Virtual ward challenges and how to overcome them

The workforce 

Virtual wards make more efficient use of clinical expertise through a properly coordinated tasking of healthcare professional to patient, but the problem is the amount of staff available and the amount required.

Dr Noel O’Kelly, Clinical Director for Spirit Health, told the Hospital Times of the risk that staff shortages poses for virtual wards and the benefits to patient care that are waiting to be reaped. Spirit Health’s own Freedom of Information (FOI) request found that of 107 NHS trusts in England, 40% of them would require new staff to be able to deliver virtual wards.

New healthcare ventures often need new staff, so that’s not too problematic, but the NHS has a staff shortage already. As this Lowdown article points out, the complication is that there is little consensus of how many staff members virtual wards may need; it depends on the care required and staff availability. How many clinicians? What hours? How many days a week? Can we borrow from other departments? The risk then is that this “borrowing” may deprive staff resources elsewhere.

This is demonstrably the case according to NHS England. In a supporting information document about virtual wards, NHSE admitted that in the case of Frimley Health NHS Foundation Trust there were issues of care coverage. This has resulted in out-of-hours patients being managed by the existing healthcare pathways, aka the clinicians who would have cared for them before this frailty virtual ward was implemented. This is not to say the patients are not well cared for, and night nursing services are always available in an emergency, but the point still stands that what is a dedicated day team for virtual ward care is not yet capable of being a dedicated all-hours team.

Chair of Healthcare and Workforce Modelling at London South Bank University, Professor Alison Leary summed up the problem nicely in an interview with Nursing Times.

We’ve already got an overstretched community workforce, and we don’t need any more [staff] leaving.

If you’re going to give people more work, you need to see how it’s going to affect the work they already do.

There is hope though. Health Innovation Network did point out that, while the virtual ward service had recruitment issues at first, “positive word of mouth has helped generate interest, especially among internal candidates”.

Statistics from Norfolk and Norwich University Hospitals NHS Foundation Trust also showed that the flexibility of such work resulted in zero sick days. This isn’t to say that staff didn’t get ill, but during the trial period those who did were minorly afflicted and could safely perform lighter tasks from the comfort of home – such as patient monitoring and video calls.

In addition, the flexibility and lower intensity of these tasks, perhaps alongside a longstanding sense of duty, is even starting to attract nurses and clinicians out of retirement.

All of this can quickly turn into a snowball effect too. Success breeds success through proper practices, but also the appeal to staff to apply knowing there’s flexibility and positivity. Nobody wants to join a sinking ship or tarnish their reputation, but by properly establishing virtual wards the recruitment problems will disappear quite rapidly.

Cost

It might seem odd to think cost is a challenge, given virtual wards cost approximately one third (1/3) of the cost of a physical ward, but it’s not so much the operating costs that are an issue as the initial setup costs and the available funds to support this.

There are a number of funds available that can support the financing of starting up virtual wards, the main and most widely used to date is the Service Development Fund (SDF).

• Better Care fund also – not specifically for VW but could be argued
• Adult social care discharge fund – for LAs

The SDF comes from NHS England’s Primary Care Group and has made £200 million available for FY2022/23, and another £250 million for FY2023/24, but beyond that no funds have been ringfenced.

NHS England ICS and virtual ward research breaks down this SDF funding – which is the only funding being publicly discussed – and the maths basically suggests less than £5 million per integrated care system and less than £1.5 million per acute hospital trust. NHSE airs concerns that its own earmarked funding might not be enough to cover the equipment required and the setup of a base of operations, let alone recruitment and staffing costs.

Health Innovation Network points out a rough estimate of £3,000 to £4,500 worth of savings per patient in a virtual ward, which seems like an obvious win, but this figure doesn’t take into account the aforementioned costs and raises an obvious omission: virtual wards need a costing model.

All organisations should work from a costing model to ensure they are financially viable, and the NHS is no different. NHSE must invest in virtual wards, and plan both short-term for their establishment and long-term for the savings made.

Clinical buy-in

This is arguably the most difficult challenge of all: getting clinicians to “buy in” to the idea of virtual wards and to change well established working practices.

The layman argument is “if it isn’t broken, don’t fix it” but the NHS is provably broken and in need of support. Virtual wards, and supporting software solutions, can provide this support and a much needed win.

