in 2021. The COVID-19 pandemic has provided an opportunity for the NHS to accelerate its digital capabilities, not least within community nursing, where mobile working has presented an additional opportunity for transformation. Health policy, local initiatives and patient needs have combined to produce an environment of transformation, delivered at an unprecedented pace across the healthcare landscape. Clinicians across all areas have learnt new skills, and organisations have embraced new governance and procedural challenges against a backdrop of increased patient acuity and an environment of collaborative learning to meet the needs of safe patient care. To illustrate this, a case study of the work undertaken at Sussex Community NHS Foundation Trust (SCFT) is presented in this article.

The NHS Long Term Plan (NHS England, 2019) emphasises the future of digitally enabled care, laying out ambitions which go even further than has already been achieved during the COVID-19 pandemic. Community trusts are at the forefront of delivering on these the ambitions by:

• Empowering patients through increased accessibility to healthcare services, their own records and appointment booking and virtual consultations
• Using enhanced and remote patient monitoring to improve care
• Reducing errors through greater access to information, for example, by using e-prescribing and data sharing
• Increasing efficiency through decreased paperwork and greater use of artificial intelligence (AI) and robotic process automation (RPA).

Although the phrase ‘digital transformation’ appears to be relatively new to the NHS, many community services have been using digital products to enhance care from as early as 2012 (Par, 2012). It is usual practice for community nurses nationally to document care using electronic patient records (EPRs) while with the patient. Accessing patient information from other health and care professionals to provide contemporaneous care and maintaining contact with their teams while working remotely is everyday practice. Digital technology is no longer new for community services. However, there is room for development and improvement through transformation projects.

Digital transformation is ‘the integration of digital technology into all areas of a business, fundamentally changing how you operate and deliver value to customers' (Tang, 2021). Therefore, digital transformation projects within healthcare, should only be implemented if they meet the needs of customers-that is, patients-and support the clinical workforce in delivering care. At a time when the clinical workforce has experienced a prolonged period of uncertainty, implementing new systems which are not directly related to improving how they work will only compound the widely reported fatigue that clinical colleagues are experiencing (Ford, 2021). Goals should be clear from the outset-Natasha Phillips, the Chief Nursing Information Officer (CNIO) at NHSx, outlined eight priorities for the digital transformation of healthcare in the NHS (Box 1), and these form the basis for any digital transformation project (Phillips, 2020).

Box 1.Eight priorities for the digital transformation of healthcare in the NHS

Source: Phillips, 2020

The first community Digital Aspirant

In order to achieve the required pace of digital change, NHS England created Global Digital Exemplars in 2019 (NHS England, 2019), which were mental health, ambulance and acute NHS trusts that were digitally advanced and could share their learning and experience with others. In 2021, a new programme of Digital Aspirant trusts has been announced (NHSx, 2021), and Sussex Community Foundation Trust (SCFT) has been designation the first community trust to receive funding from the programme. The spotlighting of community providers that lead the way in digital transformation and innovation is an exciting step forward.

SCFT provides a wide array of community services, from community nursing, intermediate care beds and specialist nursing and children's services to minor injury units, carers' health, therapy services and immunisation services. The trust employs over 6000 staff members, and levels of confidence when using digital technology vary. Thus, an assessment of digital maturity and a plan for support and training must be a part of any digital transformation.

SCFT has been implementing the SystmOne EPR over the past 10 years and this is well embedded in almost all clinical teams. Over these 10 years, digital has become integral to all teams, as illustrated by the shift from ‘the IT department’ to SCFT digital and linking across all aspects of the organisation. In 2021, a new strategy focusing on integration and shared goal setting with other local providers has been implemented. This brings together the intelligent use of data to benefit patients and clinicians, working to improve inter-operability and usability of systems, as well as patient access to services through digital solutions.

As the implementation of the SystmOne EPR nears completion, there has been a shift of focus. The digital team has returned to clinical teams to carry out transformation projects, looking at optimisation of processes and tools, as well as implementation of new technologies where appropriate. Digital transformation is ongoing in many of these services, and community nursing provides a good example to consider in greater detail.

