Introduction
Virtual wards (VW) or Hospital at Home (HaH) services were introduced by NHS England in 2021 to offer patients requiring acute care an alternative hospital-based treatment. They allow patients of all ages to safely receive care in their usual place of residence.
Implementation of VW/HaH services has not been well studied, however. The NHS England Midlands region thus commissioned a study to evaluate the implementation of services in three Integrated Care Boards (ICBs) in the Midlands region.
Headline findings
Current Virtual Ward (VW)/Hospital at Home (HaH) services have been implemented in accordance with 2022 NHS England policy guidance, and are contributing to acute care capacity across integrated care systems (ICS) in the Midlands region. The implementation of these service models, however, represents a complex service innovation, where the available evidence base is very limited. VW/HaH operationalisation is currently associated with a wide variety of service configurations, with clinicians and managers trying to establish best fit for their locality. This is consistent with recognised early-stage innovation processes. As the innovation journey continues and services mature, the evidence base will develop and support more standardised practice across service models over time.
During innovation, clinicians and managers need to maintain compliance with professional standards whilst reconfiguring care processes and MDT (multi-disciplinary team) arrangements to deliver acute care in a geographically dispersed way, often via support from various electronic communication-based technologies. This presents a more challenging innovation context for clinicians and managers relative to innovation processes involving hospital-based models of acute care. This complexity needs to be acknowledged, with resourcing tailored to supporting skills development across managerial and clinical change agents.
Resourcing needs to be organised across system and service levels to foster stronger innovation environments that support:
- collaborative, interdisciplinary learning both within and between systems and service providers;
- professional leadership development focused on change management and innovation up-skilling;
- clinical skills development across the full MDT during the innovation journey.
The NHS England Midlands Virtual Ward Implementation Regional evaluation report is available to download here.
Study Objectives: What were asked to do.
The project brief set out the following requirements:
- The enablers and barriers to the implementation of virtual wards across integrated care systems and service providers across the Midlands, including how any barriers might be overcome.
- To what extent Integrated Care Systems (ICS) and service providers (e.g. hospitals and community services) have operationalised virtual ward care processes across the Midlands, including impacts on service and patient outcomes.
- The contribution virtual wards are making to extending acute care capacity across the Midlands.
A comparative case study design was used (Keen, 2006; Pope and Mays, 2006). This is a methodology for studying health policy implementation and change practices within real world contexts. Cases were chosen from three integrated care systems within the NHS Midlands region, all at different stages of implementation and representing a variety of service configurations. Eighty interviews were conducted with clinicians, managers and policy makers; site observations were done with ten service providers; and relevant documents were reviewed.
Findings
Objective 1: Implementation enablers and barriers
The evidence base for organising and implementing Virtual Ward/HaH models is not well established (Wallis, et al., 2024). In this study we found service implementation was influenced by the following factors:
Enablers
- Change agents with experience of adapting professional practice.
- Opportunities to test & experiment with practice innovations.
- Resourcing & support from senior management.
- Multidisciplinary relationships which support shared learning & collective innovation.
- Active dialogue about innovative practices with clinicians delivering traditional hospital-based models of care.
Barriers
- Change agents without experience of adapting professional practice.
- Lack of resourcing & support from senior management.
- Sustained disagreements within multidisciplinary teams about innovating clinical protocols and roles during set up.
A literature review on barriers and facilitators by NHS England Midlands is available to download here.
Objective 2: Extent of operationalization
All models considered in this study were consistent with the national NHS guidance (NHS England, March 2022), at the time of the study. Guidance, however, has been interpreted in different ways to accommodate local system contexts and service needs.
The wide variety of service configurations we observed are consistent with complex innovation processes (Garud, et al., 2013) and the limited, emerging evidence base on service implementation (Wallis, et al., 2024; Levine, et al., 2024).
Further experimentation and exploration needs to be encouraged to support development of the evidence base, and identification of best practices over time.
Objective 3: Contribution to acute capacity
There has been a substantial increase in VW/HaH beds across the Midlands region. As of May 2024 there were 144 virtual wards across the 11 ICBs accounting for 2282 beds. This is a 249% increase relative to December 2022 when there were 914 beds.
Different VW/HaH service configurations focus on different acuity levels. For lower acuity models, we saw evidence of services focusing on chronic disease management/ social care activities to support faster discharge/reducing readmissions. In contrast, HaH models tended to see higher acuity but lower volumes of patients compared to other models.
Contribution to acute capacity cannot be specified more precisely because traditional measures of hospital based acute care capacity do not translate easily to VW/HaH models of care.
Conclusions
Current Virtual Ward (VW) / Hospital at Home (HaH) services were consistent with NHSE policy guidance (2022) and are contributing to acute care capacity across integrated care systems (ICS) in the Midlands region.
These service models, represent complex service innovations, where the available evidence base remains very limited. VW/HaH operationalisation is currently associated with a wide variety of service configurations, with clinicians and managers trying to establish best fit for their locality.
This is consistent with recognised early-stage innovation processes. As the innovation journey continues and services mature, the evidence base will develop and support more standardised practice across service models over time. However, further experimentation and exploration is needed for this.
During innovation, clinicians and managers need to maintain compliance with professional standards whilst reconfiguring care processes and MDT arrangements to deliver acute care in a geographically dispersed way, often via support from various electronic communication-based technologies.
Clinicians and managers need to institute a bundle of practice adaptions to achieve this and utilise a range of change management and leadership skills. This complexity needs to be acknowledged, with resourcing tailored to supporting skills development across managerial and clinical change agents.
Resourcing needs to be organised across system and service levels to foster stronger innovation environments which support:
- collaborative, interdisciplinary learning both within and between systems and service providers;
- professional leadership development focused on change management and innovation upskilling;
- clinical skills development across the full MDT during the innovation journey.
Further research is required to:
- establish which service configurations work best, in which contexts;
- understand how to adapt practices and develop clinical skills to deliver virtual ward/HaH services.
References
- Garud R, Tuertscher P, Van der Ven A. Perspectives on Innovation Processes. Acad Manage Annals. 2013; 7(1):775-819.
- Keen J. Case Studies. In: Pope C & Mays N (eds).Qualitative Research in Health Care. 3rd Ed. Ebook: Blackwell Publishing; 2006.
- Levine DM, Findeisen S, Desai MP, et al. Hospital at home worldwide: Program and clinician characteristics from the World Hospital at Home Congress survey. J Am Geriatr Soc. 2024; 72(12): 3824-32.
- NHS England. Supporting information: Virtual ward including Hospital at Home version 2. 2022. Available at: https://www.england.nhs.uk/wp-content/uploads/2021/12/B1207-i-supporting-guidance-virtual-ward-including-hospital-at-home.pdf.
- Pope C & Mays N. Methods in health research. In: Pope C & Mays N (eds). Qualitative Research in Health Care. 3rd Ed. Ebook:Blackwell Publishing; 2006.
- Wallis JA, Shepperd S, Makela P, et al. Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2024; 3(3): CD014765.