The latest figures from NHS England paint a bleak picture of emergency care. With 1.91 million A&E attendances in February 2023, and nearly 35,000 people having over a 12 hour wait from decision to admission, it is clear that the sector faces near unmanageable challenges.
In response to ongoing pressures on services, the government has now released a two-year delivery plan in an attempt to get urgent and emergency care services back on its feet. To get hospital admissions down, care given outside of hospital will expand in the form of virtual wards.
The concept of virtual wards are not a new thing, with elements of it being used under the auspices of hospital at home services. However, they became more widely introduced during the COVID-19 pandemic to prevent hospital admissions, assist with early discharge and ease pressure on NHS staff.
While expanding the number of virtual wards in England will take a step towards recovering emergency care, chief executive of the Institute of Health Visiting (IHV), Alison Morton believes that the Government’s plan misses a very important part of the pathway, which is to ‘stem the tide in the first place.’
‘The current definition of a virtual ward talks about something that is enabled by technology as an alternative NHS bedded care,’ says Nuffield Trust fellow Rachel Hutchings. The technology used in a virtual ward can include remote monitoring using apps, technology platforms, wearables and medical devices such as pulse oximeters.
Current virtual wards are treating patients with frailty, acute respiratory conditions, heart failure and in North West London there is now even a diabetes virtual ward. Staff working across these virtual wards have all spoken about the positive feedback they have received from patients after using the service. Vicki Williams and Paula Boyer, virtual ward nurse consultants for the Rotherham Foundation Trust told Independent Nurse: ‘We’ve had such good feedback, I think it’s because patients are getting that daily support from somebody, somewhere within the team.’
Existing virtual wards have shown to be a safe and efficient alternative for many patients who prefer to be treated in the comfort of their own home. However, there are still certain challenges that need to be addressed before virtual wards can be successfully rolled out more widely across the UK. These include; being able to recruit enough staff to run these wards during an NHS workforce crisis; and having fit for purpose technology to enable staff to carry out their roles effectively.
Existing virtual wards
Virtual wards offer ‘wrap-around’ support to people in their homes by providing them with care that meets their needs with the aim to reduce avoidable hospital admission. They aim to provide personalised care that is digitally inclusive to meet an individual’s needs.
In Rotherham, Paula Boyer and Vicki Williams began their virtual ward in January as nurse consultants, with 10 frailty beds and 10 respiratory beds. Both highlighted how the operation of their virtual ward comes from a collaborative approach by all services.
They worked closely with the team of frailty nurses in their hospital to identify patients who could be put on to a virtual ward as well as accessing the hospital online system ‘Meditech’ to look at which patients were admitted overnight and could benefit from being put on to the virtual ward. ‘I’ve literally interrupted a doctor on his ward round because I identified a patient and went behind the curtain and said: “Hello, I’m Paula from virtual ward, can we take this lady home please?” and the doctor was more than happy to late us take the patient home,’ says Ms Boyer.
Ms Williams and Ms Boyer also hold multi-disciplinary team meetings which include members from the hospital discharge team, representation from the council, a social prescriber and social services. ‘We’ve got several therapists who are involved in these meetings as well, so as far as working collaboratively is concerned in these meetings we’ve got most people represented,’ says Ms Williams.
The virtual ward has received referrals from GPs and also the Yorkshire Ambulance Service through its ‘push model’. The ambulance service categorises its patients from one to four depending on the severity of their condition. ‘They’ve set up a process where clinical coordinators, will go through their category three and four patients and we’ve said we’ll accept anyone over the age of 65 as a referral into virtual ward,’ explains Ms Williams. Once it is decided a patient is suitable to be on a virtual ward, its staff steps them up and responds. ‘It’s working really well with referrals from the community and I think people have really accepted it,’ says Ms Williams.
The current virtual wards in England have produced positive feedback from patients who would prefer to be cared for at home than in hospital. ‘There was a man who literally cried when he found out his wife wouldn’t need to come back into hospital because she could be virtually monitored from home,’ says Sharon McCarthy, a diabetes nurse consultant running a diabetes virtual ward in Northwest London.
However, going forward there may be challenges that need to be addressed before virtual wards capacity can be increased to ensure that they are efficient and effective for both patients and staff involved.
NHS England released guidance for integrated care system clinical leaders to refer to when setting up their virtual wards. It pointed out that commissioners and providers should ensure they have the appropriate workforce in place to deliver virtual wards and that teams have access to appropriate skills, training, tools, equipment and support.
