How Can We Evaluate Virtual Wards in the NHS?

Nick Hex

Associate Director, YHEC

Virtual wards, where patients can receive hospital-level acute care in a home setting, are becoming increasingly prevalent in the NHS. Join us as we interview Nick Hex, YHEC Associate Director, about why virtual wards are important and how they can be evaluated in the NHS.

Tell us a bit about yourself and your role.
I am the Associate Director for the NHS and Public Sector workstream at YHEC, and I started this role over 14 years ago. My team conducts a range of research, including evaluating the impact of new technologies on healthcare resources and patient outcomes. Together, we have conducted five projects evaluating virtual wards – contributing to a NICE Early Value Assessment [1] and culminating in a peer-reviewed publication [2].

Can you briefly explain what virtual wards are and why this topic is important?
NHS services are experiencing ever increasing demand – a problem that was exacerbated as a result of the COVID-19 pandemic [3]. While these pressures and backlogs are experienced across the system, one of the largest pressure points is the availability of hospital beds. Virtual wards (also known as ‘hospital at home’) have been identified as an approach that could ease some of the pressures experienced by the NHS.

A virtual ward allows people to receive hospital-level, acute care in the comfort of their own home. Care is provided remotely and is supplemented by face-to-face care where required. Importantly, a virtual ward should provide (at least) the same standard of care as someone would receive in hospital, and there is a clinical threshold to decide whether someone is eligible for virtual ward admission. The delivery of care in a virtual ward can be supported by a range of technology. For example, digital technologies (e.g. apps for doctors to talk to people) and devices to facilitate remote monitoring (e.g. pulse oximeters or blood pressure monitors). The aim of virtual wards is to increase capacity and remove some of the pressure on hospital bed availability.

In January 2023, NHS England mandated the implementation of virtual wards for two key patient cohorts in every Integrated Care System (ICS) in the NHS: old-age frailty and acute respiratory infections [4].

How do virtual wards currently affect patients?
This is one of the key questions for virtual wards at the moment. The key value proposition for virtual wards is that they provide equivalent care to hospital admission; therefore, patients should have (at least) the same health outcomes compared with if they were admitted to hospital. There is currently limited published evidence to suggest that virtual wards are safe and effective [5,6], and it is important that more research is conducted. There are also potential benefits of avoiding hospital admission, for example avoiding hospital-acquired infections.

Qualitative studies can help us to understand patients’ views on virtual wards. Anecdotal evidence suggests that people have very positive experiences on virtual wards and that these initiatives are popular with patients but, again, more published evidence is needed [7].

Are there any recent advancements in virtual wards?
The initial NHS England vision for virtual wards was for care to be delivered remotely – with very little face-to-face care. However, at the end of 2023, NHS England acknowledged that face-to-face care can form an important component of virtual wards. This presents a key question about cost effectiveness: if someone on a virtual ward requires face-to-face care every day, it is possible that this may not be an effective use of resources and admission to hospital may be more cost effective.

YHEC has spent the last 18 months evaluating the differences in the resources required when providing virtual wards and hospital care – with one of these evaluations now published [2]. Virtual ward patients will use less of some resources (e.g. hospital bed days) but more of other resources (e.g. remote monitoring and community care visits). The amount of resource used translates into cost, and hospitals and healthcare commissioners (ICSs) are mandated to avoid increasing costs where feasible. By considering these resources, it allows us to evaluate whether virtual wards are cost saving or cost incurring.

One of the main advancements is the types of virtual wards that have been created. While every ICS was mandated to provide frailty and respiratory virtual wards, many hospitals have also introduced virtual wards for other indications and specialties. For example, heart failure, oncology, paediatrics and palliative care.

What are the biggest challenges related to virtual wards that we need to address?
One of the biggest challenges with evaluating virtual wards is that there are two routes to admission: step-up or step-down care.

‘Step-down care’ describes where virtual wards can facilitate an earlier discharge from hospital, which may reduce ‘bed blocking’. In this cohort, you can evaluate the impact of virtual wards by calculating the number of hospital beds days reduced following virtual ward admission. A simple example could be where patient stays in hospital average 10 days, but they can be reduced to 5 days plus virtual ward care.

‘Step-up care’ or ‘anticipatory care’ describes where people can be admitted to a virtual ward if, in the opinion of clinicians, there is a good chance that they will be admitted to hospital. This is a particularly prevalent referral route for frailty virtual wards. In this cohort, the aim of a virtual ward is to stabilise the person without needing to admit them to hospital. Initially, NHS England assumed that every step-up patient admitted to a virtual ward avoided a hospital stay, but YHEC’s work with ICSs has identified that this is not always the case. It is difficult to ensure that every virtual ward patient has the same level of need (‘acuity’) at the time of admission. Therefore, different areas within an ICS may admit patients to virtual wards with varying acuity – something that is very challenging to measure.

For example, average lengths of stay in one virtual ward (VW1) may be lower than in another virtual ward (VW2). However, if there is a lower average acuity in VW1, then this may be a less efficient use of healthcare resources than VW2 because fewer people would have been admitted to hospital without the provision of anticipatory care. When evaluating virtual wards, you need to think about these extra dimensions of need.

This is why YHEC has produced a model that allows an ICS to consider all these different factors. This model can be used in decision making to identify if virtual wards incur more or less cost than inpatient care and what the results might be for different patient cohorts. This can also help ICSs to consider how appropriate their admission criteria are to virtual wards in different areas.