The NHS is investing £1bn more in virtual wards - will it work?

The NHS is investing more in virtual wards to reduce avoidable hospital admissions and free up inpatient beds taken up by ‘medically optimised’ patients

The government and NHS England have now published the Urgent and Emergency Care Plan, outlining strategies intended to bring waiting times back down, including investing more in ‘virtual wards’. The aim of virtual wards is to support mostly elderly patients, as well as those with respiratory conditions, in their own homes rather than hospitals.

Doctors review their cases each day and patients using wearable devices can report daily readings and results so they can be remotely monitored. Patients can receive home visits where necessary, and the technology can also be used to reduce the risk of falls.

There will be a target of up to 50,000 people being supported in this way each month, up from around 10,000 at the end of last year. There will also be more community response teams aiming to get to vulnerable patients within two hours - officials say up to 20% of hospital admissions are avoidable with the right care in place.

This investment follows a range of small NHS pilots that were delivered throughout the pandemic to explore the idea that virtual ward capacity could, in effect, grow the bed base and allow ‘medically optimised’ patients to be safely discharged. With the right acceptance criteria, technology and staffing models, virtual wards were heralded as being one of the ways the NHS could free up beds for those more acutely unwell in physical hospital wards, and thereby allow the flow of hospital admissions from the front-door, the Emergency Department and de-pressurise ambulance forecourts waiting to offload.

Especially during Winter, all hospitals - even the best performing - have struggled with this for many years, working desperately hard and innovating relentlessly in an effort to keep their EDs, assessment units and wards safe and meet constitutional targets.

It has been widely published that bed shortages have reached dangerous levels due to patients being unable to leave hospital because of a lack of social care in the community; a fifth of beds are occupied by people who could be at home if only they could be discharged safely. The government set a target of 50 virtual "beds" per 100,000 people - the equivalent of two inpatient 25-bedded wards.

Is this a big vote of confidence in tech?

The technology that is deployed as part of mobilising a virtual ward isn’t particularly Black Mirror - it’s technology that has been around for years: devices monitoring blood pressure and measuring blood oxygen levels, video calls on tablets.

What’s more interesting is the platform capability that is being used by the staff for red-flagging when patients need intervention or are deteriorating, and the interfaces for patients themselves to interact with health professionals. Best of breed suppliers like Current Health and Luscii have been developing this sort of technology for a number of years, co-designing many virtual ward-appropriate pathways with NHS disruptors and responding to feedback from patients along the way,

In some recent pilots, the tech has attempted to push the boundaries of what virtual wards can and should monitor. Some suppliers like Lilli have cracked non-intrusive environmental monitoring, with their devices tracking metrics like domestic humidity and temperature levels and even ‘learning' a resident's typical routine, such as when they boiled the kettle or opened the fridge door. This lets staff know remotely when that routine had been deviated from, signalling the patient might have been taken ill suddenly or had a fall. Pilots proved particularly useful last summer when the UK experienced blistering heat waves. Very cool.

Will it work?

Virtual wards are perhaps the most fetishised tech trend in the digital health world right now - and so we can expect lots more interest, evaluation and funding for the next couple of years, especially as we look to embed some of the benefits of remote care that were accelerated during the COVID-19 pandemic. But if the whole intention here is to liberate beds and allow the NHS to deliver more care without investing in more staff, we might not want to get too excited.

Staffing

Staff costs are approximately 48% of the £120 billion NHS budget. We can therefore understand why this may be seen as a goal to help the NHS achieve efficiency and best results for taxpayers. 

But until the robots can come along and truly save us, these virtual wards will need to be staffed and monitored by - you guessed it - the same staff that are running around trying to support patients in overpopulated hospitals and within the community.

Patients will have routine queries, request home visits and adverse events will happen. On and offboarding a virtual pathway will need resourcing. The patients we are targeting with these sorts of pathways may be vulnerable, they may not be functionally independent, they may not be regimen compliant, they may not be digitally literate and struggle with the devices (not to generalise too much here - I hate it when we it is suggested that elderly people don’t get tech).

Serious thinking needs to go into how this will affect the need for community district nursing - as well of course as social and domiciliary care.

According to a recent study quoted by the HFMA, less than 40% of community nursing shifts are fully staffed and ultimately the responsibility to care for these patients will fall to these already over-stretched teams. With current strikes, pay disputes and staff retention as low as 50% for some roles, actually keeping enough people in the NHS to run these tech-enabled services isn’t a given.

