For a recent HTN Now webinar on the topic of virtual wards, we were joined by a panel of experts including Francesca Markland, senior programme manager for remote monitoring and virtual wards at NHS England; Fhezan Ashraf, senior pharmacist clinical configuration manager at The Dudley Group; and Abigail Scullion, virtual ward manager at Maidstone and Tunbridge Wells NHS Trust.
Our panel tackled a range of questions and key debates in the virtual wards space, sharing insights on their own approaches, experiences and learnings; as well as considering opportunities for future development and the potential for emerging technologies to make an impact across workforce, patient care, operational efficiency, capacity, and more.
Fhezan started out by telling us about his role and involvement with Dudley’s virtual wards programme, helping to turn some of the great ideas from the trust’s clinicians into solutions. “We had to adopt this different way of working, and it was about setting up the fundamentals and the principles involved with that; what staff needed to be able to do with our IT systems and linking that up to ensure the process was safe and secure.”
Since then, it has expanded drastically, according to Fhezan, covering seven specialities including paediatrics, complex nutrition, heart failure, and frailty. “More recently, we’ve been looking at acute medicine,” he updated, “as our acute teams are very keen to adopt some of the aspects of virtual ward care to achieve some great outcomes.”
Francesca shared her experience working on remote care and virtual wards with NHS England focusing on the London region. “Through that COVID period, we were able with the help of the regional scaling programme at the time, to fund various different remote monitoring projects, and we did stand up some of the early technology-enabled virtual wards as part of the COVID response,” she said.
Post-COVID, there was a big investment in virtual wards, not only for the technology, but also for the implementation resources, Francesca told us, “but I think we’ve plateaued at around a third of virtual ward utilisation being tech-enabled, and I’m keen to explore why that is, how we can increase the use of technology, perhaps be a bit more ambitious in our use of that technology, and how we can secure clinical buy-in to improve that transformation piece. We have a real opportunity for digital transformation here, but that’s not going to happen if we just try and digitally enable traditional virtual ward pathways; we’ve got to think more creatively, and that’s been some of the discussion taking place in our region, thinking about what happens next.”
The acute virtual ward at Maidstone and Tunbridge Wells has been open for two years, recently supporting its 2,000th patient, Abigail told us, and is now branching out into outpatients and long-term conditions. “We seem to have done it the opposite way round to most of the country,” she said, “because we went with acute first, and we’ve just been successful in winning a bid with SBRI, who are going to be doing a big research evaluation paper on our virtual ward. We’re very proud, and we’ve worked really hard.”
There’s lots happening, Abigail continued, “we’re looking at rethinking the language we use, because that’s one of the biggest clinical binds we see from the nursing side, as the wording we use can be misconstrued”. Work is ongoing around this with clinicians, she shared, “and especially the doctors across our patch to help them understand the new ways of working – we haven’t got any more beds, so we’ve got to think differently”.
Challenges around new ways of working
On explaining the model to colleagues so they can understand what it would look like to adopt a new way of working can be challenging, Fhezan told us. Offering reassurance that the same high level of care can be provided, and getting feedback from staff who might already have experienced working in this way can help, he said.
“A challenge, though, is probably the technology. In paediatrics it works well, you’ve generally got parents there who are willing and capable of using that technology; in a frailty virtual ward you often have a population where that technology might not be so easy to adopt, so the change is quite different.”
The area the trust could “probably do more in” is around delivering on truly tech-enabled virtual wards, Fhezan shared, “making sure data can flow seamlessly from the patient’s home into our EPR without manual intervention, and making sure the technology is cost effective but also practical to use”.
What has been a success has been the team’s drive and innovation from a process perspective, Fhezan considered, “because we’ve got teams who are willing to work in different ways, who are seeking out funding for staff training, and putting a lot into that”.
Abigail noted that from her team’s experience, older patients didn’t necessarily struggle with the technology. “Most of our patients are over 65,” she said, “and our oldest patient was 106 – he managed to use the equipment”. There will always be patients requiring extra support, she went on, “so it’s integral to look at how we work around that, so that nobody is excluded just because of their age”.
Getting the systems to work is definitely a challenge, Abigail agreed, “because there’s still a lot of double doing, and getting NHS systems to work with external systems requires a lot of work in the background – two years down the line we’re still trying to get those platforms linked in”. Having that in place can help improve patient safety, however, to help overcome human error when copying readings between systems, she went on, “so I think there’s lots we can do with technology to improve, and we’ve already improved massively since COVID – it will get better as time goes on”.
Francesca picked up on the challenge around integration with EPRs, highlighting some of the issues which often arise with suppliers who are trying to get those integrations in place. “It can be a long and expensive process,” she told us, “and as the NHS we’ve invested huge amounts of money into these EPR systems, so we find ourselves in a challenging position.” Whilst workarounds do exist, that doesn’t solve the bigger problem that the NHS has more generally around needing things to integrate with EPRs, she continued.
