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Virtual wards: The good, the bad and the costly

Virtual wards: The good, the bad and the costly
By Jess Hacker
5 March 2024

Virtual wards are in full swing across integrated care board areas but recently their cost effectiveness was called into question. Senior reporter Jess Hacker takes a look to see if the benefits outweigh the costs

It’s no secret that NHS England is proud of its virtual wards scheme.

First pioneered by a handful of trusts, NHS England turned the approach into a central mast of its flagship policies in 2022 as a means of cutting down high occupancy rate in hospitals and eliminating challenging discharges into the community.

In May 2022, NHS England tasked integrated care boards (ICBs) with getting 10,000 virtual ward beds up and running by the end of 2023, with £200m funding from the service development fund (SDF) available to help establish them.

Over the course of the year, the number of virtual beds jumped by 60% from 4,485 to 7,653, with the latest data indicating there are 11,635 across England (as of February 2024).

By the end of 2023, more than 240,000 patients had been treated on virtual wards, with a number of them likely to have avoided a hospital admission. And when publicising this data, NHS England cited research showing people who are treated at home recover at the same rate or faster than those treated in hospital.

But a new study seems to have steered the virtual ward flagship into stormy seas and cast doubt on the policy’s ability to live up to its promises.

Published in the BMJ in January, a North West-based study suggested the cost of discharging patients to a virtual ward were nearly double that of traditional in-person care.

Researchers at Wrightington, Wigan and Leigh (WWL) Teaching Hospitals found that the average length of stay for patients discharged to a virtual ward was much higher, with greater rates of readmission.

The researchers utilised a ‘step-down’ model, assessing the length of stay in days from the date of admission to the hospital and the date of admission to the virtual ward.

‘By analysing the length of stay,’ they wrote, ‘we aim to assess the effectiveness of virtual wards in reducing the duration of hospitalisation and therefore increasing the number of beds available for hospital patients.’

It determined the cost of this averaged £935 a day per patient, compared to £536 to keep a patient in a hospital bed.

But those running virtual wards understandably take issue with how the study has been received. 

‘I don’t think the findings were enormously helpful,’ says Dr Lucy Abbott, a consultant geriatrician at Frimley Health Foundation Trust.

‘The majority of what the [study authors] were assessing was early step-down from hospitals. If all you are doing is step-down, then you won’t see a significant cost impact, because that patient has already been in an ambulance, they’ve already been in A&E, and they’ve been in hospital for however many days. In that scenario you’re only saving on the last couple of days of an admission.’

Dr Abbott – who runs her trust’s frailty virtual ward – notes that virtual wards save money when patients are referred from their GP or the ambulance service.

Frimley Health’s 10 virtual wards – including its frailty, respiratory and stroke wards – are among the highest performing in the country, in terms of hospital avoidance.

Since launching in December 2021, the wards have seen 10,321 patients admitted. Between October 2023 and January 2024, more than 2,300 hospital admissions were avoided in total as a result of the wards.

The frailty virtual ward, in particular, is a money saver, Dr Abbott says. This ward has had a 96% admission avoidance rate, with a total of £631,000 saved a year.

Dr Abbott also emphasised the system benefits. Frimley Health’s virtual wards prevent around 70 primary care visits a month, saving £95 each time.

‘We’re well placed to support primary care on the frailty virtual ward. While a patient is on our caseload we’ll do a falls review and a review of their medications, so we take a proactive approach as well as reacting to the present medical issue.’

On the claim that virtual wards are not cost effective, she says: ‘I think the study authors are right in a sense. If all you are doing is running a step-down service, shaving off a couple of days, then it’s probably going to be an expensive model of care. But if you can prevent that admission for the majority of patients that’s when it becomes a cost-effective option.’

When it comes to step-down care, health leaders tend to agree on that front.

In a March 2023 report, the Nuffield Trust warned: ‘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.’

The report authors referred to a 2021 study, published by JAMA Network, suggesting there is a risk that a person may actually stay enrolled in the service longer than they would have otherwise done in hospital.

They advised that any integrated care board (ICB) or trust looking to establish a virtual ward must have a ‘clear understanding of what success would look like’ that doesn’t simply focus on ‘occupancy’ as a measure, but the wider impact on patients, carers, staff and services.

Nigel Edwards, co-author of the Nuffield report, but who now chairs the National Centre for Rural Health and Care, told Healthcare Leader: ‘There is a good evidence for virtual wards and they can be an effective model of care but, like all interventions, the evidence is for a particular set of design features and there is often a tendency to think that these can be changed without altering the potential effectiveness of the model.’

He warned, however, that what counts as a virtual ward must remain clear.

‘The term has become rather confusing and there is a need to really ensure that the services are a substitute for hospital care and not just an expansion of services that have a lower threshold for admission,’ he says.

Much like Frimley Health, Humber Teaching NHS Foundation Trust has seen similar success with its frailty virtual ward, albeit on a smaller scale.

‘We’ve had 175 patients through so far and less than a quarter of those patients have gone back into hospital,’ Joanne Marshall, locality matron for Humber Teaching NHS Foundation Trust says.

‘That gives us around 130 patients who we’ve successfully helped avoid that full hospital admission.’

The trust’s frailty ward launched initially with five beds available in in January 2023, growing to 15 over the course of the year and with a view of offering 25 by April 2024. Open to patients over 65, the average length of stay on the ward is four to five days.

The common theme is how the ward benefits local primary care providers, and the associated cost savings.

‘The fact the GPs are no longer responsible for their patients while they’re on the virtual ward is an obvious benefit,’ says Sarah Locker, service manager and operational lead for the virtual ward. ‘GPs are very pressured with high demand, so there’s clear reassurance that if a patient is on the virtual ward at home, rather than just at home, they can feel confident that somebody else is taking on that care.’

She adds: ‘That was a big concern among GPs when we launched the wards: that they would still need to see these patients and they’ll be more unwell than most other patients.’

As the ward has progressed, that concern has been cleared, she suggests.

‘Looking at how the ward runs when compared to the cost of inpatient hospital stays, it must cost less to see a patient through our virtual ward than to admit them to hospital,’ says Ms Locker.

A 2022 study published by the National Institute for Health and Care Research (NIHR) supports Ms Locker’s stance.

The trial involving around 1,000 patients looked to assess the clinical effectiveness and cost-effectiveness of geriatrician-led admission avoidance hospital-at-home services. Researchers found that the hospital at home approach offered a ‘cost-effective alternative to hospitalisation’ for selected older people.

There’s clear evidence that virtual wards can be cost-effective. Frimley Health Foundation Trust’s virtual wards have allowed for significant savings.

A 2021 evaluation of the Croydon model – which sparked the virtual ward approach – estimated a total cost-saving of £742.44 per virtual ward patient compared to the rapid responses control group.

While these examples demonstrate the success of virtual wards, January’s BMJ published study has drawn eyes to concerns that health leaders such as Mr Edwards had shared.

It highlights that taking a one-size-fits-all approach to a virtual ward will simply not allow the ward to work as intended. Their success requires leadership fully devoted to developing the service to its ultimate potential, beyond a step-up or step-down service, and considering it as a ward in its own right.

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