A mixed methods evaluation of the impact of frailty and respiratory virtual wards in South Yorkshire

by Suzanne Ablard

High demand for hospital care is placing increasing strain on emergency services. Recent statistics have shown that over 95% of hospital beds are consistently filled. High bed occupancy reduces the smooth flow of patients through hospitals, contributing to crowding in A&Es and causing ambulances to queue outside departments unable to respond to 999 calls.¹

There is an ambition to design and expand new types of care in people’s homes, as a way of addressing some of the challenges being experienced in hospitals. Specifically, NHS England and NHS improvement are asking all Integrated Care Systems (ICSs) to extend or introduce for the first time the virtual ward model (also known as ‘hospital at home’). There was a rapid expansion of virtual wards during the COVID-19 pandemic and they are a key ambition in the ‘Delivery plan for recovering urgent and emergency care services’ published by NHS England in January 2023.¹ ICSs were expected to work towards a national ambition of having 40-50 virtual beds per 100,000 of their population in place by December 2023.

What is a virtual ward?

The terms ‘hospital at home’ and ‘virtual ward’ describe NHS services which support patients to receive hospital level care, monitoring, and treatment in their usual place of residence, for a limited period (rather than being admitted to hospital). VWs can prevent the need for a patient to go into hospital at all (termed ‘step up care’) or allow a patient to be discharged from hospital sooner than normal (termed ‘step down care’). Usually, a team of specialist consultants based in the hospital provide clinical oversight and support to a multidisciplinary team (which often includes advanced clinical practitioners, nurses, therapists, and pharmacy) based in the community. The community-based team are responsible for co-ordinating the day-to-day management of care in the patient’s own home, reporting any concerns or signs of deterioration to the specialist hospital consultant team. The hospital and community-based teams discuss the patient case load as part of regular multidisciplinary team (MDT) meetings, often held online. Patient monitoring involves a combination of face-face and telephone consultations. A technology enabled virtual ward uses remote monitoring equipment, which uploads patient observations to a clinical dashboard, allowing clinicians to manage patients remotely, potentially reducing the number of face-to-face visits.  

What does the existing evidence say about the impact of virtual wards?

Existing studies have found that virtual wards result in similar or improved care (e.g. fewer deaths, fewer admissions and shorter stays in hospital) compared with hospital inpatient treatment,^2-3 and that patient satisfaction with VWs care is high.^3-4 Evidence on potential cost savings is less clear and requires more study.⁵ Effective information sharing, clear lines of clinical responsibility, and effective collaborative working between organisations involved is important in the delivery of virtual wards to promote care delivery. ⁷ Other factors contributing to VW success is having community virtual ward staff visiting hospitals (‘in-reach’) to identify patients suitable for early discharge to a VW and developing a comprehensive training offer for virtual ward staff.⁸

Challenges faced in setting up VWs can include gaining consultant-buy-in; a lack of administrative support; and staff recruitment issues.⁸ One study found clinical virtual ward staff felt anxious leaving if patients were  unmonitored over long periods of time at home (e.g. at evenings and weekends).  These concerns were reduced when VWs operated seven days a week.⁸

VWs will increasingly rely on technology for remote monitoring of patients in their homes. However limits to patient understanding of their conditions, variable internet access or affordability of technology might affect access to technology based VW care, particularly in more deprived populations.^3,9-1011 The use of telephone-based monitoring has been found to be more inclusive for some patients.^4,9   As well as patient preferences regarding care at home, consideration needs to be given to the views of carers or families.³ Caregiver ‘burn out’ during the “hospital at home” period has been described in some studies.^3-4,12

Existing evidence is often based on small scale, single-site studies. There is a need for further evidence to understand the overall value of virtual wards on patient outcomes and associated costs, as well as an exploration of the benefits and unintended consequences of virtual wards on virtual ward staff, the wider health and social care system, and patients.