Finding the appropriate, trained staff to have on the wards, may be difficult at a time when NHS nursing vacancies are rising. Latest figures showed there were 43,619 vacant posts as of 31 December 2022. Amanda Gillett, a specialist nurse practitioner on a virtual ward in England highlights the challenges of low levels of nursing staff when trying to increase the capacity of virtual wards. ‘I believe the Government is very naïve if it thinks virtual wards can be staffed within the current workforce, nurses cannot be miraculously produced and a competent nurse needs three years of training and further months to consolidate,’ says Ms Gillett.
Not only is it about finding the correct staff to run the service, it is also about making sure they have the appropriate technology to maximise the opportunity virtual wards offer for both patients and staff.
The NHS says that virtual wards should be technology-enabled, this means the management of patients via a digital platform. ‘As long as the patient can prick their finger and somebody in the house has a form of IT, whether it’s an iPad, or a smartphone, then it’s very easy,’ says Ms McCarthy.
Other technology used in virtual wards can include remote monitoring apps, wearables and medical devices such as pulse oximeters. Patients can measure agreed vital signs and enter data into an app or website, or there are cases where patients wear a device that continuously monitors and reports vital signs.
Ms Boyer and Ms Williams, get their remote monitoring in April, and they believe it will be a big aspect of their ward. They are even looking at IV antibiotics in pumps that patients can connect themselves. ‘Patients can be shown quite easily how to connect to a cannula or midline and then the antibiotic infuses over 24 hours,’ explains Ms Williams.
Both nurse consultants says they were open to any technology they could get as they feel assistive technology is so important in maintaining frail patients to live a well life. ‘We’ve even got patients in the community who have bought their own Alexas to set reminders for them to do things,’ says Ms Williams.
Virtual ward guidance recommends that patients should be considered for a technology-enabled service where one exists. However, a recent QNI survey, made up of mostly (42.9%) district nurses, suggested that technology enabled virtual wards increased workload for 10% of respondents. Although this is a small number, 22% of respondents said they did not know, the QNI suggested this could be because it was too early to see impact on workloads fully.
To understand what technology staff can benefit from in virtual wards and what may need to be changed to increase its effectiveness in service delivery when they are expanded, there needs to be better data collection processes.
Ms Hutchings says: ‘It’s really important to have better data collection processes to really understand what makes virtual wards most effective. I think it’s a really important priority going forward to make sure that evidence is being generated to really understand what the impact of the service is and how staff and patients are experiencing them.’
Stemming the tide
The IHV’s Alison Morton points out that the NHS has seen a 60% increase on children A&E attendances, but this hasn’t translated into increased hospital admissions. ‘What this is telling us is that families are going to hospital because they are anxious their child or baby is unwell and can’t get the support elsewhere,’ says Ms Morton.
She discussed how community services have been stripped back, such as drop-in clinics being shut down, causing families to find it more difficult to access a health visitor for advice. ‘What we’re doing nowadays is because people are ending up in A&E more and we’ve stripped back community services, the picture we’re painting is that the only way to tell if your baby is unwell is by going to a hospital to be seen by a doctor,’ says Ms Morton.
While the Government’s plan was welcomed by Ms Morton, she believed that the plan missed a very important part of the pathway , which is to stem the tide in the first place. ‘What we’re saying as health visitors is we need to go back, to supporting parents with parental health literacy, to recognise signs and symptoms so that they know conditions they can treat themselves confidently and when they need to go and see a doctor.’
An example, Ms Morton provided was the work she did with community initiative ‘Healthier Together’ which relies upon patients and healthcare professionals working together to improve how local healthcare is delivered. It is run between GP’s, A&E consultants and health visitors which provides safety netting advice.
She believes the Government’s plan would go some way towards reducing the need for people to attend A&E. However, more investment should be put into initiatives like ‘Healthier Together’ and the community.
‘What local authorities are telling us is that they don’t have the resources, the staff, or the budget to take their full place within the integrated care partnerships that are being rolled out across the country,’ says Ms Morton
The pandemic demonstrated how integral technology has become to keeping people connected, and how health care providers needed to take this on board. ‘COVID-19 brought us into the 21st century with technology and, I know it’s not for everyone but would you want to be in a hospital bed when you could have an app at home and a nurse that can call you? You wouldn’t because being at home is a better environment,’ says Ms McCarthy.
The virtual ward concept is not a new a thing but increased technology use and the ability to support people remotely have created huge opportunities for the service to be effective. However, Ms Hutchings explains that it’s really important to provide training and support to staff, having clear processes in place to identify patients and having a multi-disciplinary approach. ‘I think there are opportunities there but from evidence we’ve looked at that doing it in the right way requires a really clear focus on all those factors.’
While expanding virtual wards will go some way to reducing hospital admissions, there needs to be focus given to why people are going to hospital in the first place and what support could they be offered in their community that will prevent from needing to be admitted. ‘The government really does need to act now. The urgent care plan needs a public health and community to it,’ says Ms Morton.