NHS 'virtual wards' are expanding – could they backfire?

So-called "virtual wards" are increasingly touted as a win-win for hospitals running out of beds and patients who would prefer to convalesce in the comfort of their own homes.

Health services in both Scotland and England have been rapidly expanding hospital at home services, with investment accelerated by the pandemic.

Since 2020, the Scottish Government has allocated around £12 million to scale up Hospital at Home services to more than 20 health and social care partnership (HSCP) regions, including rural areas such as the Highlands, Borders, and Western Isles, with a total of 468 "virtual" beds set to be operational by the end of March 2024.

This compares to roughly 13,000 'real' beds, but given that occupancy is running at 90% on average and more than 150,000 Scots are on waiting lists pending a planned operation there is an urgent need to free up capacity.

So what's the catch?

Cost conundrum?

A new study in England has attracted attention in the past week after finding that virtual wards cost the health service almost twice as much as inpatient care.

NHS England is on track to double its virtual beds from 10,000 to 24,000 by the end of this year, so the question of value for money is an important one to answer.

The study, said to be the largest of its kind to date and the first in the UK to evaluate cost-effectiveness, was carried out by a team at Wrightington, Wigan and Leigh Teaching Hospitals in the north-west of England.

It compared 318 patients in virtual wards against 350 patients in hospital with similar characteristics.

The researchers found that while the virtual ward patients spent less time in hospital for their initial treatment, they were more likely to be re-admitted than those who had been kept in for longer as inpatients.

The 40-bed virtual ward freed up three hospital beds per day on average, but the researchers found that the cost of a 24-hour period in the hospital bed was £536 while providing the same care using a virtual ward had been £1,077.

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Summarising their findings, the authors said: “In order for the virtual wards to be cost-effective they need to halve their costs without affecting patients’ clinical outcomes.

“However, the higher rate of readmission to hospital from virtual wards patients, compared to hospital patients, can hamper any gain from reduction in costs, highlighting the necessity of appropriate plans and procedure for the selection, design and management of the virtual wards and their patients.”

One criticism levelled at the study, however, is that the virtual ward was in its first year of operation at the time and had a very low occupancy rate of just 24%. Had it exceeded 75%, supporters argue that the per-bed running costs of the virtual ward would have been much cheaper.

Previous US studies have estimated that hospital-at-home services are around a third cheaper.

A spokeswoman for the NHS said the results were "misleading" and the virtual ward involved "is now able to do four times as much activity".

Benefits and risks

According to the most recent progress report by Healthcare Improvement Scotland, a total of 11,686 patients – mostly over-65s – were managed by Hospital at Home services in the year to March 2023. On average, patients in Scotland spend 5.5 days on a virtual ward typically receiving interventions such as drips or oxygen.

Key readings like blood pressure and temperature can be monitored in real-time remotely by hospital-based staff, with care overseen by a consultant and urgent access to tests available when needed.

Patient satisfaction is generally high and virtual wards are also associated with lower risks of infection, delirium and use of sedatives.

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However, the Royal College of Physicians Edinburgh – while supportive of Hospital at Home – cautioned that "any additional impact" on unpaid carers must be factored in, and that it should not be resourced "at the expense of existing services".

As think tank, Nuffield Trust, has also cautioned, virtual wards will be unlikely to succeed in relieving pressure on hospitals "unless the entrenched challenges within the social care and community sectors are addressed".