New guidance from NHS England, and the positive findings of a large-scale evaluation in the South East, have delivered a “hugely encouraging” boost to virtual wards, writes Tara Donnelly
A great deal has happened recently in the world of virtual wards. First, the publication of a very large evaluation of virtual wards across the South East of England which found that emergency admissions are reduced in the cohort and the model is highly cost effective.
Then a letter, sent to the CEO of every ICB and trust, setting out actions to improve urgent and emergency care, building on what the best sites are doing in terms of using tech enabled virtual wards for admission avoidance and to improve flow, requiring more of this and providing incentives.
I find this hugely encouraging. It is a great time for teams looking to be bolder with digital home care locally to expand their programme offer, get into upstream proactive care, and avoid admissions linked to major long term conditions such as COPD (coronary obstructive pulmonary disease) and heart failure, as well as equipping their urgent care response teams with remote monitoring capability. They can design services that reduce health inequalities and have impact at scale on emergency hospitalisation rates across the NHS.
Support for emergency care
While the 33-page letter covers a number of areas, a consistent theme is making even greater use of virtual wards to support emergency pathways and flow. It opens with some of the less heralded improvements in the urgent care pathway, including the year ending March 2024 being the first non-pandemic year since 2009/10 that A&E 4 hour performance was better than the previous year. Category 2 ambulance response times were also 13 minutes faster than the year before and 240,000 people have now benefited from hospital-level care at home.
While it is described as a two-year plan, the timing of the letter sends a clear message about the need to prepare early to have a better winter in 2024/25. This sense of urgency is conveyed in the stated aim to help systems and providers “plan and prioritise over the coming weeks in order to make progress over the summer and improve resilience ahead of winter, by bringing together in one place what we know works”.
It describes plans to improve access to virtual wards through increases in utilisation and new pathways to be accessed from home, extending the model to more people with frailty, acute respiratory infection, and heart failure, as well as children, so that it becomes a routine part of NHS care in these pathways.
The letter references actions to support delivery including implementing best practice as set out in the virtual ward framework, due to be published shortly – “in spring/summer this year”. The purpose of the framework is “to help tackle variation, achieve further standardisation and ensure the benefits of virtual wards/HaH [hospital at home] can be realised at scale”. This all sounds extremely useful.
Hub model best to achieve scale
There is also an emphasis on teams within ICBs working together locally to increase access to virtual wards as an alternative to hospital attendance or admission – a suggestion perhaps that a ‘hub’ model may be the best way to achieve scale, rather than very small local teams at each trust. Certainly, the larger hubs that we see operating across ICBs – such as North West London and Cheshire and Merseyside – are enabling impressive scale of tech enabled care. It also references a new patient-level data set for virtual wards that will help provide stronger operational oversight as well as national benchmarking.
A £150 million of operational capital can be used to support this work, particularly focusing on improving four-hour, category 2 and 12-hour waits, with further funding “up to” the same level allocated in 2025/26 and distributed in line with performance improvement.
Evaluation demonstrates positive impact
The largest ever evaluation of the virtual ward model in the NHS Virtual wards consultancy – evaluation and delivery – PPL – looked at 22,000 admissions across 29 virtual wards in the South East of England. The findings are largely very positive in terms of impact on emergency admissions, cost-effectiveness and benefits augmenting over time. A total of 9,000 hospital admissions have been avoided in the South East in the past year due to virtual wards, which if scaled up across England, would mean that 178,000 admissions could be avoided over the next two years. The report also highlights some valuable areas for learning and further work.
Best practice features
The virtual wards making the biggest difference to emergency admissions (at close to the 1:1 rate) shared a number of features: they operated 8am-8pm, seven days a week, and provided daily multidisciplinary review of patients.
The maturity issue is demonstrated very clearly in the cost effectiveness data where those virtual wards that have been operating for two years or more – “legacy” wards – demonstrate the highest net benefit of £877 per patient. In the South East these wards care for over 11,000 patients and obviate 5,540 emergency admissions per year. This demonstrates the importance of committing to virtual wards in the long term and being patient as they mature rather than expecting benefits and savings to flow immediately.
No one left behind
It is important that everyone can benefit from virtual wards, but are they good at supporting people who are more deprived? Could they inadvertently, as has sometimes been suggested, increase health inequalities?
The results from the evaluation are interesting, and overall, positive. There is a good match between those being supported by virtual wards in the South East and local deprivation levels. Most wards are within +/- 1 or 2% of their population. Several wards are over indexed towards supporting more deprived groups in areas with lower IMD [indices of multiple deprivation] areas at 4-6%. That is, there are 4% more admissions to the virtual ward in the more deprived groups than would be expected when matching for population.
However, when it comes to virtual wards supporting black and minority ethnic people, the results are much more mixed. The data is also very inconsistently reported, making it hard to be definitive about the current picture, but the data that is available shows an underrepresentation of between 1 to 13 percentage points. We also know from national virtual ward data that most people using a virtual ward are older, 75% are over 65, and it may be that ethnic diversity locally is in different age groups. While the researchers attempted to account for this, where it was completely clear that a ward was intended for a specific group such as frailty, it may remain a confounding issue. The researchers found some examples of good practice that they recommend are utilised more such as improving the range of languages accessed and community outreach activities.
Designing services so everyone benefits
There are examples across the country of services that have targeted more deprived groups with their digital home care services, to good effect. These services use thoughtful design to help close the digital and health inequalities gap rather than exacerbate it. NHS Frimley ICB has used population health data to target services so that the most deprived are prioritised for remote monitoring support.
We know certain conditions are much more prevalent in those living in deprivation, including COPD. I was impressed to see that within a project I have been working on in Bristol with Doccla, Living Well with COPD, the single largest cohort of patients who have joined the digital service are from IMD group 1 – the most deprived group – at 20%.
Across Bristol, North Somerset and South Gloucestershire ICB 26% of the population living with COPD are in IMD groups 1-3, however the proportion recruited to this programme from IMD 1-3 is 40%, an over-indexing on deprivation of over 50%. This has been achieved by thoughtful programme design which is entirely replicable: providing information on the programme in English and the five most common languages spoken locally (Spanish, Romanian, Polish, Arabic and Somali); providing all the tech and data that is needed to participate, including a tablet computer that is SIM enabled; and targeting the invitations to people at highest risk of hospital admission from their COPD.
It is great to see that virtual wards have become part of the mainstream of care, and that the policy direction of travel is to expand them, based on the evidence of impact at the system level. The potential to support more people to receive care from the comfort of home is clear.
Tara Donnelly is the founder of Digital Care and former chief digital officer of NHSX/NHS England.