It is no secret that the NHS is in crisis. Poor and worsening performance on ambulance response and waiting times are being compounded by high occupancy rates in hospitals, a lack of staff, and difficulties in discharging people into the community once they’re ready to leave hospital.
Although there is no quick fix, virtual wards have been presented as part of the solution to address these pressures and support future resilience. The latest plan for supporting urgent and emergency care recovery has expanding virtual wards as a key part of preparing the NHS for next winter.
In November, we held a roundtable with clinical leaders from BT’s clinical advisory board to explore their experience of virtual wards and identify future priorities. Drawing on that discussion, wider evidence and the latest policy developments, this long read discusses priority areas where further development and action could help improve their effectiveness.
What is a virtual ward?
A virtual ward is a remote service that helps patients to manage their health and care at home.
NHS England define a virtual ward as “an alternative to NHS bedded care that is enabled by technology. Virtual wards support patients who would otherwise be in hospital to receive the acute care, monitoring and treatment they need in their own home. This includes either preventing avoidable admissions into hospital, or supporting early discharge out of hospital.”
This envisages a single service with a continuum from all virtual to hybrid and face-to-face delivery.
Integrated care systems (ICSs) have been provided with funding to develop – at a minimum – virtual ward pathways for acute respiratory infections (ARI) and frailty. Targets were introduced for systems to have the equivalent capacity of 40 to 50 virtual ‘beds’ per 100,000 population by December this year.
Although elements of the virtual ward have been around for some time (often referred to as “hospital at home”), changes during the pandemic and improvements in the use of technology have introduced new questions about how to make best use of them.
Models of virtual wards: balancing variation and consistency
A virtual ward can include people who may otherwise be admitted to hospital (“step-up”), or who are in hospital and needing to be discharged (“step-down”). Within this, however, models are widely variable. During Covid-19, services have varied significantly, but this flexibility was considered important for taking account of the local population, service and workforce context. This is also the case now with local areas developing a wide variety of virtual ward models that operate in different ways.
Despite this variation, there are things that seem to make virtual wards most effective. This includes clear processes for what to do if someone’s condition deteriorates, and dedicated teams with defined roles and responsibilities. Guidance around developing virtual wards has set out several steps to support ICS leaders develop local services that build on these, which recognise the importance of working with local providers and organisations to tailor the service appropriately.
Identifying the right patients for a virtual ward is important. Generally it is thought that virtual wards work best where there is a clear diagnosis or disease trajectory, and where clinicians have access to the person’s clinical history.
In all cases this creates some risks, and while the evaluations of virtual wards have not shown any impact on mortality (in either direction), managing risk within a virtual ward is important. In part, this requires having clear decision-making processes – research on the use of virtual wards during the first two waves of the pandemic highlighted this as a key enabler of effectiveness.
Equally vital is having accurate data and information that is integrated between services such as primary and community care, hospital and emergency or 111 services – to support the referral process and enable the right decisions to be made about a person’s care. But, although progress is being made, data quality in community services is still limited.
Supporting patients and carers
As well as increasing capacity, NHS England guidance also reflects on the need to increase the use of virtual wards. Previous evaluations have generally found low uptake of virtual wards, despite additional efforts to involve people who may be at greater risk of health inequalities, such as older patients, patients with a disability, and non-White ethnic groups more likely to report difficulties engaging with services. Importantly, there is a need to ensure that both patients and carers feel confident and supported when part of a virtual ward.
Roundtable participants discussed the opportunities of technology-enabled virtual wards in allowing greater transparency and access to information via remote monitoring. Participants also saw a connection with initiatives such as patient-initiated follow-up (PIFU), which NHS England has also outlined as a way to manage capacity in outpatient services. Given that PIFU is also – frequently – technology enabled, and encourages patient self-management (as previously identified), many of the issues overlap.
System oversight: making better use of data and relationships
There are benefits of developing systems that ensure there is oversight of all the capacity for supporting patients across a system. Having this available in real time and collected digitally gives those responsible for overseeing and managing the system a much better chance of ensuring that resources are in the right place, and reduce the risks associated with overloading parts of the system. Roundtable participants considered that, to do this effectively, there is a need for collaboration and partnership working between primary, secondary and community care.
There is also a need to make better use of available data at a local level to oversee capacity both within the hospital and community, and target support most effectively. Importantly, data needs to be integrated between systems including social care, community care and hospitals, as well as 111 and 999, as well as other organisations such as adult and paediatric ARI ‘hubs’, which are considered an important source of virtual ward referrals.
