What are virtual wards?
Virtual wards are remote services which help patients to manage their health and care at home.
Patients and carers are asked to take health readings (e.g. blood oxygen levels, blood pressure, temperature) in a location convenient for them, such as their home. They can submit these to health care providers either via telephone or digitally (e.g. using an app). The readings may then be reviewed and responded to by professionals elsewhere, or patients may be asked to seek further help, for example if their readings are of particular concern. Remote monitoring models have been previously used for a range of chronic health conditions (e.g. Peretz and others, 2018; Castelyn and others, 2021; Jonker and others, 2021).
There is currently a national policy push in England towards virtual wards being developed for a range of conditions, such as COPD and urinary tract infections. The ambition is for the NHS to have 40–50 ‘virtual ward beds’ per 100,000 population by December 2023. Some of these services already exist, while others will develop from Covid-19 virtual wards. There are a number of lessons from the experience of the latter – see the final section of this explainer for more detail.
How have virtual wards been used during the Covid-19 pandemic?
At the start of the pandemic, clinicians and services realised that some patients with Covid-19 were arriving at hospital too late. This was because Covid-19 can cause very low blood oxygen levels but doesn't always cause patients to feel breathless. Patients may not realise that there is an issue until they feel extremely unwell. This resulted in some patients needing invasive treatment and/or being admitted to intensive care units, and in some cases even dying.
Covid-19 virtual wards using pulse oximeters were developed and introduced in a number of countries during the pandemic. In England, services were developed locally, before being rolled out across England by NHS England and Improvement. These included pre-hospital models, in which patients were referred via community routes (e.g. GPs, NHS 111, hot hubs, emergency departments) and post-hospital models, in which patients were referred upon early discharge from hospital.
Some of the aims of these services were to:
- provide patients with appropriate care in the appropriate place (e.g. avoiding unnecessary hospital admissions or readmissions) and quickly identifying and escalating patients who required further treatment (e.g. in hospital)
- reduce infection transmission
- shorten length of stay in hospital.
What happens when you are referred to a Covid-19 virtual ward?
The box below describes a patient’s journey through the Covid-19 virtual ward.
Are all Covid-19 virtual wards the same?
No. A study of Covid-19 remote home monitoring services found that Covid-19 remote home monitoring services in England varied considerably.
While all of the services provided patients with a pulse oximeter and information, and followed the stages mentioned in the box above (referral and triage, onboarding, monitoring, and recovery and discharge), the specific characteristics of services varied. For example, services varied in:
- the type of referral methods used (community referrals or hospital early-discharge referrals, or both)
- who leads the service (primary and community care, secondary care or both)
- type of monitoring and submission (using tech-enabled solutions together with telephone phone, or telephone only)
- admission criteria (age and risk factors)
- workforce size and type of staff
- start date
- the proportion of Covid positive patients they enrolled (see Phase 2 findings slide set; Vindrola-Padros, 2021).
There were many reasons for variation across services (including patient, workforce, organisational and resource factors). For example, many of the sites designed their service to be inclusive of their local population needs.
Do Covid-19 virtual wards work and how much do they cost?
Further evidence is still needed on whether Covid-19 virtual wards work. So far, evaluations have been unable to provide conclusive evidence regarding the effectiveness of Covid-19 remote home monitoring services. This was possibly due to the lower enrolment to services than expected.
The cost of these services varied depending on the type of service provided, and the type of monitoring and submission mode used (e.g. digital and telephone, or telephone only).
What do staff and patients think of Covid-19 virtual wards?
Staff, patients and carers generally liked Covid-19 virtual ward services.
Staff reported that services were mostly easy to deliver but that they needed some additional training. Barriers and enablers to delivering these services included staff knowledge and confidence, NHS resources and workload, multidisciplinary team dynamics and patient engagement. The evaluation found that using digital submission modes helped to manage large patient groups but did not completely replace phone calls.
Patients and carers valued the services and felt reassured by the human contact provided as part of the service. They felt that services were mostly easy to engage with but there were some barriers and facilitators to engagement, including patient factors (such as knowledge and physical health), having enough support from staff and family members or friends and resource and service factors. While many services were designed with patient needs in mind, the evaluation still found that some patient groups had more difficulty engaging with the service than others (for example, older adults, those with a disability or health condition and ethnic minorities).
What are the key lessons for development of virtual wards for other conditions?
Learning from the use of Covid-19 virtual wards can be used to develop similar services for patients with other health care conditions (for example acute respiratory infections, and COPD). Key lessons from the evaluation of Covid-19 remote home monitoring services are summarised below.
Lessons for planning and implementing services
- Services and national programmes should expect and encourage local variation and flexibility in service implementation. The context and priorities of local services should be considered (for example the local population needs and how this may affect enrolment decisions).
- Service planners should provide local services with the following:
- strategies to proactively identify eligible patients
- an indication of the level of clinical oversight, staffing and resources needed
- support to work collaboratively across settings
- Learning networks and communities of practice can support local services to share and receive information on how services adapt national models, and what is working or not working.
- To evaluate services, we need better data collection processes, which include comprehensive information on patients, staff and service implementation. This should include linkage between data collected by virtual wards and routine secondary care data.
- Service users (patients and carers) and staff should be consulted at the design stage of a remote home monitoring service to ensure services are appropriate.
Lessons for the workforce
- Remote home monitoring may be able to be used in lieu of traditional face-to-face models. However, the views of staff and patients in non-pandemic contexts need to be considered as these findings may have reflected the need for minimised face-to-face contact during Covid-19.
- Virtual ward services should still include elements of human contact, e.g. telephone calls (for health-related support and reassurance/emotional support for patients and carers), especially for safety netting.
- We need to support staff to deliver virtual ward services, by providing enough staff to manage demand, enough senior clinicians to provide oversight and sufficient training and guidance.
Lessons for patient engagement
- Consideration needs to be given to the burden these services may put on patients and their carers, for example in submitting readings.
- Some groups of patients have more difficulties using remote home monitoring services, such as older patients, those from ethnic minorities, and patients with existing health problems. Services need to put strategies in place to address these, including for those who are unable to engage with these services.
Further information on these lessons can be found in the following resources: Phase 2 findings slide set; Sherlaw-Johnson and others, 2022; Georghiou and others, preprint; Walton and others, preprint; Crellin and others, preprint).
Find out more about the RSET and BRACE study of remote monitoring methods used during the pandemic here.
The Rapid Service Evaluation Team (‘RSET’), including Holly Walton and Naomi Fulop, comprises health service researchers, health economists and other colleagues from University College London and the Nuffield Trust who have come together to rapidly evaluate new ways of providing and organising care.