Last week for a HTN Now panel we were joined by Heather Young, virtual ward programme manager at Nottingham University Hospitals NHS Trust, and Christina (Chris) Prada, virtual ward service lead at Northampton General Hospital, to discuss learnings and experiences around virtual wards.
Chris explained that Northampton General Hospital is currently home to three virtual wards: a remote monitoring virtual ward focusing predominantly on respiratory and colorectal care; a diagnostic waits model which sees patients sent home who are waiting for investigations; and a face-to-face model which adopted from orthopaedics and was running prior to the programme’s launch.
Chris acknowledged that the terminology around virtual wards and remote care can sometimes get confusing. “It’s hard to produce a blueprint because all of our services have evolved out of the foundations we already had; you’ve got to identify what works well and use that.”
From the Nottingham University Hospitals perspective, Heather shared that the trust’s virtual wards are predominantly step-down, with “acutely unwell patients who are still being monitored by consultants and who still need a degree of face-to-face care”. The virtual wards see a lot of activity from surgery, respiratory, frailty, and palliative.
Noting that the trust’s approach is very much clinician-led, Heather considered: “When it comes to entirely digitally-led virtual wards, you’ve got to ask whether a patient can be managed purely with the pulse oximetry and a blood pressure cuff, or whether they need to be in a hospital bed. We have to also consider what resources we have to manage that admission avoidance; we need to clearly define which patients we are going to be looking after and how.”
The needs of patients also need to remain in focus, she added. “We’ve found that they sometimes need that face-to-face contact, and that confidence that somebody’s in front of them; otherwise they will self-refer to ED or elsewhere”. However, being able to “step back slowly” from patients “particularly in community settings who are a little bit more nervous” has also been a major benefit of the programme.
Key successes of the virtual wards programme
On how the virtual wards programme at Northampton General has taken off, Chris said it grew on the back of an existing ward set up for COVID “as we knew that we had an established and a really safe model there that worked well. I think we’ve demonstrated good safety with good patient feedback; and that’s important for us as we try to grow and get more engagement. It’s vital that we can share that feedback.”
Heather acknowledged that the virtual wards programme is “one of the hardest things we’ve ever had to do” and noted that it can be challenging to move the programme forward, but ultimately it has brought together “a really great group of people – we’re learning a lot about what our communities can do, and we’ve been able to do things we never thought possible before”.
Patients “love” the service, Heather added. “They want to be at home, to be able to comfortably recover, and get well, and the virtual ward can deliver that for them. Also, when patients are in hospital, they miss their support networks. As an acute trust we have patients coming from all over the county, and that can be a long way to travel. The financial and moral burden on their families can be difficult, particularly in palliative care. To be able to die at home is something special, so that’s been absolutely superb to be able to give people that.”
Chris agreed: “We also get feedback around simple things like virtual wards making it easier for people with pets, as cats and dogs at home can be looked after. It’s all part of just being able to carry on that normal lifestyle.”
Challenges around virtual wards
What about some of the challenges?
Heather reflected: “It has been really hard at times. We’re taking organisations that have never worked this closely together before and trying to build relationships, a programme of care, and care pathways. Then of course we had the complication of a global pandemic. Everyone was exhausted and working at 120 percent of their capacity, but actually they have stepped up to the challenge.”
Other challenges have included working with clinicians to help them understand that people are safe out in the community; and the aspiration of a single system that everyone can see.
On the topic of information sharing, Heather noted that consultants raised concerns around how to manage an acutely unwell patient at home from a step-down perspective. Heather’s team worked with partners to set up honorary contracts and devices to enable teams to “step into each other’s records and share knowledge. For our community partners, they can all see how that patient is before they leave hospital, so there’s a huge amount of information they’ve never had before. That has been is absolutely brilliant; they can join MDTs to see how patients are doing, and our teams can see how patients are doing at home.”
Funding from NHS England has also been a challenge, Heather said. “That’s been really tough – essentially it’s asking us to grow more and more on a shoestring.”
Having no EPR in place at Northampton has been a significant challenge, Chris acknowledged, necessitating the development of “convoluted processes and work arounds to make sure our patients are safe and nothing is missed”.
On record sharing, Chris talked about trialling a “hybrid model” in frailty, between primary and secondary care. It’s “tricky”, she said, as although the Northamptonshire shared care record is in place, it is “read-only, and doesn’t pull all of the detailed clinical documentation; so there are still some limitations”.
Chris explained that her team has been working with its community supplier to view some of the notes in there. “Again, it’s about those relationships we never had before and understanding how different people work. That’s been a challenge, but something we’re overcoming.”
From a clinical perspective, Chris emphasised the importance of engagement. “We’ve tried to grow it from the ground up, going to the top and daring to go higher still, which is so important. You have to be persistent and keep going, not get knocked back, which is why patient feedback is is brilliant.”
Having that digital technology in place to support clinicians in “doing this extra work in as easy and as seamless of a way as possible” is also crucial, Chris continued, “as is being flexible and trying things, seizing opportunities, and making sure governance is in place to support everything you’re doing”.
Getting staff on board with virtual wards
Picking up on the point around engaging staff with the virtual wards programme, Chris noted the challenges in consultant-led models around “trawling for patients – consultants know they’re still going to be accountable for patients, so it’s almost like you’re increasing their workload.” She reflected that she has noticed other models which take on a separate virtual ward consultant, which could make it easier to get those referrals through.
“I think the tide will turn,” she said. “As more clinicians see and experience virtual wards that are working and successful, there will be more buy-in. We’re still at the point where we’re trying to get on the radar across the whole board, so it’s quite challenging.”
