Virtual Wards
Virtual wards are a major component of how the Department of Health and Social Care plans to tackle the demand for beds in hospitals. Hospital trusts are targeting the reduction in the number of patients present in hospital beds who have 'no criteria to reside' (NCTR). Virtual wards are considered to be a way to reduce NCTR patients and those with non-acute conditions.
Virtual wards were the centrepiece of the Conservative government’s delivery plan for recovering urgent and emergency care services announced by the Department of Health and Social Care back in February 2023. The plan includes virtual wards to treat up to 50,000 elderly and vulnerable patients a month at home by the end of 2023-24.
Then in July 2023 NHS England set out its plans to avert the winter crisis in the NHS, part of which is a rapid increase in the number of virtual wards. NHS England has continued with this approach.
What is a virtual ward
A virtual ward allows the NHS to support people at home, or in a care home using technology, such as remote monitoring apps, wearables and medical devices, however support may also involve face-to-face care from a multi-disciplinary team based in the community.
Virtual wards have been under development for several years, but the Covid-19 pandemic accelerated their development.
The acceleration of ‘virtual wards’ for Covid-19 patients was due to clinicians realising that some patients with Covid-19 were arriving at hospital too late as they were not aware of having very low blood oxygen levels until they felt extremely unwell. This resulted in some patients needing invasive treatment and/or being admitted to intensive care units, and in some cases even dying. If they had known earlier about their oxygen levels then they could have been treated at an earlier stage.
The Covid-19 virtual wards use pulse oximeters to monitor oxygen levels. In England, two models were used: pre-hospital, in which patients were referred via community routes and post-hospital, in which patients were referred upon early discharge from hospital.
‘Virtual wards’ now cover a variety of conditions, including cardiovascular and respiratory problems, such as chronic obstructive pulmonary disease (COPD). In December 2021 NHS England published guidance for setting up a frailty virtual ward for those with frailty aged 65 or over who have an acute exacerbation of a frailty-related condition and updated guidance for virtual wards for acute respiratory infection, which expands on the guidance for Covid-19 virtual wards.
Analysis of Covid-19 virtual wards has found that they assisted with earlier discharges and reduced clinically necessary re-admissions for patients admitted with COVID-19, saved money but without compromising on patient safety.
The new plans from the DHSC are primarily focused on frail and vulnerable patients with the creation of more "urgent community response teams" to provide patients with at-home support "within two hours". There will also be an expansion of the frailty and falls service.
How many virtual beds are planned?
The targets for virtual bed numbers are not new; they were set back in February 2022 in NHSE’s 2022-23 planning guidance. This gives the target of 40 to 50 virtual beds per 100,000 population by December 2023, and this was backed with £450m in funding over two years. This is between 22,400 and 28,000 virtual beds across England, an increase of around ten times the estimated 2,500 virtual beds in place in December 2021. According to the new plans the target of 40-50 virtual wards per 100,000 people, will allow more than 50,000 admissions a month.
By December 2022, 7,000 virtual beds were reported to have been delivered. The February 2023 announcement plans for another 3,000 to be available by Autumn 2023 taking the figure up to 10,000.
However, uptake of the virtual beds has been slow. Of the 7,000 opened by December 2022, only just over half had been actually occupied. In December 2022 HSJ reported that NHS England director for community transformation Stephanie Sommerville told a NHSE webinar that occupancy stood at around 52% (3,602 of the 6,944 beds). HSJ was then told by NHSE sources that this has now increased to around 55%. And HSJ noted that it had seen internal figures that said just over half of the 7,000 new virtual ward beds opened under the new national programme are occupied by patients.
By May 2024 the expansion of virtual wards had slowed down considerably almost certainly due to the ending of ring-fenced funding in March 2024. From the end of 2023 to May 2024 the number of occupied beds on virtual wards increased only 1%. Total virtual ward capacity – including “unoccupied” beds – increased from 9,713 to 12,325 (27 per cent) in the 11 months leading up to May 2024, but the majority of the growth came in the first five months. Growth from December to May was 4.4%.
An analysis by HSJ of ICB data published in July 2024 found that of the 42 ICBs in England, 26 saw an increase in virtual ward capacity in the 11 months leading up to May 2024. Seven ICBs reported no change, while nine ICBs saw their virtual ward capacity decrease.
Despite the lack of funding, in May 2024 NHS England issued new guidance for the expansion of virtual wards in an update to the urgent and emergency care recovery plan. A particular target is expansion to heart failure patients.
NHSE reports that an evaluation of virtual wards in the South East region showed more than £10m of savings plus 9,000 admissions avoided in the past year.
An analysis done by management consultants PPL concluded the longer virtual wards run the more likely they are to show impact as volume increases and cost per admission start to fall.
Concerns
Are there enough staff for the planned wards?
The NHS has a staffing crisis with many thousands of vacancies. Whilst patients in virtual wards do not need hospital staff feeding and washing them, they still need trained staff to analyse information received from the technology and staff to respond if the technology says an intervention is needed.
There are numerous devices and technology platforms now available for virtual wards, but despite the presence of technology, the Nuffield Trust, in an overview of virtual wards, noted that there is still the need for an element of human contact and sufficient staff to make the wards a success.
The British Geriatrics Society (BGS) welcomed the increase in virtual wards but noted that the “biggest challenge” will be ensuring that appropriately trained staff are in place to provide services. The BGS noted that “the NHS faces record workforce shortages and simply moving staff around from one part of the NHS to another can only work as a short-term fix.”