Our current ARC YH evaluation

The ARC YH Urgent and Emergency Care Theme is undertaking a mixed-methods evaluation of the impact of frailty and respiratory virtual wards implemented at four locations across South Yorkshire. This is in partnership with South Yorkshire and Bassetlaw Integrated Care System (ICS) and the NHS trusts delivering the VWs. The evaluation comprises three work packages:

Work package one:

The aim of the first work package is to gain an in-depth understanding about how virtual wards operate in each locality. This will be achieved by undertaking a document analysis and face-to-face meetings with the virtual ward team.

Work package two:

The aim of the second work package will be to undertake semi-structured interviews with strategic leads involved in the implementation of virtual wards, virtual ward staff, and staff working in other health and social care services, to identify ’what works’, challenges and unintended consequences associated with the delivery of virtual wards.

Work package three:

Work package three will involve collecting routine anonymised data to describe demographics, clinical activity (e.g. number of virtual ward admissions), and outcome data (e.g. length of stay, readmission in 7 days, mortality) of patients admitted to virtual wards and of hospital inpatients with a matching primary diagnosis; and determine the impact of virtual wards on cost outcomes.

The ARC YH evaluation will deliver its preliminary findings on the effectiveness of VWs at the end of the year with a final full report planned in the spring of 2025.

References

1. NHS England, Department of Health and Social Care. Delivery plan for recovering urgent and emergency care services. Jan 2023. https://www.england.nhs.uk/wp-content/uploads/2023/01/B2034-delivery-plan-for-recovering-urgent-and-emergency-care-services.pdf
2. Leong M Q, Lim C W, and Lai Y F. Comparison of hospital at home models: A systematic review of reviews. BMJ Open. 2021; 11:043285.
3. Norman G, Bennett P, Vardy E R L C. Virtual wards: A rapid evidence synthesis and implications for the care of older people. Age and ageing. 2023; 52:1-12.
4. Wang X, Stewart C, and Lee G. Patients’ and caregivers’ perceptions of the quality of hospital-at-home service: A scoping review. Journal of Clinical Nursing. 2023; 00:1-22.
5. Jalilian A, Sedda L, Unsworth A, and Farrier M. Length of stay and economic sustainability of virtual ward care in a medium-sized hospital of the UK: A retrospective longitudinal study. BMJ Open. 2024; 14:e081378.
6. PPL. South East Region Virtual Wards Evaluation. May 2024. https://ppl.org.uk/wp-content/uploads/2024/05/ANONYMISED-South-East-Region-Virtual-Wards-Evaluation-Final-version-1.3.pdf.
7. Westby M, I Sharea, Savovic J, Mcleod H, Dawson S, Welsh T, Roux H L, Walsh N, and Bradley N. Virtual wards for people with frailty: What works for whom, how and why – A rapid realist review. Age and Ageing. 2024; 53: afae039.
8. Health Innovation Network South London. Evaluation of virtual ward models. November 2022. https://healthinnovationnetwork.com/wp-content/uploads/2022/11/SWL-VW-evaluation-report_final-version-21.11.22.pdf
9. Fox R, Saeed Z, Khan S, Robertson H, Crisford S, Wiggam A, Foley A, Raza F, and Wright M. Lessons learnt for digital inclusion in undeserved communities implementing a covid virtual ward. PLOS Digital Health. 2022; 1(11):e0000146.
10. Hutchings R. The impact of COVID-19 on the use of digital technology in the NHS. August 2020. https://www.nuffieldtrust.org.uk/sites/default/files/2020-08/the-impact-of-covid-19-on-the-use-of-digital-technology-in-the-nhs-web-2.pdf
11. British Red Cross. Virtual inequality: Investigating risk, responsibility and opportunity on virtual wards (also known as hospital at home) for health inequalities. file:///C:/Users/cm1smax/Downloads/Virtual%20inequality%20v05.pdf
12. Pearson M, Hunt H, Cooper C, Shepperd S, Pawson R, and Anderson R. Providing effective and preferred care closer to home: A realist review of intermediate care. Health and Social Care in the Community. 2015; 23(6):577-593.