In the space of just a few years, virtual wards have gone from being a relatively obscure technological solution to a veritable buzzword in NHS circles. They now occupy a unique space in the healthcare system, acting as both a step up from the community and a step down from acute settings.
The model offers a tantalising solution to the unprecedented demand and capacity issues currently faced by the NHS. Staff talking to Nursing in Practice have been generally positive about its rollout.
However, some have raised concerns that virtual wards might not be a silver bullet for the NHS’s woes and might even increase the workload of nurses in the community.
To be effective, virtual wards require dedicated staff, careful patient selection, 24-hour coverage and extensive cooperation between primary and secondary care.
While they have their champions, others worry that the NHS simply is not equipped to make the most of what can be expensive investments.
At this key juncture, we ask whether virtual wards can improve patient flow and reduce demand, and what the implications are for community nurses.
What are virtual wards?
The NHS is increasingly introducing virtual wards to support people who would otherwise be in hospital. Patients are monitored remotely (e.g. for blood oxygen levels, blood pressure, temperature) using technology such as apps, wearables or other medical devices. They are contacted daily as they would be on a hospital-based ward round, but by phone or video call. Additional support such as home visits can be provided by community teams, including nurses, as required.
Many virtual ward models are run by multidisciplinary teams, which may function as part of an existing in-person ward, a community team, or from a GP practice. Usually, care coordination and day-to-day operations will be led by a senior nurse or practitioner. Many virtual wards are run from hospitals, but in some areas are based in the community.
Source: NHS England. Virtual wards. 2022.
Rapid expansion
Interest grew in virtual wards during the Covid-19 pandemic, when they presented a solution to two big problems facing hospitals.
First, as hospitals worried wards would quickly fill up, patients who could be cared for at home under remote supervision could be moved into a virtual ward, freeing up physical beds for more critical patients.
Second, hospital staff who needed to shield and could no longer work on the ward or in people’s homes were still able to contribute valuable assistance. However, as the waves of Covid receded, the virtual wards remained.
‘I don’t think we’d have thought we could provide all this care the way we do if we hadn’t had Covid,’ says Dr Elizabeth Kendrick, medical director at Hertfordshire Community Trust.
‘We were forced to change what we were doing, and we were forced to think, how can we do this differently?’
Virtual wards are not new; Croydon PCT won a national award for their introduction in 2006.2 However, their key role in the pandemic response has led to a policy push in England towards having 40-50 ‘virtual ward beds’ per 100,000 population by December 2023. This could mean to up to 24,000 virtual beds.
They have also become more valuable as the extent of problems with timely hospital discharge has become increasingly apparent. A Nuffield Trust analysis published in February3 shows a 57% increase in delayed discharges in the 12 months between April 2021 and April this year, from 8,039 to 12,589, with researchers estimating 15% of patients were in hospital due to delayed discharge at the end of that period.
While the size of virtual wards varies significantly, almost all are rapidly expanding. In the Humber and North Yorkshire ICB, the 14-bed respiratory ward is set to grow over the next 12 months and has already been joined by a virtual frailty ward treating 40 patients a month.
Meanwhile, NHS Leicester, Leicestershire and Rutland, aimed to more than triple the 72-bed capacity to 231.
In April, NHS England announced that an initial £200m would be available for virtual wards in 2022/23 and a further £250m in 2023/24, to help reach the goal of 40-50 virtual ward beds per 100,000 population by December 2023.
A win-win situation?
Those who work in virtual wards are enthusiastic about the opportunities to improve patient care.
Amy Booth, head of nursing for the community division at Wrightington Wigan and Leigh (WWL), says virtual wards are ‘groundbreaking’.
She explains: ‘It’s about facilitating quicker discharge out of hospital. We know no one wants to spend more time in hospital than needed. And the longer you stay in a hospital, the more problems can occur.’
