Remote monitoring and the potential benefits for patients with long term conditions

Dr Annette Pautz has been a GP at Holmwood Corner Surgery in South West London for 16 years. She is Deputy Chair for the Borough Committee in Kingston, Chair of the Council of Members for Kingston (a group representing Kingston GPs) and is also the clinical lead for community, care homes and respiratory in Kingston for SWL CCG. She believes introducing remote monitoring systems into care homes can have huge benefits both for primary care clinicians and care home residents. More than that, she believes it could be a first step to unlocking better care for larger portions of the population too.

Remote monitoring provides a way for us to effectively and actively monitor our patients in care homes, identify early deteriorating patients and get a much better idea of who needs a home visit urgently. This is particularly important when care homes are understandably trying to reduce the amount of people visiting because of the pandemic. It should also give GPs more certainty around their decision making – it can be difficult for a non-clinical person to describe why they are concerned over someone’s health, whereas the data provided by remote monitoring is in the ‘same language’ the GP uses.

In addition, if general practice has all this data, we can potentially link up with hospital consultants more easily and quickly to discuss a patient’s care. This will provide better and more responsive clinical care for care home patients without them having to wait for GPs or Community Healthcare Staff to do a home visit and then come back and prescribe. I think sometimes the system is a little slow for care home residents and this will provide a much more interactive, responsive service for them which will be better for patients and the care home staff who worry about them. That has to be a real selling point.

Listen to Dr Pautz talking about the benefits for primary care

I know primary care colleagues have concerns about whether these systems will integrate with their existing clinical systems or increase their workloads. That’s why we’ve made sure in South West London that the software which we have chosen will integrate with EMIS, the system which the majority of our GPs use. And rather than roll this out to all GPs at once, we will pilot it with a couple of our GP care home leads first. We’ve had good engagement from them through their PCNs and our hope will be that through the pilot we can identify a good process for monitoring and using the data.

Excitingly, if we can make a success of this in care homes then it opens up the possibilities for how we can look after people who are still in their own homes and move more care out of hospitals and into the community. It would definitely be useful for people with long-term conditions – patients will be able to learn more about their condition and take more control, reducing the need to go to a doctor’s surgery or hospital. It could also help with discharging patients earlier if they can be monitored at home.

Listen to Dr Pautz talking about the benefits for primary care

We have an opportunity now with the pandemic to see if we can roll this out and find a way to share this way of working with colleagues in secondary care. We’re already having virtual MDT meetings and there’s the possibility that the vital signs that are recorded on devices could be expanded to include spirometry, ECGs and ultrasounds. With these it will be vital to have the view of secondary care consultants and allied health professionals like radiographers where we can all see the same data in real time to give advice.

It is clear what we are looking to do with care home is the first step on what has exciting possibilities for how we care for large numbers of people in the near future.

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If you’re interested in finding out more you can contact the London Innovation Collaborative programme lead Fay Sibley.

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Meet the innovator: Vivek Patni

Meet the Innovator

In this series we’ll get up close and personal with an innovator asking them to share their thoughts and experience from their journey into the world of health and care innovation. In our latest edition, we spoke to Vivek Patni, Director and Co-Founder of WeMa Life; an online marketplace that brings customers and their families together with social care and community care service providers.

Pictured above: Vivek Patni.

Tell us about your innovation in a sentence

WeMa Life is an online marketplace that brings customers and their families together with social care and community care service providers; giving choice, accessibility and efficiency in the service procurement and delivery pathway.

What was the ‘lightbulb’ moment?

As an informal carer for my grandfather, I was immediately shocked by the lack of innovation in supporting families to find, coordinate and manage local care services for their loved one, hence WeMa Life was born. I find online marketplaces very convenient and use them for so many aspects of my life – products, clothes, hotels, restaurants – I knew a similar digital environment was needed for care services. Using WeMa Life as a customer I can search, compare, purchase and rate local care services whilst as a provider I can digitise the outdated, manual, paper-based visit records and manage my daily business activity.