Another challenge can be found in some of the earlier procurements, with some systems “finding themselves at the end of contracts but being left with a load of tech which isn’t interoperable with any other platform”, Francesca said. “Those kind of learnings can be taken forward into future procurements, but we also found that because virtual wards was relatively new, people needed some support, and as a region we did some work on producing a generic virtual ward spec that could then be adapted by local systems.”
At the beginning, a lot of focus was on the monitoring technology with point of care testing as an aside, according to Francesca. “As we’ve moved forward, I think we’ve learned it’s a good idea to look at those as a bundle, because we’re now playing catch up with the point of care testing, which can be quite transformative to your pathway if you can adopt some of those technologies.” Sharing learnings and joining up conversations with others using the same systems or other trusts in the region can be helpful, she added, “as is having that collaborative mindset and the forums to talk to neighbouring ICBs”.
Plans for the future
“We’re working on our outpatient episodic model to free up space,” said Abigail, “because we know clinicians often want to bring patients back in ten days to review them, when actually they don’t need to be there, which stops the flow for the rest of the trust.” The trust is looking at using AI technology for patient-initiated follow-up, she went on, as well as reviewing process maps to see if any tweaks can be made to make the pathway smoother for the patient, and looking at offering continual education to clinicians, especially to new intakes who may not have experience of the model.
Maternity is another area of focus, Abigail shared, “as it’s a large patch and we have lots of patients that come from other areas, so we’re trying to support them as well as freeing up midwives in the community, and we’re potentially looking at a gynae pathway and a gastro pathway too”.
Responding to a question from Francesca about patient-initiated follow-up, Abigail explained how the team currently has two different approaches, one for outpatients who might not need strict monitoring, which is done through the NHS app; and one for patients who need to be monitored, who will stay on the platform. “They’d answer some questionnaires, potentially daily, or whenever there’s a problem, and then we would follow the escalation pathway to the specialist so they’d be seen first time rather than going through A&E, freeing up space in A&E.”
Francesca noted the direction of travel coming from the Health Secretary around the shift to community. “It would make sense in my mind to try and shift a lot more care to the home or outside of the hospital. There’s definitely a desire to see more in the step-up space, but then when we start talking about things like the neighbourhoods programme and population health management, then we can start joining some of those dots and doing that in a more robust way.”
The introduction of AI tools will hopefully allow a broader look at systems and a more holistic approach, Francesca told us, “because the other bit is that some of this technology that has already been invested in isn’t being used, and is gathering dust, when it could be repurposed for some of the long-term condition pathways, for example”. Joining up data is another area to explore, with this kind of care offering “much more contextual data for some more vulnerable cohorts”, she said, “and we’ll be able to use that to take those conversations between health and local authorities and join up some of the care”.
Ultimately, it’s how we can join the dots, avoid duplication, try not to undermine existing investments, and maintain some alignment with both NHS and local authority digital strategies, Francesca concluded.
Looking ahead, there’s a focus on using virtual wards as an enabler to reducing length of stay for the Dudley Group, Fhezan shared. “It’s very much early days, but the acute medicine team are currently trialling some new processes, and we’ll be looking again at our process maps and the tech behind it to try to better enable our clinicians to offer that care.” The trust will be looking to opportunities to learn from others doing similar things, and at where the model can be expanded to outpatients.
“We’ve got PIFU and outcomes, but it’s about joining it all together,” Fhezan said, “so we can really use this virtual space to bridge up care from secondary care teams over to community teams and try to give the patient a seamless experience.”
What will virtual wards look like in five years’ time?
Our panel next picked up on what virtual wards might look like in five years’ time, and what needs to happen to help reach their full potential. For Francesca, the emphasis needs to be on integrating systems, both within the NHS and in social care. “We also haven’t touched on the need to look at how we make the home more appropriate where needed, for those receiving care,” she considered. “If we don’t start looking at that other end of virtual care, we might risk inadvertently creating health inequalities that didn’t exist before, purely on the basis of a patient’s home environment.”
More overlap with local authorities and the healthy ageing agenda is also to be expected, Francesca continued, “and we’ve got smart housing being built for the retirement age group, and homes being built with monitoring tech installed focusing on data-driven living. Outside of that, we’ve got consumer health data coming into play, so I think we’ll see the public expecting more from virtual care and systems will need to respond to that.”
“I think EPR suppliers will need to be far more open to working more closely with tech providers for tech-enabled care,” Fhezan shared. “Francesca mentioned coming up with a virtual ward spec, and I think if there was more of that type of thing out there providing a single specification for us to work to, that would help. It’s going to be who is willing to adapt their systems to work with that, and because of funding decisions I don’t see that happening soon.”
In an ideal world, nobody from a care home would be in a hospital bed unless they had a real need to be, Abigail said. “That’s one of our big drives – we support the community a lot with their care home patients, and in five years I’d like to see every specialty using virtual care as a first choice where possible. We’re seeing less DVTs and hospital acquired pneumonias, because these patients are up and mobile at home. We’re looking after palliative care patients where they have an acute infection, and then we’re transferring them across to that hospice care, so we’re freeing a hospice bed up for someone that needs it when they’re in their dying phase.”
We’d like to thank our panellists for sharing their insight and experience with us on this topic.