There are three arguments that keep being brought up in opposition to virtual wards:

• A lack of guarantees
• Confusion over the duration for virtual ward care
• ‘Too good to be true’ sentiment

The Lowdown NHS article focuses heavily on guarantees; first criticising the lack of ringfenced funding beyond the financial year 2023/24 but then moving on to circumstances. Nobody is yet to argue against the premise of virtual wards, but in Lowdown’s words, they couldn’t find anything via NHS England about flexibility with care in a virtual ward depending on a patient’s home circumstances.

This then leads into the time limit issue. At present, the NHSE guidance from March 2022 suggests that virtual ward care is short duration only; up to 14 days. This is potentially problematic in case somebody needs longer, and is contrary to the advocacy of virtual wards as a flexible care solution. Does the patient then return to the physical ward if they time out of virtual ward care? Even if it’s one day extra needed to be observed remotely?

This is the frustration from patients and clinicians. The lack of clarification on the matter heavily impacts confidence, which could suggest a bigger issue at the heart of NHS England whereby the push for virtual wards isn’t being supported by an overarching plan. Thus we lead in to the final complaint: virtual wards are too good to be true.

Throwing back to the earlier Hospital Times article, their piece cites the film ‘The Truman Show’ and how the right person is there at the right time… or so it seems. This analogy suggests that in the case of virtual ward trials, success was properly cultivated because it was the new project and received special attention. Should virtual wards be rolled out nationwide however, the priority for such projects is likely to be lessened, which will then lead to problems in terms of staff coverage and equipment usage, and inevitably patient care outcomes will feel the effect.

On top of this you can then raise issues about deteriorating health and the chronic delays with ambulance arrival, issues with improper use of kit not informing clinicians of deteriorating health, patient deterioration at the same time and who gets priority… the list goes on.

Hospital Times argues about how the virtual care kits, with the tablet devices and other wearables, are meant to operate at home. What if they lack phone signal? What if they lack internet access? These are key questions, and while some digital telecare providers account for this in their solutions, do we know that NHSE is using just those providers? Once again we return to the issue of clarification and transparency. NHS England needs to be far more open if it is to win over the sceptics.

Consultants are also understandably reticent to hand over their patients to virtual wards, after all its their GMC number on the line if something goes wrong. Ironically, this is really where technology comes into its own. Arguably providing a greater access to oversight and visibility over patients’ welfare than in a physical ward. A joined-up ecosystem of technology, of software, means that patients are never lost in the system.

Integration

Integration is a challenge affecting not just the whole NHS, but the entire health and social care system. For virtual wards to succeed they must be able to share data, and quickly. This means that a software solution – whether in conjunction with digital telecare equipment – must be onboarded with the core goal of ensuring this interoperability between existing and new software so that departments can properly cooperate and coordinate.

For integration between all health and care services to be feasible, functional, and efficient, information needs to be securely shared and accessible between all those services involved in the care of the patient.

This is possible. But only through digitisation of health and care records in each service, and crucially, using systems that are able to share data and information, either through a direct integration or through a mediating technology. Put simply, an integrated approach requires technology that is integrated.

Beyond this, the ability to talk to other virtual wards that have already established themselves in previous trials would be a huge bonus for a nationwide rollout. Everyone’s starting from scratch, but what if they had support from those who had already made mistakes and adapted? What advice could they give to smooth the setup process and avoid any delay in patient care?

Inclusivity

Modern healthcare needs modern solutions, but it must not forget that not everyone possesses the same grasp of technology. Digital literacy is a big issue in the United Kingdom, so for NHS England to launch more virtual wards it must expect NHS Trusts to account for these hurdles.

NHSE’s own research says “There is a risk that the use of digital technologies will disproportionately exclude people from certain groups, including older people, those in social housing, those on lower incomes, the unemployed, those with disabilities, rural populations, traveller communities, homeless people, those with no recourse to public funds, and young people not in employment, education or training (NEETs).”

Virtual ward staff need to be fully trained in the digital telecare equipment, such as wearables and tablet devices, to ensure that they can explain to patients in a clear and understandable way how to use them without aid.

