‘This is a situation that cannot go on indefinitely’
STEVE FORD, EDITOR
02 November, 2022 By Ella Devereux
Source:  Spirit Health
Virtual wards have been hailed by some as a potential way to improve patient flow and reduce workforce pressures. Nursing Times has spoken to nurses who are pioneering virtual wards in their trusts to see how successful the roll-out has been so far and whether they think they will meet national targets.
At the start of 2022, NHS England laid out ambitious plans that asked integrated care systems (ICSs) across the country to deliver on virtual wards, which allow patients who would otherwise be in hospital to receive acute care in their own home. The plan said ICSs must deliver virtual ward capacity equivalent to 40-50 virtual beds per 100,000 population by December 2023 (around 24,000 virtual ward beds in total).
To enable the roll-out, £200m was made available from the NHS Service Development Fund in 2022-23 and a further £250m will come in 2023-24. NHS England guidance said ICSs have “local determination” over funding allocation, but that the majority (82%) of funds should be spent on the workforce.
“It will help us make really good clinical decisions, and free up bed space and home-visit spaces for those who need them”
Jane Van Aken
The workforce underpins the success of virtual wards and is one of the most pressing obstacles that trusts are having to overcome.
The roll-out comes at a time when nurse vacancies are at an all-time high, with almost 47,000 vacancies recorded in England. Meanwhile, data from 107 trusts found that 40% need to recruit additional staff to support the delivery of virtual wards.
The figures, collected by Spirit Health, a company that provides remote monitoring services to health and care settings, also found that a third (32.6%) of the trusts needing to recruit had anticipated making appointments across up to three roles.
At Leicester, Leicestershire and Rutland (LLR) ICS, a large piece of virtual-ward work has been undertaken this year in collaboration with Spirit Health. The company has equipped patients and staff with a remote monitoring platform; if clinicians have deemed it safe for a patient to be discharged, nurses use the interface to monitor patients while they are in their place of residence.
Jane Van Aken, nurse and director of service development at Spirit Health, told Nursing Times that the platform, CliniTouch Vie, is a “medical tool device governed by best practice” and led by a board and a clinical lead.
The at-home device has a camera to which patients have access; using an interface, patients receive daily questions to answer – for example, on their vital signs – which allow staff to monitor their condition. Clinical teams can see, via a dashboard, measurements for each patient for whom they are responsible.
Jane Van Aken
CliniTouch Vie alerts nurses when a patient moves outside of agreed parameters: a simple red, amber or green system (with red being the most urgent) allows staff to take appropriate action.
“At the very least”, patients reporting any change in symptoms will receive a phone call from whoever is looking after the virtual ward to discuss a care plan, said Ms Van Aken. Hospital teams work closely with community teams, in case a patient has to be seen face to face, she added.
Ms Van Aken described CliniTouch Vie as a “tool in a nurse’s toolbox” that sits beside them, rather than replacing them.
“I really want to get across that this will never replace our clinical experts or nurses, and it will never replace a hand. But it will help us make really good clinical decisions, and it will help us free up bed space and home-visit spaces for those who really need [them].”
The roll-out, launched in April, was small initially, and achieved 10 patients on a virtual ward at any one time by October, but there are aims to increase this to 30 patients by December. The trust and Spirit Health are, however, looking to eventually implement the initiative across 16 clinical care pathways, including asthma, diabetes and palliative care. Ultimately, LLR is looking to have around 450 patients on virtual wards, according to Ms Van Aken.
Nurse and cardiorespiratory lead at LLR, Ali Shaw, said the implementation of virtual wards had been “quite busy”. But she told Nursing Times that nurses have embraced the idea. “I think everybody realised the importance of getting patients out of hospital as quickly as possible and [to] continue that supported discharge [by] monitoring those patients at home,” she said.
“We’ve has some great outcomes and lots of patient feedback about how good it’s been”
Clinical teams have been given training to make sure they are able to use the CliniTouch Vie equipment properly, Ms Shaw explained.