In hospital, says Mrs Booth, older patients can quickly decondition and often see their mental health suffer, ‘but if we can get people home, they can have that social interaction and support from their family and friends’.
Simple benefits like being able to make yourself a cup of tea or go to bed when you want can have a big impact on patients’ wellbeing and even on their rate of recovery.
Since Norfolk & Norwich University Hospital launched its virtual wards in 2021, 1,600 patients have been seen, with a satisfaction rating of 98%.
Recent research, conducted by the National Institute of Health and Care Research4, found older patients in homecare were less prone to delirium and required smaller social care packages on discharge.
This is a ‘win-win situation’, says Arul Bangalore, an advanced clinical practitioner and registered nurse, who is associate matron for the Whittington Health NHS Trust virtual ward in north London.
‘The patient gets to live in surroundings known to him or her. But also, we are also looking at bed days saved and reducing the amount of time in hospital. This is economical, this is efficient, and this is best practice.’
And greater technological innovation has increased the variety and complexity of conditions that can be safely treated in the community. Many more trusts are also in the early stages of expanding virtual wards to include postoperative, cardiac and diabetes care.
Mr Bangalore says: ‘With education, with learning, with guidance and with technology, I think we are able to safely manage high acuity of patients in the community’.
The impact on community
However, to live up to their potential, virtual wards will need more than technological innovation and enthusiasm; they must begin to act as a bridge between the community and acute care.
Pritesh Mistry is a policy fellow at the King’s Fund think-tank, specialising in digital innovation and how technology can improve healthcare. He says virtual wards are still often seen as a ‘solution to a problem in a set organisation’, such as demand for bed space or capacity issues.
‘But it’s a healthcare system,’ he says, ‘and that’s one of the things we need to consider. When you implement a solution like virtual wards, it might solve capacity issues within an acute setting, but you’ve got knock-on implications for people in the community setting.
‘Something like virtual wards can be seen as a solution to a problem in an organisation, but because it has ramifications across hospitals into the community, it needs to be seen more as a transformation that happens across walls and across organisations.’
In their early stages, virtual wards often struggled to win trust among clinicians. The issue was that even when a patient was released to a virtual ward in the community, the hospital clinician would still retain clinical responsibility.
If anything happened in the community, then the hospital doctor or advanced clinical practitioner would still be held accountable. This, says Dr Kendrick, initially led to some ‘push back’ from doctors.
‘One of the things we discovered when we started doing this work is that the doctors don’t really understand all that happens in community,’ she says. ‘There are people who don’t like the thought that people leave hospital early, and are really concerned about it.
‘If we’re really going to make virtual wards and remote monitoring work, everybody in the system needs to be brought into it.’
However, getting people to buy into a new system isn’t always easy. ‘You can’t just tell people: this is what you’re doing, you’ve got discharge to the virtual ward,’ says Phillip Bliss, chair of the WWL virtual ward programme.
‘Doctors aren’t going to use the service if they think it’s unsafe or patients aren’t going to get good care.
‘But I think every time you show it to somebody, and they see what it’s like and they realise patients actually get monitored more closely at home on the virtual ward, it shows them that there’s a safety net for patients.’
As Mr Bliss points out, virtual wards are still a new way of doing care and support can’t be built overnight.
The nursing point of view
For nurses, virtual wards can be a mixed blessing. If implemented correctly they can reduce workloads and offer exciting career opportunities. If not, they may be more trouble than they are worth.
Mr Bangalore is one nurse who believes virtual wards can open up amazing opportunities in the community.
‘Since I came to this country, I wanted to see what the scope of career opportunities were. Especially being an immigrant, we can often be stuck in our own shell or cocoon, so I wanted to see what the community might have to offer.
‘At that time there were A&E closures, increasing frailty in the population, so the question was where best to treat the patient.’
Likewise, Lucy Smith, assistant clinical operations director at Provide CIC in Colchester, is currently working to implement a programme of rotations on virtual wards for newly qualified nurses.