What three bits of advice would you give budding innovators?

    1. Stay flexible: it’s tempting to start a business with a clear idea of how things will unfold; but this is rarely the case. Pivot and react to obstacles and have an open approach to finding the best solutions to all your problems.
    2. User experience: test your product constantly and get as much feedback as you can from all your user groups. Simple solutions sit very well in such a diverse industry.
    3. Be creative in your approach to developing tech and running your business. There are so many applications and tools to create efficiency and cost saving in finding resources, marketing and development, so use them!

What’s been your toughest obstacle?

Where I had faced the difficulty from a customer side of social care, I was less aware of the complexity in delivering publicly funded social and community care to different user groups. This meant learning the nuances of each service type/provider and creating a fluid product that would fit all.

What’s been your innovator journey highlight?

Designing the tech architecture from scratch, building an international technology development team and bringing my ideas to life in just eight months is something I am very proud of.

Best part of your job now?

Taking my product into the market! Now that the product is live, I am driving its use through digital marketing and sales. I meet so many interesting people on a daily basis who bring exciting new ideas to what we do – my mental technology roadmap is never ending.

If you were in charge of the NHS and care system, what’s the one thing you’d do to speed up health innovation?

I would give more opportunity and financial incentives to SME’s. There are a huge number of SME’s with great ideas and technology, they tend to be more fluid, interoperable and customisable to the needs of the NHS; they would be able to make a real change to the daily lives of providers and customers.

A typical day for you would include..

Typically, my days are devoted to technology and selling. My morning tends to be engagement with my India tech team to make sure we are always refining and innovating our solution. Afternoons will be selling, calling and meeting as many people as I can. I get energised by talking to people about what we do so I try to do that as much as possible.

For more information on WeMa Life visit or follow them on Twitter @wemalife

Evaluation into ‘Red Bag’ Hospital Transfer Pathway

Key learnings for Red Bag emergency transfer pathway revealed in report

The ‘Red Bag’ Hospital Transfer Pathway, which was highlighted in the recent NHS Long Term Plan, is now running across south London. But how effective is it? The HIN has produced this evaluation report which explores the impact and stakeholder experiences of implementing the pathway within three south London boroughs.

A new evaluation report has found that vital communication between paramedic crews, care home staff and hospital clinicians has been improved by the Red Bag Pathway when all measures were adhered to, but there are still a series of barriers to best practice to overcome.

The study, which included survey responses, interviews with hospital clinicians and paramedics, and a focus group with care home managers, found that the majority of care homes are using the Red Bag as intended. Conducted by the Health Innovation Network, the report said that improvements need to be made at both ends of the pathway to ensure it is adhered to and the benefits are fully realised.

Pioneered by Sutton Homes of Care Vanguard, the pathway ensures vital medical information, such as current medical condition and medicines regime, travels with the care home resident in a specially-designed red bag when they make emergency hospital visits.

Over two-thirds of the 90 survey responses from care homes, ambulance crews and hospital clinicians in Kingston, Richmond and Lambeth, stated that the Red Bag had improved communication between care homes and hospitals and made the handover to ambulance crews smoother.

Over half of care home managers believed the pathway had improved the transfer process for residents and both ambulance and hospital staff stated that the two forms most helpful in the Red Bag documentation were the ‘Do Not Attempt Resuscitation’ form, for older people making decisions about what happens towards the end of their life and the Alzheimer’s Society’s ‘This Is Me’ form to help healthcare professionals know more about people living with dementia.

As well as highlighting some of the positive effects the pathway has had on emergency hospitals for care home residents, the study also flags some of the challenges faced in implementing the transfer pathway. These included finding that, on some occasions, standardised patient information was either missing or incomplete when residents were transferred to hospital, that medical discharge information was not always sent with the patient and that locating and retrieving bags that had become lost in hospital transfers was particularly difficult.