As well as training existing staff, she described how the virtual ward launch had enabled LLR to recruit more staff to manage them. They were “very lucky”, she said, to have doubled the number of nurses on the ward since the launch. She said the goal for all staff was to “get patients out of hospital quicker and prevent them from going back in again”.
It is not just hospital settings that have taken this approach – community settings have adopted virtual wards too.
Steph Lawrence, executive director of nursing and allied health professionals at Leeds Community Healthcare, is part of a team that runs face-to-face virtual wards in the community. Instead of using technology, however, they are delivered as part of an integrated neighbourhood team.
For this reason, Ms Lawrence said virtual wards were, in many ways, an extension of what is already being done in community services “to a greater or lesser extent”. But, she said, virtual wards were now seeing patients who were “more acutely unwell than [they] have ever seen before”.
Community matrons run the virtual ward from 8am until 8pm, as NHS England guidance specifies that virtual wards should be run for a minimum of 12 hours per day. After 8pm, the neighbourhood night service, which also features nurses, takes over. If, after assessment, a patient on a virtual ward appears unsafe to keep at home, they have “a direct route into the hospital” via a geriatrician, to which the community teams have 24-hour access.
Ms Lawrence said the service “runs really smoothly” and was the right choice for patients. “We’ve had some great outcomes [and] lots of patient feedback about how good it’s been – that people wanted to stay in their own home, it felt safe, they felt they got enough support.”
Currently, the trust operates at 40 virtual ward beds. Ms Lawrence said they were looking to increase it to 60 beds but was clear that they will only do this when they have enough staff for it to be done safely. There have been times when they have refused to take on more patients, because nurses were “at their limit”. Ms Lawrence said the trust “would love to go further, faster” but the workforce is not there to support it right now.
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Professor Alison Leary, chair of healthcare and workforce modelling at London South Bank University, told Nursing Times that some models of virtual wards relied on an expectation that existing staff would take on the workload.
She explained that the more well-established models in the community were “relatively low risk”, because many patients were being treated for long-term conditions. Newer models of post-acute care, however, in which people were still at risk of deterioration, come with “a very low staff-to-patient ratio”.
She warned that the newer model, being promoted by NHS England, often “still relies on existing community staff to make it happen”, adding: “That, of course, then puts more pressure on people. We’ve already got an overstretched community workforce, and we don’t need any more [staff] leaving.”
Professor Leary said for virtual wards to be rolled out safely, workforce impact assessments must be carried out to evaluate how they would affect the workforce: “If you’re going to give people more work, you need to see how it’s going to affect the work they already do.”
In October, the Virtual Wards and Urgent Community Response Capabilities Framework was launched to support the expansion of virtual-ward models.
Commissioned by NHS England and developed by Skills for Health, the document identified the skills and knowledge nurses needed to deliver high-quality care in virtual wards. These included communication and consultation skills, seeing families and carers as partners in care, working with colleagues, gathering information and interpreting data, and demonstrating leadership.
Looking ahead, NHS England said it was “working with systems to provide further support and develop guidance on staffing and case studies”.
Additionally, it said early evaluation “will be critical” to assess how well virtual wards are delivering for patients. Local evaluations will demonstrate the impact of virtual wards on bed usage, workforce and technology enablement.
Geraldine Rodgers, director of nursing, leadership and quality at NHS England and Improvement, co-authored the framework. She told Nursing Times the framework was “key to informing workforce, education, training and career progression” as well as local workforce models.
Ms Rodgers added that the framework provided “a standard and greater clarity” on the scope of practice for nurses in multidisciplinary teams working in virtual wards. Creating a standardised scope of practice for nurses was important because it ensured services were provided “in an integrated way” and contributed to reducing health inequalities.
“It will help support teams safely and confidently deliver care in the virtual wards and the urgent community response outside of the hospital setting,” she said.
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