The workforce issue has also been highlighted by The Royal College of Nursing director for England Patricia Marquis who said: “More hospital beds and more community and social care services are desperately needed to ensure patients get the right care in the right place at the right time. But the real problem is the lack of staff. Extra beds are only safe when there are enough nurses for the patients in them. And because of the workforce crisis, existing services are unsafe.”
In May 2023, a report on virtual wards from the NHS Confederation noted that the “steady lack of available workforce over the years continues to affect the feasibility of delivering virtual wards at scale.”
As well as the issue with a lack of NHS staff, there is the additional issue of lack of social care staff as without support from this area in the community, it is difficult to see how virtual wards in particular for elderly patients with frailty will succeed. In October 2022, there was a vacancy rate of 14.1% in social care, with 165,000 vacancies, up 52% over the previous year.
Insufficient funding
The original guidance published in February 2022 for around 25,000 beds by 2023/24 was backed by two-years of funding of £450m, which according to the guidance, is expected to be spent on “workforce pay costs (including clinical, operational, administrative and programme delivery resource) to fund the staffing models required for virtual wards.”
There is no new money for the more recent announced expansion of virtual wards. The new plans, the expansion of virtual beds plus the additional 5,000 permanent hospital beds and 800 new ambulances, will have to rely on £1bn of funding previously announced in the autumn statement. In addition, there will be around £1.6bn already allocated to social care to be spent on initiatives to speed up discharge of patients from hospital.
The February 2022 guidance noted that the money (£450mn) ends after two years and: “No ring fenced recurrent funding will be made available from 2024/25. Systems will therefore need to ensure virtual wards are built into long-term strategies and expenditure plans.”
As the ring-fenced funding ended in March 2024, the expansion of virtual wards has slowed down, significantly. From January 2024 to May 2024, numbers of occupied virtual beds grew by just 1%, compared to 38% between July and December 2023.
Total virtual ward capacity – including “unoccupied” beds – increased 27% from 9,713 to 12,325 in the 11 months leading up to May 2024, but the majority of the growth came in the first five months.
Money for the expansion of virtual beds now has to be taken from wider urgent and emergency care funding, and with so many other challenges for the health system, the programme has ceased to be as important. An integrated care board chief executive told HSJ that the national virtual wards programme had become “peripheral” to wider challenges facing the health system, whereas it had previously been treated as a high priority on its own.
The NHS Confederation had previously noted that “Investment in virtual wards need to be long-term and flexible” as “short-term funding models are hindering recruitment, planning and impact assessment of virtual wards.” They also noted that the lack of adequate funding for social care is “preventing systems from fully addressing the holistic and wrap-around needs of patients away from only clinical virtual ward support.”
Are virtual wards appropriate for all patient groups?
Virtual wards now cover a variety of conditions, including cardiovascular and respiratory problems, such as chronic obstructive pulmonary disease (COPD). In December 2021 NHS England published guidance for setting up a frailty virtual ward for those with frailty aged 65 or over who have an acute exacerbation of a frailty-related condition and updated guidance for virtual wards for acute respiratory infection, which expands on the guidance for Covid-19 virtual wards.
The success of three pilot virtual wards for children, in Blackpool, Dorset, and Dudley, which have treated 6,400 children over 12 months, has led to the expansion of virtual wards to cover children in every region of England from July 2023.
The BGS notes that “Among the various virtual ward models being developed by the NHS, it is Hospital at Home for older people with frailty which is most likely to make a difference. Research has shown that this type of care can enable some people to receive hospital-level care where they live, with equivalent health and wellbeing outcomes as would be expected if they went into hospital.”
Analysis of Covid-19 virtual wards has found that they assisted with earlier discharges and reduced clinically necessary re-admissions for patients admitted with COVID-19, saved money but without compromising on patient safety.
However, other evaluations of virtual wards have highlighted issues, predominantly around the engagement of certain patient groups. Some patient groups had more difficulty engaging with the service than others, for example, those with a disability, older adults, and ethnic minorities, and there were also patient factors (such as knowledge and physical health), and having enough support from staff and family members or friends, that affected engagement in the virtual ward.
The Royal College of Physicians are concerned that the setting of targets for virtual wards by NHSE is leading to low-risk patients being placed on virtual wards, when they do not need monitoring. The Royal College of Physicians described the 10,000 target as “not helpful”.
RCP clinical vice president John Dean told HSJ: “There is a need for increased community care for a number of patients who remain at home. But we mustn’t be over treating and over monitoring patients who would not otherwise have been in hospital in order to count the numbers and fill NHS targets. The 10,000 virtual beds is not a helpful target, because we’re focused on counting, not in delivering hospital level care at home.”
There is also the problem of health inequalities. Not everyone lives in a warm, dry home, with their own bedroom, a modern mobile phone, and access to fast, reliable broadband. Virtual wards could potentially provide patients with internet connectivity and hardware devices, but it would not be possible for the digital devices to solve the problem of inadequate heating, mould and cramped accommodation.
Opportunities for privatisation of the NHS
One unwelcome aspect of the provision of ‘virtual wards’ across England is that it is set to be another opportunity for independent providers to gain NHS contracts.
In the NHSE’s published guidance in April 2022 to Integrated Care Systems, commissioners of services are reminded that:
“Given the independent sector is already a valued partner in many local health and care systems, as providers of a range of NHS healthcare services, the delivery of virtual wards is an opportunity to build on these relationships.
“Partnerships with independent sector healthcare providers (ISHCPs) may expand local capacity and enhance capability through strong local partnerships with existing acute and primary care providers”
The commissioners were also reminded that the independent sector should be considered as both a provider of healthcare and of technology for the virtual wards.
Virtual wards have a lot of positives and technology is available now that has expanded their use to many different situations, however their success is not a given if the government continues to ignore the issues of workforce and training.
