Virtual wards: no place like home?

Virtual wards, also known as Hospital at Home, treat patients in their own homes who would traditionally be cared for in hospital. Their rapid rollout by NHS England has led to lots of discussion – heralded as both a potential solution for the capacity pressures on the NHS and cautioned against due to a lack evidence about their effectiveness. 

The current 11,635 virtual ward ‘beds’ across England represent a huge investment of funding, staff and other resources during a time of unprecedented pressures on the NHS. With an initial allocation of £450m over 2 years, it’s not a surprise many have been asking – do virtual wards actually work?

That’s a very complex question to answer. The Improvement Analytics Unit, a partnership between the Health Foundation and NHS England, has been working to understand the evidence – and gaps in evidence – on virtual wards. Here's what we think are the current challenges to evidence and some ideas about what can be done.

Challenges to evidence

Our recent analysis of Situation Report (SitRep) data found that virtual wards across England are diverse, with different patient populations, referral pathways, technology use and staffing models. Although this means virtual wards might be tailored to their local context, it makes generalising evidence across them challenging.

Virtual wards also collect data in different ways, making it difficult to have standardised national patient-level data. And the use of different information systems in community and hospital trusts makes it hard to compare virtual wards to inpatient care. For example, patient diagnoses are captured in acute ward data but not in virtual wards. 

So what should we do?

These are known challenges. NHS England has brought together key evaluation stakeholders and is developing an evaluation strategy. It also plans to create a national minimum dataset for virtual wards that would include standardised patient-level data by 2026. 

There are also many ongoing evaluations. But there are not unlimited data or resources to evaluate every iteration of virtual wards. Evaluation requires significant investment – but there are some decisions that can be made to ensure this is used effectively.

Be clear about the aims

Virtual wards have been suggested as a solution for many issues in health care provision – reducing capacity pressures, improving patient experience and personalised care, reducing risks associated with being in hospital and saving costs. But they are unlikely to be a panacea, and it’s unlikely every virtual ward model will be successful across all outcomes. What outcomes should be prioritised, and how should these be measured?

This issue recently came to the fore in the public debate around a new study on the costs of a virtual ward in Wrightington, Wigan and Leigh. The study found that freeing one hospital bed by using a virtual ward cost around twice as much as an inpatient bed, which quickly became a headline finding. 

But how much should we expect virtual wards to cost? If evaluations were to report better patient health outcomes and experiences on virtual wards compared with inpatient wards, would a higher cost be justified? Would it be more justified when hospitals are, say, down to their last available beds? 

Be clear about the measures

One particular sticking point in the debate over this study was whether the high cost was because of underused capacity on the virtual ward. 

What the debate misses is that there’s no consensus on how to measure virtual wards. Unlike on a hospital ward, capacity on virtual wards isn’t reliant on a physical number of beds but the number of staff available to monitor patients remotely and attend at-home visits. The way this is calculated has changed over time and could change again as different staffing and operational models arise. Capacity of new virtual wards could also increase over time as staff develop more efficient processes and gain more experience managing risks on the virtual ward. 

Other traditional hospital measures also don’t translate well to virtual wards. There may be less pressure on virtual wards to reduce ‘bed days’ in order to admit new patients. And long lengths of stay are unlikely to be associated with the same adverse outcomes as in hospitals. 

Where do we start?

With gaps in the evidence and challenges to filling them, it may seem that we’re left with more questions than answers about virtual wards. Even though a national minimum dataset is still a couple of years away, there are steps to evaluation that can be done now:

• Be clear on priorities and how they will be achieved. Drawing a ‘theory of change’ or logic model can help define ‘success’ for virtual wards and how exactly it could be achieved. This could also help local implementers and evaluators think about what data are needed to check their assumptions, monitor inputs and outputs, and measure outcomes. Qualitative formative research can complement this.
• Invest in local data collection for monitoring and evaluation. Evaluations may require additional data that aren’t routinely collected, such as those that allow for comparisons with inpatient care. Including evaluation metrics in routine data collection processes could help reduce the burden on staff later. 

The question of whether virtual wards ‘work’ 'is complex but also part of a bigger picture. An ageing population in England with higher rates of multiple chronic diseases and the shift towards net zero care in the face of climate change mean the NHS needs to radically shift towards more proactive, community-based care. Virtual wards are likely to be a part of this future. Instead of simply asking whether virtual wards work, we may need to ask what needs to happen to ensure they do.