Yes please to virtual wards, but the focus needs to shift

NHS England (NHSE)’s planning guidance has set out an ambitious plan for systems to establish 40 to 50 virtual beds per 100,000 population by 31 December 2023. This equates to 22,400 - 28,000 beds in total.

Up to £200m of central funding is available for trusts in 2022-23, and a further £250m will be available in the following year to support nationwide implementation plans.

This means the additional funding provided to integrated care systems (ICSs) per bed is £7,100 - £9,000 in 2022-23. Assuming a 90% occupancy rate, this equates to roughly £22 per bed day, which is less than 10% of a normal hospital bed cost.

Clinical staffing accounts for approximately 80% of hospital bed costs. This figure does not differ between a hospital bed or a virtual ward bed. The £22 covers a couple of minutes of clinical staffing time per day, excluding the costs of medication administration, technical solutions [KM1] and home monitoring equipment needed to provide safe and effective virtual care.

It is difficult to see how this economic equation will be solved.

Despite carefully looking for recommended staffing levels for a NHS virtual ward, we haven’t found a clear desirable or mandated standardised number.

Are we focused on the right ambition for virtual wards?

The HSJ recently reported that the NHS is “on trajectory to fall short of a flagship pledge to have around 24,000 virtual ward beds in place by December 2023.”

This is not surprising as neither the financial resources nor the clinical workforce is in place to provide virtual ward beds at the current ambition level.

There is nothing wrong with the ambition to provide remote care and free up physical hospital beds for elective recovery. The problem however, is that an organisational solution of ‘the virtual ward’ has been put at the centre of this ambition, rather than outcomes such as better evidenced prevention, freed up hospital resources and cost effectiveness.

As Professors Elaine Maxwell and Alison Leary from London South Bank University point out[1]: “If the aim is to reduce hospital attendances, patients need more than technical care, they need reassurance and advice. They also need proactive, vigilant care”. Further they stated, “All the evidence shows junior staff will need more not less supervision.”

Seven outcomes the sector needs to enable a system wide reduction in hospital care

Having worked with integrated and remote care models for many years in the UK and Europe, we feel it is imperative to enhance the current virtual ward drive, and back it up with adequate funding, to achieve the intended outcomes that are so urgently needed.

We believe that it is imperative to include the following seven factors if we are to enable ICSs to focus on the key goal of reducing the population’s need of hospital care in an effective, safe and equitable way.

1. The sector needs a clear overview of remote care and admission avoidance models which is backed up with clinical evidence, with only evidenced models having access to financial support. For example, HN’s recently published data from its randomised control trial which ran for four years has proved that a nurse-led virtual ward has significant impact. The model used AI on routinely collected healthcare data to identify and contact those patients at highest risk of clinical crisis. In doing so, it helped Vale of York CCG demonstrate that eight out of ten patients who will need extensive unplanned hospital care can be identified three to six months in advance. The virtual wards intervention, which was nurse-led, digitally inclusive and equitable, provided an alternative clinical pathway to urgent and emergency care. It is these clinically backed models which should be scaled.
   
   
2. Scaling of any virtual ward model should be monitored by pragmatic real-world evidence evaluation. The extra cost for this rigour is money well spent as the models implemented will have the potential to set standards for years to come. We should take this opportunity to enhance evidence-based medicine in practice and place the UK at the centre of the international drive for virtual care models.
   
   
3. Target setting and rewards should focus on the individual’s reduced need for hospital care, clinical outcomes, and patient experience. These outcomes are much more important than the number of (ill defined) virtual hospital beds an ICS has in place.
   
   
4. The virtual ward effort should have a much stronger link to anticipatory care resources within primary care and be fully integrated into urgent care pathways. Claire Fuller’s recent primary care report describes how we need to ‘think differently about how we design integrated primary care services that better anticipate the needs of different groups of people’. If we are going to focus on anticipatory care it needs to be effectively targeted and we need to ensure every hour of clinical time supports the best outcomes and effectiveness.
   
   
5. The sector needs to establish a national procurement framework for virtual wards to reduce hospital care. The framework should actively support digital inclusion, given that most targeted virtual ward patients are elderly and age is the largest single driver of digital exclusion.
   
   
6. The virtual wards opportunity should be used to reduce health inequalities. This can be achieved by using a data-driven approach to identify and actively reach out to deprived and under-served groups to offer them remote care. This remote care should use traditional methods, such as telehealth alongside or instead of digital methods to support people in the most appropriate way for them.
   
   
7. Finally, it is essential that any virtual ward concept needs to have a central strategy that builds trust, resilience and empowerment among patients and their families. Patients and family confidence is a predictor of hospital attendance so we need educated and trained coaching approaches which give individuals and their families autonomy over their health and wellbeing. The Personalised Care Institute has a central role to play in this.

Ultimately, we need to look at the bigger picture when it comes to virtual wards. If we are solely focused on the number of beds that are in place by December 2023 without having the evidence to back up the model of care that works for the individual patient, we are missing a trick. We should be looking at predictive and preventive care intervention with a focus on the outcomes it can have for both the individual and the sector. This needs to be achieved in a safe, effective and equitable way for us to see the true benefit long term.