Digital transformation in community nursing

There are 23 community nursing teams at SCFT, in a large geographical area ranging from very rural areas to small towns, to Brighton city centre. Despite many differences, there were also common challenges faced by all the teams, and a scoping exercise was undertaken to look at how digital transformation could help. Some of the key challenges faced by these teams were:

• Larger caseloads
• More complexity in caseloads
• Long periods of the day spent allocating to large geographical areas.

In some of the larger teams, allocating was taking a senior clinician up to a whole day. If a solution could be found to reduce the time this took, it would free up these clinicians so they could see more patients. A better digital solution was required.

AutoPlanner—a visit-scheduling tool for community nurses

At the start of 2020, a digital transformation project was commenced, which aimed to implement AutoPlanner (TPP, 2018), an intelligent visit-scheduling tool supplied as part of the SystmOne EPR, for use in to all 23 teams. SCFT looked at the various products available that offer visit-scheduling functionality and chose AutoPlanner for the following reasons:

• There is no additional cost to SCFT in implementing AutoPlanner, as this is already included within SystmOne software
• There is no requirement to copy patient information from one system to another
• It is fully customisable by the allocating clinician
• It provides oversight in the office base regarding where clinicians are when out on visits
• It reduces the need for highly skilled and experienced clinicians to be office based for manual allocation of the work. Releasing senior staff time in this manner will improve patient care by enabling more advanced assessment and review
• It strengthens the evidence base, helping to inform workforce planning and skill sets required for the workload
• It reduces over-allocation of visits, reducing pressure and risk to staff, as well as providing a clearer view of demand and capacity. It also helps with standardisation of workload across teams
• The system defines an appropriate order of visits for efficiency, meeting any requirements for timed visits; this saves all clinicians time in planning the order of visits for the day, releasing additional time to care.

When using AutoPlanner, the community nursing teams input information about their patients and their staff, and it automatically schedules visits, matching the right clinician with the right patient, based on geography, clinical need and the skill sets of the staff. Some of the anticipated benefits were time saved on allocation, a reduction in mileage claims and increased patient-facing time.

Implementation was agreed at the start of 2020, with planned completion in November 2020. Following the arrival of COVID-19 in the UK, an accelerated roll-out was put in place for completion in July 2020. Remote training was provided using MS Teams and screen sharing, which meant multiple teams could be supported at the same time. This was only possible due to the rapid deployment of MS Teams to all staff, although this, in turn, necessitated training in the use of MS Teams alongside AutoPlanner training from the project team.

Despite some reservations among community teams, AutoPlanner was well received. Concerns included a desire for more control over how the allocation was completed, due to patient safety considerations. However, compassionate conversations with clinicians led to an appreciation of the ability of teams to alter an allocation based on clinical safety, reducing any anxieties the staff had through reassurance and ongoing communication.

The phrase digital transformation has become synonymous with healthcare

Despite the overall success of AutoPlanner implementation, two teams continue to manually allocate work. This is due to the complexity of the caseload and the characteristics of the workforce, which requires clinical input and not a technological solution. Clinical judgement remains an important part of the allocation process in all teams nonetheless.

It has been challenging to link benefits directly to AutoPlanner due to the non-controllable variables involved. However, initial data suggests the following:

• Time spent allocating was reduced by 38%
• There was a mileage reduction of 47%, which represents a cost saving to the trust, as well as releasing time to care, as staff are on the road less and with patients more
• There was an increase in activity-14% more visits per day were undertaken once AutoPlanner was implemented.

AutoPlanner has been embedded in the teams for over a year at SCFT, and the transformation project is moving to the evaluation stage. Initial qualitative feedback from clinicians showed that there are benefits in teams with optimised skill mix. However, it becomes more difficult to use the software when demand significantly exceeds capacity. In these cases, much of the time-saving benefit is lost, and due to extensive rearranging of visits to ensure clinical safety, much of the mileage benefit is also lost. The challenge of increased demand is not unusual to SCFT, with a national shortage of nurses impacting all community areas. SCFT continues to work with the suppliers of SystmOne to improve the product, as any product intended to save time on community nursing allocation must be able to manage this reality.