Infrastructure basics

On top of that, some of the infrastructure basics may need to be focused on first or at least in parallel:

• Wifi and 5G infrastructure so that connected devices can function properly
• Upgrade infrastructure like devices and re-imagine working with mobile working - not let it take 30 mins to login to individual systems to access patient data
• Have clinical teams be able to communicate and collaborate; EHRs, unified communications including clinical communications
• Start using RPA in more impactful ways that help them deal with care quality and workforce scarcity issues
• Be able to have the tools to act on insights from what's happening in each NHS organisation with Command Centres
• Investment in skills and new workforce models to actually deploy and run the technology seems to be light in the current plans

Is the NHS as excited about this as the government?

Short answer - probably not. NHS Trusts had to set up pilots really quickly without all the usual planning in place so a lot of what the NHS is doing now is reviewing how they are faring.

Most staff know that they have to adopt these new technologies which undoubtedly will help in the long-run, but this won’t be a panacea. The acceptance criteria for a virtual ward won’t be the same as it was during the pandemic, when keeping frail people in hospital beds at risk of getting COVID encouraged perhaps a more risk-tolerant use of virtual wards. There will be many reasons staff will opt to keep people in beds for physical monitoring, and the transition to trusting a virtual ward admission will take a few years, as will the role of family members and carers shifting to accommodate this.

With the government’s new investment, this isn't an innovative trial anymore, this is the future and a new way of working and that will come with new expectations, new targets and performance pressures. The cynicism will set in as we cross the chasm of early adopters to early majority - the hardest part of any change. We’ll start to see a proliferation of senior roles being created in the centre and within ICSs. System-wide improvement plans with project management investment will kick in. Change management will be important so NHS staff who know their patients are active participants in designing safe and effective virtual pathways. Onboarding patients with galvanising and caring information and support, and ultimately being advocates of this sort of care will be key.

NHS 2040 - where will we be with virtual wards by then?

If we accept that virtual wards are here to stay and will form part of the future health service, let’s think about where we will be in a few years. And let’s remember the Bill Gates quotation: ‘Most people typically underestimate what they can do in one year and overestimate what they can do in ten.’

Change will be incremental, slow and feel hard amidst current pressures. Staff won’t have the headroom for running pilots and schemes on top of just getting through the day.

What’s more, we’ll need to prove that virtual wards are safe, effective and efficient. Quality and safety monitoring and inspections delivered by the CQC will need to adapt. Health economic evaluation will need to take place - we are assuming it’s better value than a £300 hospital inpatient bed day cost (the price of a luxury hotel), but we don’t actually know yet that a virtual ward is better value when the costs are fully rolled-up including staff, tech platforms, devices, patient support, onboarding and off-boarding, and potentially including readmission costs.

But there has to be huge optimism here.

Without the innovation that the pandemic forced upon us as a society and the current post-COVID pressures, it might have taken us years longer to arrive at this point. And technology will provide answers to questions we haven't even thought to ask yet.

One of things we are working on at Thriva Solutions is the technology to support in vitro sampling within a virtual ward. Getting physical biomarker data out of patients (typically blood tests) is often one of the reasons patients have been kept in hospitals historically for the age-old medical intervention: ‘wait and see’. We are working on fully decentralising in vitro sampling and building reliable technology that integrates with the NHS systems to support this being done a) by a fleet of cost effective phlebotomy staff in the community (peripatetic and drop-in), and b) in some cases, empowering patients to conduct their own self-sampling with at home postal kits with rapid turnaround times at the labs. We don’t want to replace the NHS systems and portals that already have widespread adoption, we’re building this capability using simple APIs to work within tools practitioners already know.

Conclusions

Telehealth generally and virtual hospital wards will grow, but slowly. Like much of the change in the NHS, given the current pressures in some service areas staff won’t have the headroom for much incremental change, especially when some of the basics need investment and focus first, plus we need to think about some of the trickier hybrid components like access to biodata from in vitro samples that can’t be solved with ‘bits and bytes’ alone.

The government - in need of some good news - will talk up the ‘pledge’ and the target, but the proof will be in the pudding: do virtual wards actually liberate beds and help staff manage the pressures of the day?

Until some of the fundamentals of staffing are properly sorted out, especially in social care, our population that’s getting older, fatter and sicker may prevent us from ever truly feeling the benefit of this added virtual bed base.

A final word - we keep hearing about population health management, earlier intervention and prevention being cheaper than treatment - and we all know this to be true. Let’s see some real impetus to implementing innovative preventative approaches. If we empower patients to live in a more healthy way and give them the right tools at their fingertips, perhaps we won’t be in need of an ever expanding physical and virtual hospital bed base that the NHS can’t safely staff and the Treasury can’t afford - no matter how exciting and impressive the technology is.