Virtual wards are here, and the NHS is currently rolling them out to boost capacity with the aim of creating 24,000 virtual ward beds by 2024. However, the precise function of an NHS virtual ward, and its impact on patient care, is still under review.
Looking from my perspective as a registered nurse, who was deploying virtual wards at regional scale during Covid-19, this article considers how integrated care systems (ICS) are progressing with virtual wards and what challenges they face in delivering virtual wards scale. Will the NHS, as hoped, deliver not just the beds but the hoped-for health outcomes?
In 2020, the Covid-19 virus hit and virtual wards went from a fringe idea to a vital NHS service, almost overnight, serving two prime purposes. Virtual wards were able to facilitate safe and early supported discharge for patients in hospital, so they could be at home supported with remote vital signs monitoring and care from a ‘virtual’ multidisciplinary team. Secondly, they were able to support and monitor patients who might be at high-risk of admission, still at home, with the aim of preventing their admission
With the goal to ensure that some patients have the option to access care and treatment from home as a safe and effective alternative to hospital bedded care, there are in the region of 6,000 virtual ward beds in England and a wide variety of models, all at various stages of maturity and implementation.
The scale and pace needed to have 24,000 beds in place by 2024 has led to a number of common challenges. In our experience, most systems are focusing on the challenge of recruiting appropriate numbers of staff to provide comprehensive care. However, there are wider complexities that need to be considered to deliver scale:
- Using resources in the most effective way
- Establishing the number of virtual ward beds needed for the target number of patients who may benefit from care
- Overcoming the reluctance from services to refer patients to the virtual ward - current reported occupancy rates of some virtual wards is c.45%
- The integration of virtual wards into the local system, for example with emergency, community and primary care services
- Ensuring that virtual ward services have effective operating models to:
- - ensure patients are offered the choice of a safe and effective care alternative to hospital bedded care
- - evaluate the quality of the care they provide
- - assess the safety of the care they provide, and
- - appraise the outcomes in comparison to other virtual ward providers
In relation to some of the challenges, we believe that re-evaluating and questioning current virtual ward deployments in an ICS can lead to new insights that can help scale virtual wards at a pace, supporting patient demand for high quality technology-enabled care at home.
And we’re at a point where determining the maturity of virtual wards will help to evaluate progress to date and identify the uncertainties or further opportunities. Ways to do this are many and varied, but here are several areas we consider priorities, if you aren’t already looking at them.
Understanding the capacity, demand and activity of virtual wards
We believe ICSs should measure the current and forecast capacity for a planned virtual ward (by number of slots and by pathway – e.g., Frailty or Acute Respiratory Infection). More widely, can the ICS forecast the number of patients who might benefit from care from a virtual ward? Consideration should also be given to reporting the throughput of patients from its current virtual wards and measuring the outcomes of those patients, such as understanding how many are discharged back to the care of their GP or community team, and how many patients are admitted or readmitted to hospital.
Operating model variation and service configuration
Another area of priority is looking at whether the ICS can map the number of beds open and current occupancy rates, and how the current service models map in operation – including the right staffing models (number of staff by numbers, roles, and hours of operation, technology in use). Operating models need to consider a wide range of factors including clinical governance, patient flow and integration with other parts of the care eco-system such as primary care and/or social care.
Targets and outcomes - are they being met and delivered?
In order to know whether targets are being achieved, the ICS will need to articulate what outcomes it’s expecting for patients in relation to service quality, safety for its virtual wards, including patient and carer satisfaction, complaints and compliments. It’s then important to determine how the ICS can report on the outcomes of the virtual ward operation in relation to:
- discharges, deaths, transfers of care to higher or low levels of care i.e. hospital admission or readmission
- length of stay versus estimated date of discharge
- number of incidents and issues experienced in giving care
Resources and costs
Can the ICS evaluate what are the current costs of running virtual wards and in the future? And can the ICS estimate the resources needed to run effective and safe virtual ward services in the future? We believe it’s also important to baseline performance against local and national virtual ward models, shown to deliver safe and effective technology-enabled care as an alternative to hospital bedded care.
Data and reporting
Beyond the ability to locally report activity and report nationally required ‘SitReps’, what else are virtual wards able to report in relation to patients and their clinical outcomes from care in a virtual ward? It’s worth considering also whether the reporting should be able to leverage data from other sources to provide insight and improvement.
What needs to change?
For an ICS to scale the rollout of virtual wards safely and effectively, we believe that in addition to the question of maturity, the ICS needs to undertake a clinically focused ‘stock-take’ of where they are now.
We suggest the ICS will only be able to scale and demonstrate the effectiveness of virtual wards if they consider the following key points:
Integrated support to staffing
Effective staffing comes from investing and developing an integrated service to recruit, train, schedule and support staff, with alternative workforce models and new mixed roles in delivering virtual ward care. Scarce and specialist medical and nursing staff can then work flexibly across many virtual wards, ensuring patients have access to the staff and knowhow needed to maintain safe and effective care.
Technology
Work towards an integrated technology with a single clinical information management platform. This will enable patients and clinical staff to have access to an integrated ICS suite of remote technology and data deployed to support the effective monitoring of patients at home whilst clinical staff have access to patient-reported data and workflow platform. This will reduce the technology anxiety and support needed for patients and reduces the need for multiple log-ons and training for staff.
Operational process
Provide a centrally managed suite of clinical and operational protocols aligned to clinical governance and wider system integration. A coordinated function will ensure the support of safe, effective practice for clinical and support staff, working across virtual wards to support continuity of care, issue management, governance, audit and reporting. The coordinated function will ensure that the virtual ward is a truly integrated part of the care system, to deliver the best possible outcomes and experiences.
Patient support
The objective is to ensure centralised, professional contact and communications services for both staff and patients across the ICS. This will support reliable and comprehensive patient and staff contact, care coordination and communication management for all the ICS virtual ward services.
Support services for virtual wards
To be able to operate virtual wards at scale requires a wide range of clinical and non-clinical activities to happen effectively in the background, and a services provider can take responsibility for delivering this on behalf of the NHS. This ensures that clinical staff focus on supporting their patients and responding to their needs, whilst patients feel they can contact the virtual ward team with any questions clinical or non-clinical, to get help they need.
Managing change
Virtual wards are still in their early stages of development. ICSs will need support to create new processes and ways of working to optimally support virtual ward staff to deliver high quality, safe technology-enabled patient care. So, organisations that can support the NHS with operations and change will be a welcome addition.
Achieving maturity will not come from trying to optimise or bolster point deployments. It will come from having the right foundations in place, with one eye firmly on the demands of achieving scale.