Looking forward

The implementation of AutoPlanner is the beginning of an iterative process of quality improvement, working with community teams to continuously evaluate and develop the way they work to support the delivery of safe patient care. Many small changes to process and the configuration of SystmOne have been made, and all these changes have added up to a significantly improved user experience. Reporting and data access have been improved to inform future workforce planning and service delivery. This is an increasingly important part of digital transformation, because, although the NHS has a wealth of information available to it, the links between clinical, configuration, business change and performance teams are key, as good data can only be gathered through robust processes used consistently.

Lastly, SCFT's rural teams visit patients whose addressed are sometimes very difficult to find. The clinical staff told the project team that they write directions within the EPR, as postcodes are often not enough. To resolve this issue, a roll-out of the ‘What3Words’9 app is planned (What3Words, 2021), which will provide easily documented directions to these addresses accurate to within a metre.

One of the main reasons that SCFT's community nursing digital transformation has been so successful is the level of engagement with clinical teams. Clinical and operational staff participated in feasibility projects, offered feedback, collaborated on changes to the EPR and participated fully at all stages. It is important to ensure that these relationships were maintained beyond the end of the project. Champion user groups are a fundamental part of this relationship management, ensuring that clinical and operational teams have a way to remain engaged in digital change and are empowered to improve the way they use the digital tools available to them. To continue this, SCFT is implementing an innovations lab, where any staff member can present innovative digital ideas and be offered support and access to potential funding to pilot their idea.

From September 2021, SCFT will be moving forward with plans to implement a new digital strategy that is ambitious and bold, made possible by the Digital Aspirant investment. It has recognised that nursing leadership is crucial to the implementation of this strategy and is working to ensure that clinicians are leading the way as the trust moves forward. Nursing staff are pivotal to patient safety, and, since digital change can present unexpected clinical risk, clinician involvement is required from the outset to identify and mitigate those risks.

Nurses are best placed to know what is needed by their patients. Many digital transformation and innovation projects fail due to misunderstanding regarding the client groups that will be impacted (Angelani, 2020), whether patients or clinicians. Nurses can help with understanding both groups, ensuring that the right projects are prioritised for maximum benefit. Part of a nurse's responsibility under the Nursing and Midwifery Council's (NMC) code of conduct (NMC, 2018) is to always practice in line with the best available evidence, maintaining the knowledge and skills needed for safe and effective practice. Digital technology and innovations are an unavoidable part of healthcare now, so engaging with them is an important part of any nurse's professional responsibility. Digital nursing evangelists are needed to be a voice for the nursing workforce, to be role models who can engage with digital teams and who can provide clear direction and leadership from a clinical perspective when planning digital change. This is echoed nationally, with increasing representation from nursing leaders in the digital space. Natasha Phillips, England's first CNIO at NHSx, has been in post for over a year, and there are many more opportunities available for nurses in the digital arena, notably the CNIO network advisory panel (Digital Health, 2019) the NHS Digital Academy (Health Education England, 2021a), the Florence Nightingale Foundation Digital Leadership scholarships (Florence Nightingale Foundation, 2021) and Topol fellowships (Health Education England, 2021b), to name a few. This increasing visibility is indicative of an encouraging move towards nurses leading the way in digital health.

Conclusion

As digital healthcare is now part of mainstream NHS provision, nurses need to engage with all its aspects, including sharing their wisdom and leading where appropriate. Community trusts are full of positive and capable nursing leaders, who are equipped to lead challenging change projects. The transition to digital may appear challenging, but nurses must take on the task, advocating for patients and colleagues in an area which will inevitably impact them all.

KEY POINTS

• Digital transformation has been accelerating in healthcare, both because of the aspirations of the NHS Long Term Plan, and because of the COVID-19 pandemic necessitating the use of digital solutions
• Community nursing can benefit from digital transformation through use of digital tools to create time efficiencies, as well as using digital tools to connect when working remotely
• Challenges in digital transformation may arise when there is a lack of digital clinical leadership—nurses are key to the success of digital projects

CPD REFLECTIVE QUESTIONS

• What digital transformation work have you noticed in your workplace?
• What do you think you could do to improve your digital literacy?
• What digital tools do you think could improve the way you deliver healthcare?