Heather also acknowledged challenges with getting referrals through, saying that in Nottingham their model utilises specialty-driven nurses to help counteract the need to trawl, and that the biggest thing for her team is “taking that pressure off community teams”. Having those nurses in place also helps the team handle medicines to be taken home, she said, “as they know how the system works, and they can also be a great point of contact for patients after they get home. So that’s been invaluable.”
When working closely with community partners the logistics across “such a huge geographical area” in Nottingham can be difficult to manage, Heather added. “We have to make sure we’re not overwhelming our community partners, and that we’re getting those patients out in a safe way.”
On the point around trawling for patients, Chris considered the possibility for artificial intelligence to play a role in the future, to reduce pressure on staff and help by pinpointing who is at risk and which patients virtual wards programmes could target.
Connecting with community and measuring value in virtual wards
Heather and Chris moved on to talk about the potential for utilising virtual wards to connect with community care for long-term conditions, with Heather citing the example of COPD patients and asthma patients. “My team could probably manage in the sense of preventing admissions and picking up on deteriorations a bit earlier, but that would require looking at virtual wards a bit differently.”
“We could do it if we had hubs where GP partners and acutes can refer in directly, and we could have a central area to manage those directly, for example,” she said. “But virtual wards are limited to a 14-day length of stay, and we could be in danger of missing someone who’s quite unwell so we would need clinicians to be closely involved. But there’s a huge amount we could do. Technology is developing so fast that that is only likely to increase.”
When it comes to measuring value, Chris noted some key metrics that are useful to track such as length of stay, reduced bed days, capacity and flow. “Virtual wards aren’t going to provide empty beds,” she stated, “but they will offer a more cost-efficient bed base where we can give patients care at home”.
Her team’s remote monitoring platform offers “some really good data and a great reporting, with details on things like patient compliance, number of alerts, and so on. We are looking to develop this information into levels of alerts and NEWS scores to help build the case for further investment.”
Heather’s team is looking at cost per bed, given that as a tertiary referral centre patients are often in “quite high-cost beds”, as well as looking at the level of care patients are receiving. Although anecdotal at present, from a surgery perspective Heather noted feedback indicating that the virtual ward programme has helped to alleviate pressures and enabled them to “pull patients that little bit quicker and release beds”. She added: “For the first time in six years our elective surgical programme ran completely last winter, and we’re trying to pull the data together for that.”
Heather commented on the difficulties around reporting data to NHS England, with “everyone having their own version of data, so quality metrics can be very different for each trust”.
However, she said, it comes down to something simple. “As long as we’re releasing beds and patients are safe, well, and happy, then I believe the virtual ward programme is doing well.”
Scaling virtual wards
We asked Chris and Heather about any plans they had for scaling virtual wards, and for details on any expansions they might be planning in this regard.
Chris noted that the potential is huge, certainly in terms of remote monitoring. “Could we all have the same pathways and escalation points? It’s very difficult given we’ve got very different infrastructure, but it does make you wonder once we can share this information what we will be able to achieve.”
At the moment, she said, “It’s about making the most cost-effective use of what we’ve got, and then looking at data and reporting. Virtual wards have given us a new tool, a new framework. Although we’re tasked with certain numbers from NHS England, it’s about what our organisation needs – what are our pinch points and where are our readmissions? It’s about thinking more widely in terms of how we use this tool to improve clinical care and effectiveness for patients.”
“For us it’s going to be quite difficult,” Heather noted, “as our budgets have just been reduced. So we are working with what we have, and for the future we’re going to have to sit down as a team and look at it in a smart way. As Chris said, it’s about at our pinch points and where we can have the most impact, as well as where we can get the most bang for our buck.”
There is also an analysis underway to look at virtual wards for children and young people. “That cohort has been somewhat forgotten in all of this, as the target was frailty and respiratory. There is just no funding to do that, which for me is a healthcare inequality,” Heather said. She pointed to children on long-term ventilation who are just transitioning into adult services as an example. “As we’re an acute trust, there’s only a high-level bed we can put them in. That’s a tsunami of patients waiting to come in to our trust, as they live longer and we’ve got better at what we’re doing. It feels like we are not going to be able to support that in the next couple of years unless we take action.”
What does “good” look like for virtual wards?
To bring the discussion to a close, we asked Chris and Heather what “good” looks like for virtual wards.
“On a technical level, ‘good’ is supposed to look like meeting the numbers,” Heather reflected. “But actually we are taking a very clinical perspective. We want to see that patients are getting good care at home, getting support, and we want to see the process being seamless. For the patients it should be that their care and its quality doesn’t change, they’ve just got a different person at the door.”
As far as the numbers are concerned, Heather went on, if it means taking on fewer people on a virtual ward because staff are aware of an individual who is higher acuity and may need extra care “then so be it”.
What advice would she offer to anyone looking to implement a similar programme? “It is challenging, and I would say take a step back before you start,” Heather said. “Reach out to people like Chris and I, who you can learn from; join the groups, read the discussions on NHS Futures, and talk to your clinicians about what they need and want. If they feel like they own this, they will drive it.”
Chris said that her main priorities for a ‘good’ virtual ward focused on patient safety, patient experience, and value for money. “You need to be prepared, because this is basically building another hospital or an extension to the hospital. You’ve got your operational challenges, your digital challenges, and your clinical challenges. It’s all about change management, undertaking proper stakeholder engagement right at the beginning, and finding your clinical champions who are prepared to lead.”
Her team didn’t have a virtual ward strategy in place at the beginning of their journey, and Chris recommended starting with this. “If you address that right at the beginning, you get your governance and get your key people involved, then you can set targets.”
In terms of the future, Heather said: “We will need to look financially at what we can do in the coming few years to get the best for patients within our cost envelope. That’s going to be a huge thing that we’re going to need to do; to look at where we are and where we can go next.”
Thank you to Chris and Heather for their time in sharing their insights with us.
