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.”

The NHS Confederation has 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.