Developing the workforce
Supporting staff involved in delivering virtual wards must be a priority. Recent plans acknowledge the need to be flexible with workforce deployment depending on local area, as well as examples of local staffing models (with appropriate clinical leadership). A national workforce recruitment capacity and capability plan has been promised to support the scale up of virtual wards, through multi-disciplinary teams and flexible working for staff, for example.
Where technology enabled, previous evaluations have also shown that integrating technology into clinical care is just as much about the wider workflows and care pathways as the technology itself, and the goal should be understanding where technology can enable, not replace, care. But roundtable participants considered that the issues already outlined about risk also apply to the workforce, given that the effectiveness of a virtual ward may depend on the risk appetite of individuals and services. It’s therefore important that there are clear decision-making processes in place to support individuals involved in delivering a virtual ward.
Underlying this was a general concern around staffing pressures – particularly given that the NHS and social care are competing for the same staff. Without accounting for this more systemic challenge, initiatives such as virtual wards risk falling at the first hurdle.
Expanding the scope
Despite the initial focus on acute respiratory infections and frailty, there are also virtual wards pathways in place for heart failure, paediatric care and cancer, and there are opportunities to use virtual wards as part of the elective recovery process for people after surgery. Before the pandemic, some hospitals were providing virtual wards to care for people with conditions such as heart failure or COPD. It is important for these to be clinically led, and NHSE is working with relevant Royal Colleges and societies to develop targeted guidance and support for different specialties.
Our discussion suggested that the development of over-the-counter PCR tests for flu and other respiratory viruses could also offer the opportunity to significantly expand the use of virtual wards for a wider range of respiratory conditions by enabling people to do tests at home. This could be by reducing the need to attend the emergency department or for investigations to exclude other conditions. This could have the added benefit of reducing the risk of infections in hospitals.
Participants also recognised that having the option of a virtual ward may mean that other (often costly) solutions such as converting surgical to medical wards or employing significant numbers of locum staff can be avoided.
Measuring success and unintended consequences
The evidence on which type of virtual ward will make the most impact on hospital capacity in the long term is still uncertain. Roundtable participants considered that there may be a greater benefit in using virtual wards to prevent people attending or being admitted to hospital in the first place. In some areas, referral from 111 and ambulance services has been a growing and important source of virtual wards activity. However, there is a risk that this means more people will be included in a virtual ward who may not be admitted to hospital another way, such as through A&E. Given that part of the goal of virtual wards is to increase capacity, this is a key issue. It is important to continually monitor who is referred to a virtual ward and for what reason.
Step-down models could make a significant impact on hospital capacity by supporting people in hospital to go home, but without effective social care, rehabilitation services or seamless discharge processes they will not be as successful. Previous experience with hospital at home models suggests there is a risk that a person may actually stay enrolled in the service longer than they would have otherwise done in hospital.
Ongoing evaluation of the roll-out and impact of virtual wards will be important, but variation in the models and limited high-quality data affects our ability to do this effectively. Equally, having a clear understanding of what success would look like and what we are aiming to achieve is important – this should not just focus on ‘occupancy’ as a measure, but the wider impact on patients, carers, staff and services.
Not a quick fix to hospital capacity on their own
Virtual wards have significant potential, and the planned expansion to other conditions and patients offer promising opportunities. However, they are not a quick fix. The NHS has form in taking solutions that are well-thought-through answers to specific problems, before applying them too widely or with poor adherence to the principles that make the model effective.
If we think virtual wards will fix all the problems around hospital capacity, they will be unlikely to succeed. Unless the entrenched challenges within the social care and community sectors are addressed, pressure on acute hospital services and discharge processes is not going to yield any time soon.
A lot of emphasis is being placed on virtual wards providing a solution to the pressures facing the NHS, but whether they succeed remains to be seen. Ongoing evaluation is required to understand the impact of virtual wards on patients and staff, as well as their effectiveness in supporting capacity in both step-up and step-down care. Given the enormous pressures on the system, however, anything that helps to alleviate just some of those pressures can be considered a good thing.
*This Nuffield Trust long read was written following a roundtable with members of BT’s clinical advisory board.
Hutchings R and Edwards N (2023) “Virtual wards: the lessons so far and future priorities”. Nuffield Trust long read