Implementing new models of care is not easy – and especially so when organising community-based services that aim to tackle the challenges of more chronic disease and greater levels of emergency care.
One of the more interesting approaches of the past few years has been the Virtual Ward and we recently published a report, funded by the National Institute for Health Research Service Delivery and Organisation Programme, looking at three early examples of Virtual Wards, plus a paper in the International Journal of Integrated Care.
There has also been a good recent review of work in the South Devon and Torbay Virtual Ward published by The Kings Fund.
Overall we did not find a reduction in emergency admissions – though there were perhaps signs of lower elective admissions and outpatient attendances
As with many such service innovations, the term Virtual Ward is used to refer to slightly different things around the country.
The original model developed in Croydon and opened in May 2006, was an approach to integrate different community-based teams to coordinate care for high risk patients in their own homes. The idea was to bring the positive benefits of multi-disciplinary working seen in a hospital ward to a community setting.
One of the key drivers was the need to reduce emergency admission through better preventive management of patients who are risk of hospital admission. Since then, a variety of variant models have sprung up – and in some cases I’m not altogether sure that they are what I would recognise as Virtual Wards.
As with ‘integrated care’ which can mean all manner of different things, we have to be careful of the fancy label and check what’s happening on the ground.
In our study we looked at three sites that were early adopters and used three slightly different models. For this type of study we had to pool the results from all three sites in order to have enough patients in our sample – which is a shame as the sites were not well balanced in size and two of them were really in their infancy.
As a result, our findings were dominated by one model in one site. We tested for differences in hospital activity and in particular we looked for a reduction in emergency admissions in the Virtual Ward sites, when compared to a ‘matched control’ group of patients drawn from other sites with no Virtual Ward.
Overall we did not find a reduction in emergency admissions – though there were perhaps signs of lower elective admissions and outpatient attendances.
Our findings however have to tempered by the fact that during the course of the study we did find that in one site, the largest, the model of care had changed away from the Virtual Ward and reverted to something that was much closer to usual community care.
So even though we did the work, we are still cautious about saying that Virtual Wards either do or do not work, and are actively trying to re-evaluate one of the sites at the moment – subject to having a clear a path through the current jungle of information governance.
In fact, this type of change in the model of care, which we identified during the course of this study, is a common problem when evaluating complex interventions – in real life, the ways in which services are delivered does not necessarily stay fixed but changes over time.
As ever, the real world presents problems for a researcher wanting a nice summary of the impacts of a pre-specified service design on a few selected and pre-set outcomes. We recently wrote an overview of the problems that we face.
Even though our analysis has not quite gone the way we wanted, we still believe in the value of this type of evaluative work – most importantly in assessing whether the service changes, that people invest so much time and energy putting into place, are going in the direction that they think.
This project was funded by the National Institute for Health Research Service Delivery and Organisation Programme (project number 09/1816/1021). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.