Virtual wards: urgent care policy must follow the evidenceBMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p343 (Published 17 February 2023) Cite this as: BMJ 2023;380:p343
NHS urgent and emergency care is under unbearable strain, which is increasingly causing harm to patients.1 Overcrowding in emergency departments and stasis in acute medical units—driven by workforce and capacity constraints—prevent timely and high quality care.2 This exacerbates low staff morale, perpetuating burnout and the high absence levels which currently dominate. The covid-19 pandemic and latterly a severe flu season have arguably expedited the crisis, but the spiral of decline in urgent and emergency care has been happening for a decade and, unless urgent action is taken, we may not yet have reached its nadir.
The publication of NHS England’s Delivery Plan for Recovering Urgent and Emergency Care Services3 reflects a recognition that the capacity to deliver services is being rapidly outstripped by inexorably rising demand throughout the NHS and social care.4 A key component of this plan is an increase in the number of virtual ward beds to help mitigate the current crisis. These have attracted considerable media attention, but are they a panacea and does research evidence suggest they are the solution?
Virtual wards, encompassing hospital at home, are not new. They have been used in various guises and models in the UK and internationally for decades. Their heterogeneity means that critical evaluation of their performance is difficult.
NHS England currently uses the term “virtual ward bed” to define a patient whose care can be managed in their own home and whose care would traditionally have been delivered in an inpatient setting. This is both a laudable and achievable aim.
Key elements of acute care that have been traditionally delivered in hospital can be provided in the patient’s home. These include senior clinician decision making, multidisciplinary assessment and rehabilitation, physiological monitoring using digital technologies, and the delivery of intravenous treatments and escalation plans should there be a deterioration in the patient’s condition. These can be supported by diagnostic investigations at the bedside including point-of-care blood tests and point-of-care ultrasound.56 A range of common clinical presentations, including those relating to frailty and exacerbations of heart failure, have been demonstrated to be amenable to hospital at home approaches. A comprehensive geriatric assessment using a hospital at home approach delivers equivalent quality adjusted survival outcomes to care based in a hospital, is associated with reduced progression to institutional care, and is cost effective.7 Hospital at home approaches can also facilitate early discharge in an even wider range of conditions, including infection, toxicities after cancer therapy,8 and atrial fibrillation.
Hospital at home care requires the same clinical approach as acute medical care based in a hospital: the right treatments based on individualised clinical decisions in accordance with the patient’s wishes delivered in a timely manner. This can facilitate improved patient outcomes and satisfaction, as well as enabling emerging treatments to be delivered to selected patients in their own home.9
Virtual wards require skilled staff and considerable carer support to function. Nursing, pharmacist, therapy, and care provision are fundamental to the delivery of high quality treatment—whether that be in a hospital or home setting. Workforce shortages in these areas are a substantial barrier to the delivery and expansion of virtual wards that use a hospital at home model. Attention will therefore need to be paid to recruitment strategies for virtual wards, as reducing capacity within traditional inpatient services will increase the pressure on hospital urgent and emergency care services.
It is essential that patients treated in virtual ward beds would otherwise have required an inpatient admission. This needs to be carefully monitored and evaluated. Creating extra streams of work for patients who would traditionally have been managed at home is an extra burden and resource that cannot be sustained or absorbed within the current workforce and funding limits. It is imperative that patients are not subject to increased monitoring or clinical reviews because of a virtual ward programme. Implementation should follow evidence, and there are no randomised trial data showing the benefits of remote monitoring alone for acute medical conditions that would otherwise require hospitalisation. If patients are well enough to be at home without any acute intervention, the clinical rationale for remote monitoring is very limited.
The demand for acute care will continue to rise for the foreseeable future. NHS pressures are at unsustainable levels and current results are scant justice for urgent and emergency care teams who continue to strive to deliver high quality care for their patients. Virtual wards, if they deliver hospital level processes of care, are just one part of the solution—not a panacea. They must not distract from the need for urgent long term workforce, clinical, and capacity plans that are essential to rebuild the NHS. However, they reflect that innovative clinical solutions need to be at the heart of any recovery. Individualised approaches to acute clinical care remain the raison d’etre for those working as acute generalist specialists and to do that, by necessity, an increasing amount must be delivered in the patient’s home.
Competing interests: None declared
Provenance and peer review: Not commissioned; not externally peer reviewed.