Ms Smith explains that it is ‘really important that they see there is a place for them to use all the skills they get during their training’, so nurses don’t feel they have to start their career in a typical hospital job.
Workforce concerns
But concerns persist that virtual wards may result in even greater strain on already overstretched services across the NHS.
Mr Bliss explains that a common worry expressed by doctors is that moving patients to virtual wards only increases the number of patients under the care of a single clinician.
In the community too, virtual wards have been greeted with some scepticism over their potential impact on the workforce.
The Queen’s Nursing Institute chief executive Dr Crystal Oldman says that while the intentions for virtual wards are good ‘some district nursing services have said that patients are falling to us when the virtual ward team are not there’.
Dr Oldman points to reports of district nurses being called on to manage virtual wards during night shifts when the ward did not have 24-hour coverage.
However, she notes that such evidence is anecdotal and there is a wide variation in the management of virtual wards. All the virtual ward staff who were spoken to for this article were keen to stress that their service would not create additional workload for community and district nurses.
Managers point out that they had created new teams with additional NHS funding and that district nurses are in fact able to refer patients to the virtual ward if they require more frequent monitoring.
However, Dr Oldman questions whether it would be better to invest further in existing district nursing services and ‘grow what you’ve already got’, rather than creating a new team.
Building the bridge
Susan Gibbs, who created one of the country’s first virtual wards for Whittington Health more than nine years ago, says starting with a ‘blank canvas’ offered both opportunities and challenges.
Ms Gibbs says it was a ‘very, very difficult launch because the gaining the confidence of the consultants on the boards was really challenging’. She adds: ‘They had never experienced a service like this before where they were responsible for patients that they couldn’t see.’
However, with time Ms Gibbs was able to build those relationships with the clinical staff and develop the trust that is now at the heart of the programme.
She says the virtual ward is now ‘the lynchpin’ between the hospital and the community.
‘We’re the go-between because we’re based in the hospital but we work in the community, and we have colleagues in both.’
And, while building support from staff in hospitals is one way to improve collaboration, some virtual wards are looking at the situation from a different perspective.
Stephanie Dawe, CEO of Provide Health, operates a virtual ward with the Mid and South Essex Collaborative that is based not out of a hospital but in the community.
‘At the end of the day,’ says Mrs Dawe, ‘a virtual ward is a community resource, and the only way it will work is if it links with other services in the community.’
‘Confidence in the community workforce’
In the community, says Ms Smith, the workforce is used to delivering home-based care.
‘When you go into someone’s home you are everything to that person and I think there is a confidence in the community workforce to be able to look after patients in their own home.’
Ms Smith points out that another important factor is the links that community teams already have with other services, like social care. ‘We have those personal relationships, but also those geographical links to make sure that the care is wrapped around the patient.’
Yet while Ms Dawe and Ms Smith are clear that virtual wards do not have to be based solely in hospitals, both say they could not work effectively without close ties to acute secondary care.
Ms Smith summarises the importance of that relationship: ‘It’s having the confidence of the staff in A&E or the frailty unit to say we can look after a patient, and they’ve got to trust you to keep that patient safe.’
The future of virtual wards is still being ironed out – but one thing healthcare professionals working in hospitals and the community can agree on is that neither can make it work on their own.
And, concludes Ms Smith, it’s ‘all about winning hearts and minds’.
References
- NHS England. Virtual wards. 2022. Link
- King’s Fund. Case study: Virtual wards at Croydon Primary Care Trust. London: King’s Fund, 2006. Link
- Flinders S and Scobie S. Hospitals at capacity: understanding delays in patient discharge. London: Nuffield Trust, 2022. Link
- Shepperd S et al. Is comprehensive geriatric assessment admission avoidance hospital at home an alternative to hospital admission for older persons? Ann Intern Med 2021;174:889-898
This article first appeared on sister title Nursing in Practice.