Responses also indicated that both care homes and hospitals faced challenges with successfully promoting the pathway in the face of high turnover of staff and during the busy winter period. The report found that when the pathway was not adhered to – either in the care home or hospital setting – this caused practical difficulties and could result in despondency and frustration amongst professionals

The challenges highlighted have led to some wider learnings for practitioners. Don Shenker, who led the Red Bag project for the HIN, believes there are five key tips that can be taken away from the study:
1. When preparing the Red Bag in the care home, double check all the documentation is filled in properly
2. When receiving the Red Bag in the ambulance or hospital, read through the documentation
3. When transferring patients to different wards in hospital, check the Red Bag and documentation is with the patient
4. When discharging the resident back to the care home, make sure the Red Bag and discharge documentation accompanies the resident
5. When receiving the resident back in the home, update the care plan records.

Effective implementation of the Red Bag Pathway will contribute toward the Enhanced Health in Care Homes (EHCH) model as set out in the recent NHS Long Term Plan.

The report launched at a HIN sharing event, attended by staff from all parts of the Pathway, designed to ensure the complexities of implementing the pathway and opportunities for improvement are discussed more widely so all parties can work together to keep improving the use of the Red Bag.

Zoe Lelliott, Deputy Chief Executive for the Health Innovation Network, said:
“Our work is all about promoting innovation in the NHS and across the whole care system. The Red Bag is a successful innovation born in Sutton and recently extended across the whole of south London, but this study shows that there are still challenges and a focus on careful implementation is needed to maximise the benefits.
“True joined up work with our members and partners in south London is making a real difference to people’s lives and I want to thank all the health and care staff who have worked so hard to adopt the Red Bag Pathway in their areas.”

Berenice Constable, Head of Nursing for Kingston Hospital NHS Foundation Trust, said:
“Frail care home residents are at their most vulnerable when transferred in an emergency to hospital. It’s vital that the latest state of their health is communicated to all clinicians from ambulance crews to hospital staff so quicker decisions can be made over their care.
“It’s also a moment when they might lose important personal possessions from hearing aids to glasses, so the Red Bag Pathway is a simple innovation that, when followed fully, ensures the safest possible transfer as well as the fastest discharge.”
“This report shows that the Red Bag is really making a difference and improving the care of some of our most vulnerable residents.”

Evaluation of the Hospital Transfer ‘Red Bag’ Pathway in South London

Download the report here.

Why do we need a leadership programme for care home managers?

Why do we need a leadership programme for care home managers?

Written by Don Shenker, Project Manager for Healthy Ageing.

At the first workshop day for care home managers on the Pioneer Leadership Programme last January, participants were asked to list the things they did in a typical day as a care home manager. The 14 managers listed 55 tasks they typically undertook on a daily basis – ranging from dealing with funerals, preparing the staff payroll, dealing with complaints, checking medication systems and helping to move beds.

As someone who was very new to the care home sector, I was awed by the responsibility care home managers held and the loneliness of the job at hand – providing high levels of care to some of the most frail older people in society and dealing with the myriad regulations, controls and quality checks from CCGs, local authorities and the CQC. The managers on the programme nodded in recognition when talking about missed lunches, half-drunk cups of cold tea and waking up in the night, worried if everyone in their care home was alright.

To add to this, CCGs are continuing to push their care homes to reduce the number of residents going into hospital unnecessarily and to accept new admissions to the care home even at weekends – all to ease the pressure on hospitals struggling to cope with acute demand from a frail older population. One in seven over 85’s now live in a care home and there are three times as many care home beds as there are in the NHS. To add to this pressure on the NHS, emergency admissions to hospital from care home have increased by 65% between in the last six years (2011-2017).

The Health Innovation Network and My Home Life Care Home Pioneer Programme is a free leadership course for south London care home managers which aims to develop the leadership skills and confidence needed to lead care home teams in a demanding and pressurised sector.

