With ‘virtual wards’ being the latest big idea for NHS England to square the circle of trying to expand capacity with reduced revenue and no capital, all 42 Integrated Care Systems are required to establish them ‘at pace’. So we might expect to find a wealth of explicit guidance for local NHS management seeking to set them up.
This should include a clear definition of what virtual wards are for, what they can and cannot be expected to achieve, minimum investment required in terms of staff (with guidelines for the necessary skill mix of staff to ensure the virtual ward works efficiently) and equipment required for the target provision of 40-50 virtual beds per 100,000 population, with costings so that required resources can be calculated.
We might also expect this information to be available for the press and wider public, who may well have concerns as to the viability of virtual wards, to convince them the schemes are well thought out, based on a clear model, and safe for patients and staff.
According to NHS England’s web page, “Virtual wards allow patients to get the care they need at home safely and conveniently, rather than being in hospital.”
If this was being proposed with a guarantee of the necessary funding and staffing, with regular checks on outcomes, few would disagree that some patients would benefit from less intensive levels of care, assuming that home circumstances are suitable.
However a search through the same website for more information reveals that there is no discussion at all about assessing the home circumstances of the patients, and none of the concrete guidance we might expect: or if any such guidance does exist, it is behind a password barrier limiting the information to NHS staff.
Published NHS England guidance does say that “The virtual ward workforce commonly consists of:
“consultant geriatricians (hospital or community based); advanced clinical practitioners; pharmacists; nurses; AHPs [Allied Health Professionals such as therapists and radiographers]; GPs with specialist interest; health and care support staff; social care workers; plus operational support and third sector organisations.”
But many of these staff are in desperately short supply, and no numbers are given to indicate how many of each per cohort of patients might be required to ensure safe cover (allowing for sickness and holidays) for “a minimum of 12 hours a day (8am–8pm), seven days a week, with locally arranged provision for out-of hours cover, enabling flexibility of service provision as determined by local need.”
In other words the staffing requirement – and up-front cost – is substantial, and could in many areas only be delivered by reducing resources and staff cover elsewhere.
Some information is promised by a new range of private companies seeking to profit from this latest way of delivering health care, such as Current Health, Homelink Healthcare (whose Head of Business Development has previously held senior roles with IBM and United Health), and Spirit Health.
But since these are all selling a product, they are inevitably focused on accentuating the positive, ignoring the real problems, and making extravagant claims of cash savings per patient.
– Lowdown May 2022
NHS England’s web page features a film apparently showing a virtual ward in action at Norfolk and Norwich University Hospitals NHS Foundation Trust (which turns out to be working with Homelink Healthcare).
This film reveals that the NNUH virtual ward has supported 857 patients “since Feb 2021” but does not define the period covered. This suggests as few as 50 patients per month are covered, which would explain the idyllic and leisurely way in which services appear to be delivered.
The too-perfect picture conjured up is reminiscent of the Jim Carrey film The Truman Show: so there always seems to be the right member of staff on hand with time to take on the necessary tasks to make each aspect of the virtual ward – down to promptly delivering prescription drugs to patients at home – but there is no mention of how many clinical and non-clinical staff are in the team.
The film shows a relatively young, articulate patient being given a beautifully packaged box of pre-programmed equipment including a tablet computer, oximeter, blood pressure monitor, and more which apparently “does not need internet,” and no questions are asked about phone or broadband signal in the patient’s home.
How will it be delivered?
Nobody discusses the cost of the boxes of kit, how many are given out, whether they are later collected back in, or where a trust seeking to set up a virtual ward can obtain a stock of them.
Is there a central supply, bought in bulk, or does each trust or each private company touting for business have to conduct its own procurement? Does each tablet need to be programmed to link to local systems, or has a generic system of apps been sorted?
But as well as the technical questions there is the big practical question: even if the patient is savvy enough to get the kit to work and produce its stream of information back to the virtual ward team, how thoroughly will it be monitored, and how many staff are needed to ensure this happens?