Capita also wrote about virtual wards and inclusivity, but this time citing the concern of going digital; how do we ensure patient care is to the highest level and gauge patient sentiment about this? The answer isn’t definitive, but the hope is that software providers can incorporate a feedback mechanism into the equipment provided – or the NHS, during home visits, asks these questions up front. An honest answer may not be as easy to come by in that case though, so anonymity is a big advantage for true feedback that can lead to proper improvement longer term. [244]

Fortunately, existing virtual wards have already addressed these challenges. They have included patients’ digital capabilities as part of their initial assessment. If it is felt a person would be less able to use certain technology, or would prefer not to, they can simply call to give their readings, or a carer can enter their readings into the system for them

Keeping clinical skills up

Virtual wards are meant to be a weighted mix of virtual, remote care and the occasional in-person clinical visit to check up on the patient. The concern at present is that, with the lack of clear guidelines on establishing virtual wards, that a default position will be taken of purely remote support.

This is problematic. Not just from a patient care point of view, where your home comfort may begin to feel like medical isolation, but it also risks degradation of clinical skills. It is important for healthcare professionals to continue to engage with patients in person, to ensure their skillset remains strong, and to ensure the rapport and trust between patient and clinician. Keeping this in mind, NHS trusts must offer both comprehensive training and guaranteed (even if rotated) field work where patient visits will be performed.

Disadvantages of virtual wards

All new ideas and launches have problems, and we’ve showcased plenty, but now we turn to the disadvantages. Virtual wards as a whole are a very popular idea with strong statistics and data showcasing how beneficial they can be, but they aren’t flawless.

The Guardian newspaper interviewed Brian Bostock, Head of Sustainability and Transformation at NHS Cambridge and Peterborough. Mr Bostock’s take, as an NHS insider, was that the “end of the bed assessment” is gone when using a virtual ward; that the core part of healthcare is attention to detail and those small, passing moments where a patient is looked in on and maybe even just one detail has changed – but that could be the key clue to a change in condition and the difference between prevention and deteriorating health.

Bostok, like others, also critiques the staffing shortfall and recruitment issues and the risk that these delays and concerns could undermine the larger picture project.

Overcoming virtual ward challenges

All positive change also carries some level of challenge.

Fortunately, as I hope I've illustrated in this article, the challenges of delivering virtual wards are not insurmountable and many of them have already been overcome in different ways, by different organisations.

For those aware of the benefits virtual wards can have, these challenges also seem minor in comparison and certainly worth the effort to overcome. As Stephanie Somerville, Director of Community Health Services Transformation and Virtual Wards, NHS England has said:

We have a moral imperative to treat people at home where we can

The most obvious opportunity for a win is software. Medical software is, in many instances within the NHS, outdated. This is down to a combination of a lack of funds to enable an upgrade in software solutions and a lack of trust in the solutions providers – both of which perhaps relate to software failings in the past.

The NHS Shared Business Service (SBS) and its framework agreement are helping reassure trusts and local authorities by accrediting software providers – including The Access Group. The hope here is that they can renew the confidence and rebuild relationships between the public health sector and the private tech sector to catch the NHS back up in terms of the evolution of healthcare.

Electronic patient record software can centralise records for accuracy and clear usage. Other tools can then communicate with this EPR, particularly remote wearable tech such as that used in virtual wards. The tablets, the arm devices… they can report back to a log within their own central patient record so that clinicians have the most up to date information on a patient at any given time.

NHS Newcastle Gateshead Clinical Commissioning Group reported back in 2018 that their biggest virtual ward challenge was “the increasing complexity and size of their current caseloads”, and it led to key areas to improve which included the IT systems and information sharing occurring – or perhaps not occurring.

There is much to work on, but the right software solution can improve patient record keeping, it can improve patient data recording, it can enable input from other professionals, and cross department or even cross-organisation communication. Joined-up care is the future, and the NHS needs to adapt as soon as possible to ensure it stays functional for the millions who need it.

At The Access Group we provide the full spectrum of software to support successful virtual wards, including (but not limited to) electronic patient records, advanced digital telecare and patient administration systems.

Find out more about what virtual wards are, the virtual ward technology or, for an impartial and no-obligation discussion of our work in developing and implementing virtual wards with our partners in healthcare provision, simply contact us today and we will contact you at a convenient time.