The programme is run over nine months, with managers using exercises developed by My Home Life to improve deep listening skills, focus on collaboration, connect emotionally, discover what is working well and embed positive change together. The principle of appreciative enquiry is adopted – starting with recognising existing strengths as a team and building on that.

The overriding sentiment managers spoke of, to a packed room of care home managers, CCG commissioners and local authority staff on their Graduation day, in November, was how the programme had helped to build the confidence they needed to make changes and improve their home.

From changing how they ran team meetings to encourage staff to speak out, to developing culturally appropriate services and initiating new ways of involving residents in decision making, the care home ‘Pioneers’ spoke of how they had achieved a transformation in themselves and in their home. The programme evaluation shows a two-fold increase in the confidence managers felt in managing their team and their home.

Having developed our original Pioneers in 2018, the HIN is now recruiting a new cohort of care home manager pioneers for our 2019 programme, with the Pioneer Graduates being trained to co-facilitate and mentor the new cohort.

At a broader level for south London, the HIN hopes to support the care home Pioneers to now co-create the solutions required for older adult care with NHS, CCG and local authority colleagues to ensure continuing high-quality care pathways for older residents/patients. Having seen first-hand the remarkable resilience, strength and knowledge gained by the 14 Pioneers, I’m confident they will go on to achieve even greater things.

To find out more information and apply for the next cohort, please click here

Thousands of care home residents across south London to benefit from safer emergency hospital visits and faster discharge as novel ‘Red Bag’ scheme expands

Innovative Red Bag

Thousands of care home residents across south London to benefit from safer emergency hospital visits as novel ‘Red Bag’ scheme expands

Novel ‘Red Bag’ ensures thousands care home residents across south London will have safer emergency hospital visits and faster discharge

The ‘Red Bag’ keeps vital medical info and personal belongings safe during emergency hospital visits

Thousands of care home residents will benefit from an innovation designed to make emergency hospital visits safer and speed up discharge after health and care chiefs agreed to extend the innovative Red Bag scheme across the whole of south London.

The news comes on the United Nation’s International Day of Older Persons (1st October) and means older residents enjoy a more personal and seamless health and care service.

Started three years ago Sutton Vanguard’s Hospital Transfer Pathway ‘Red Bag’ ensures key info such as existing medical conditions and other clinical information is communicated and helps ensure residents return to their care home as promptly as possible once hospital treatment is completed.

Developed by NHS and care home staff, the Red Bag has already been adopted across 11 London boroughs and is expected to go live in south London borough Croydon in November. NHS England unveiled a Red Bag scheme toolkit in June to encourage all areas of the country to adopt the scheme.

Care homes across south London, holding more than 13,000 care home beds between them, have committed to taking part in the Red Bag – a simple innovation which ensures records and personal belongings are kept safe when a care home resident is transferred into hospital.

Under the scheme, when a patient is taken into hospital in an emergency they have a Red Bag to take with them. The Red Bag contains:

  •  General health information, including on any existing medical conditions
  •  Medication information so ambulance and hospital staff know immediately what medication they are taking
  •      Personal belongings (such as clothes for day of discharge, glasses, hearing aid, dentures or other items)

The Red Bag also clearly identifies a patient as being a care home resident and provides hospital staff with the information they need to speed up clinical decisions. This means patients can often be discharged sooner which is better both for the residents and for the NHS, as it means individuals are out of hospital more quickly and money is saved. Extended hospital time can be particularly problematic for those with dementia who can deteriorate more rapidly when away from their usual settings.

The bag stays with the patient whilst they are in hospital. When patients are ready to go home, a copy of their discharge summary (which details every aspect of the care they received in hospital) will be placed in the Red Bag so that care home staff have access to this important information when their residents arrive back home.