If the patient does feel unwell and push the ‘red button’ for immediate assistance, how likely is it, with the current chronic problems of ambulance and emergency services, that they will get the promised instant answer? Who is clinically responsible if a patient fails properly to use the kit and becomes ill with no health care worker within miles?
Is each virtual ward supposed to have its own team on hand 24/7 to deliver emergency response? What happens if two or three real patients in the virtual ward feel unwell at the same time? This can be hard enough to cope with on a real ward, but much more complex when patients are many miles apart.
The film shows phone calls being answered by unhurried qualified, uniformed hospital nurses, and additional nursing staff working in the community. How realistic is it to assume that all 42 ICSs can establish little islands of safe staffing – and beds for any virtual patients needing hospital care – while the rest of the NHS faces 110,000 unfilled posts, huge delays and a worsening shortage of beds?
Limited support, what next?
Moving on from the film, the web page explains “Support may also involve face-to-face care from multi-disciplinary teams based in the community, which is sometimes called Hospital at Home.” Reading on we find this is limited: the inclusion criteria for Hospital at Home stipulate “Expected required treatment time is short-term intervention of 1 to 14 days.”
There is no mention of this limit in the Norfolk & Norwich film, but another March 2022 guidance document on virtual wards also emphasises the same time limit, which appears therefore to relate to ALL virtual ward provision:
“Virtual wards provide acute clinical care at home for a short duration (up to 14 days) as an alternative to care in hospital. Patients admitted to a virtual ward have their care reviewed daily by a consultant practitioner (including a nurse or allied health professional (AHP) consultant) or suitably trained GP, via a digital platform that allows for the remote monitoring of a patient’s condition and escalation to a multidisciplinary team.”
So what happens after 14 days are up and patients still need support? Do they have to join the queue for an ambulance and a hospital bed?
Looking through the other documents on the NHSE website the questions keep coming: for example the ‘Guide to setting up technology-enabled virtual wards’ gives absolutely NO specifics or concrete guidance, no idea what kit should be provided as minimum, where it could come from, or how much it would cost. Worse still it has a lethargic lack of urgency:
“Teams should consider the technology partnerships and platforms already in place across their ICS in alignment with their digital strategy to support future scalability. Once the clinical and business needs are determined, a local requirement specification for the use of technology in a virtual ward can be developed.”
Another NHSE guidance document does discuss funding, but in the most general terms, and emphasises that the extra cash this year and next is only temporary, so local providers will need to cover the full cost from 2024:
“£200 million of funding is available from the Service Development Fund (SDF) in 2022/23. … A further contribution of £250 million, on a match-funded basis, will be available in 2023/24. This temporary national funding will provide significant financial support to systems for the establishment of virtual wards but is not intended to cover the ongoing cost of the service.
“No ringfenced recurrent funding will be made available from 2024/25. Systems will therefore need to ensure virtual wards are built into long term strategies and expenditure plans.”
£200m is equivalent to less than £5m per ICS, and less than £1.5m per acute hospital trust. So it’s most unlikely even to cover the capital cost of procuring the kit and establishing an operational base for the ‘virtual ward’ – let alone the staffing costs. The guidance does not say what the money is supposed to cover, or what additional costs may be incurred.
To make matters worse this has to be implemented at a time when the newly-established ICSs are required to generate total “savings” of £5 billion, inflation is ripping into the high double digits, the pay award is under-funded, a crazed potential Prime Minister is threatening to slash £10bn from NHS budgets to give to privatised social care, and 110,000 clinical posts are vacant.
And while acute trusts are struggling to create ‘virtual’ beds, the problem of efficiently using the existing actual beds continues unabated. Six in 10 hospital patients who are medically fit for discharge are stuck in hospital for lack of social care, with fewer than 9,000 patients out of the average of 21,741 patients each day assessed as well enough to be sent home actually being discharged in July.
And with a further 6,400 Covid patients in hospital beds in mid-August, even hitting the target of 7,000 virtual beds would still leave the NHS with over 19,000 beds (almost 20% of the total of acute beds) unavailable for emergency or elective care.
As a practical solution to today’s actual problems, it seems virtual wards are virtually useless.
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