The Red Bag has been used with care home residents 2,000 times in south London since April 2017 and length of stay in hospital has reduced by on average 2.4 bed days per Red Bag used.

The Red Bag initiative was created by Sutton CCG hosted Sutton Homes of Care, which was a national Vanguard programme to improve care in residential and nursing homes, in partnership with clinicians from Epsom and St Helier University hospitals, Sutton and Merton Community Services, London Ambulance Service and representatives of the care homes.

Since its introduction in Sutton, the Red Bag has also stopped patients losing personal items such as dentures, glasses and hearing aids worth £290,000 in a year.

There are half a million more people aged over 75 than there were in 2010 – and there will be two million more in ten years’ time. They are also spending more years in ill-health than ever before.

Caroline Dinenage, Care Minister, said:

“The Red Bag is a great innovation that helps link up health and care services for older people, so it’s fantastic news that the whole of south London is now committed to using it. Not only is this more efficient – saving valuable resources – but it leads to a much better experience for patients leaving hospital when their treatment has finished. It’s encouraging to see the scheme being rolled out even further across the country as we move towards our ambition of joined up care that is centred around the individual.”

Aditee Naik, Peartree Care Home Manager, said: “Care home residents are at their most vulnerable when they travel in an emergency into hospital. This is why the Red Bag is so important because it ensures all key paperwork, medication and personal items like glasses, slippers and dentures, are handed to ambulance crews by carers and travel with patients to hospital where they are then handed to the doctor.

“Sometimes it’s the personal touch that makes a big difference to patients, especially if they’re elderly, and the Red Bag helps people feel reassured and more at home. It’s great that on United Nations International Day of Older Persons, here across the whole of South London we are celebrating the fact that the Red Bag is helping ensure our older residents and patients have the very best care.”

Jason Morris, London Ambulance Service Clinical Team Leader, who helped develop the Red Bag at Sutton CCG during its national Vanguard status, said:

“The Red Bag standardises the process of handover from a care home and means we can get all the essential information in one go, no matter which home in they’re in.

“We’re delighted this scheme has led to such a wide range of benefits for us, our colleagues in hospitals as well as care home staff. But most importantly, it’s seen improvements in the care of these patients who can go to the hospital with everything they need. We’re even seeing them returning back to the care home quicker.”

Stephanie Watts, NHS Greenwich CCG Commissioning Manager, said: “The Red Bag pathway is a true example of collaboration between health and care agencies. It works well because all the agencies involved in patient transfers from care homes are invested in it.

“Use of the Red Bags has a number of proven benefits which we are already beginning to see, even though it’s only been a few months, including things like increased communication between hospital teams and Care Home staff, shorter stays in hospital and improved quality of information provided to Care Homes when their residents are discharged.”


Chris Terrahe, Deputy Director of Nursing at Croydon Health Services NHS Trust, said: “We are delighted to be working alongside our partners in Croydon CCG and local care homes as part of the new Red Bag scheme in the borough. For care home residents arriving at or leaving hospital, it should make things much more efficient because all the vital information about their health will be in one place.”


Dr Agnelo Fernandes, Clinical Chair of NHS Croydon CCG and local GP said: “I’m delighted that the Red Bag is being rolled out in Croydon.  We’ve seen that it can really reduce hospital stays for care home residents, ultimately improving their quality of life.”


Sarah Blow, Senior Responsible Officer for South West London Health and Care Partnership, said: “We’re incredibly proud of the work being done to improve the health of older people in Sutton by bringing together health and social care providers. Having seen the benefits to patients, we have already rolled out the red bag scheme in other boroughs in south west London, so we’re delighted that this will become a national scheme.”


Tara Donnelly, Chief Executive of the Health Innovation Network, said: “Our hospitals provide great care, but no one wants to spend any longer there than they need to and being transferred from a care home to hospital in an emergency can feel traumatic. That’s why the Red Bag is a great example of a simple idea with a big impact.”