The ‘winter crisis plan’ – why virtual wards won’t solve the NHS’s problems

‘Virtual wards will remain another example of how to justify underinvestment in hospital staff and services by promising resources for community care that then fail to materialise.’

Unevidenced policy that largely ignores the current crisis in the NHS

Recently, measures to deal with the NHS crisis over winter were announced. Headlining was a commitment to create an extra 7,000 beds mainly through ‘virtual wards’. When interviewed on the Radio 4’s Today programme, Jeremy Hunt even went so far as to outrageously claim this was equivalent to opening seven new District General Hospitals. Other lacklustre commitments include more call handlers to speed up the answering of 999 telephone calls (not the ambulance response times), additional ‘social prescribing’ link workers for hard-pressed GPs, and the ethically dubious recruitment of more health workers from overseas.

What are virtual wards?

While there is much confusion around this term, a ‘virtual ward’ aims to reduce pressure on the system by preventing inappropriate hospital admissions as well as improving flow through hospital by allowing patients to be discharged sooner. A ‘virtual ward’ enables some patients to remain at home or be discharged quickly and be monitored remotely via the use of technology, if well supported by trained community staff. Patient selection is crucial – you don’t want to have appendicitis and stay on a virtual ward. Staffing should include dedicated nurses available 24 hours a day, junior doctors, consultants, ward clerks, pharmacists and therapists.

While virtual wards can play a useful role, the Royal College of Physicians considered that they should be only one element in a raft of innovations to relieve pressure on hospitals. These included investment in ‘hospital at home’ services, social care teams, a sustainable health and social care workforce, and a cross-government strategy on health inequalities. Clearly a commitment to these measures is largely absent from the winter plan.

For community teams to function effectively, they would need support in the form of better regional collaboration and clinical networking across health boards, investment in training more clinicians to work in the community, rapid access to the right diagnostics and interventions, and closer working relationships between nurses, GPs, therapists, social care, and palliative care staff – all working as part of a multi-disciplinary team in liaison with hospital colleagues. Clearly, the principal challenge around virtual wards is therefore the shortfall in workforce especially since many staff working in health and care are exhausted, with higher absence rates due to stress, psychological issues, the need to self-isolate or sickness due to long Covid. Vacancies in the NHS have risen to 110,000; in social care it is 165,000.

Notably, NHS England’s first rollout of virtual wards when numbers of Covid patients were overwhelming hospitals was criticised by the Society for Acute Medicine and the Royal College of Physicians, who feared that they could put patients at risk as well as increase demands on staff given that the workforce pressures of virtual wards would have been significantly underestimated.

Overall funding needed to make virtual wards work safely and effectively is clearly lacking

All 42 of the NHS’ new Integrated Care Systems must now create 40-50 virtual ward beds per 100,000 population by December 2023 – creating a staggering 25,000 virtual beds across England. Not surprisingly, NHS internal figures suggest that this deadline is likely to be missed. In April, NHS England announced that an initial £200m would be available for virtual wards in 2022-23 and a further £250m in 2023-24. The money is intended only to support the setting up of the wards; hospitals will need to fund ongoing running costs themselves – a significant ongoing cost burden when inflation and cost of living increases are rapidly eroding existing budgets. In theory, money saved from decreased hospital admissions could pay for virtual wards, but given overall level of demand for hospital services, the huge reduction in beds over recent years, and massive staff vacancies, this is highly unlikely in practice.

Virtual beds at the expense of real beds with staff?
The total number of NHS hospital beds in England has more than halved over the past 30 years, from around 299,000 in 1987/88 to 141,000 in 2019/20 – while the number of patients treated has increased significantly. The UK has fewer acute beds relative to its population than many comparable health systems (Germany has three times as many) and before the Covid-19 pandemic there was widespread evidence of a growing shortage of beds. In 2019/20, overnight general and acute bed occupancy averaged 90.2%, and regularly exceeded 95% in winter, well above the level considered safe. Covid-related infection control measures have also led to the closure of around 5,000 beds. The Royal College of Emergency Medicine recently called for 13,000 additional staffed beds across the NHS to drive meaningful change and improvement. This would enable a significant improvement in A&E waiting times, ambulance response times, ambulance handover delays, and a return to safe bed occupancy levels. The collapse of emergency health care may even now be costing 500 lives every week, explaining the excess mortality figures.

The emphasis on rapidly increasing virtual beds is perhaps not surprising given that Health Secretary Steve Barclay has been described as serving up ‘a succession of quickfire nonsense ideas which display a near-complete ignorance of the way the NHS works and indifference to the consequences of his proposals’. As conservative politicians resolutely refuse to recognise the crisis in staffing and funding for health and social care services, the huge additional pressures on hospitals from Covid, and dire state of community support, it is difficult to imagine that the winter crisis plan is going to have any positive impact. Worse still, there are predictions that from early October after schools have reopened and the weather has cooled, cases of Covid-19 will surge to an unprecedented high.

‘Virtual wards will remain another example of how to justify underinvestment in hospital staff and services by promising resources for community care that then fail to materialise’

The proposals actually envisage virtual wards decreasing hospital occupancy and not just coping with surge in demand, while the Manchester team supporting patients at home with telephone calls and monitoring say their service ‘is not about admission avoidance’. However, unless there is adequate resourcing including the necessary hospital teams and community infrastructure, virtual wards will remain another example of how to justify underinvestment in hospital staff and services by promising resources for community care that then fail to materialise. Meanwhile, private firms are likely to be the beneficiaries of any limited increase in funds that do find their way to home care.

Precious little evidence

Initiatives to reduce demand for hospital care often struggle to succeed. Progress depends on having sufficient capacity to provide appropriate care outside hospital, yet intermediate care capacity is currently only enough to meet around half of demand and cuts in funding have led to significant reductions in publicly funded social care. Tellingly, despite the new NHS Integrated Care Systems, the winter plan acknowledges that social care is beyond the remit of the NHS.

Hard evidence in relation to overall costs and benefits is lacking.

• Watford West Hertfordshire NHS trust, nearly 400 patients with Covid-19 were monitored through phone calls from a team of clinicians, including consultants, respiratory physiologists, and physiotherapists not involved directly with frontline care. It was estimated that this saved a modest 100 bed days/week over three weeks at the height of the pandemic.
• David Oliver, a former president of the British Geriatrics Society and visiting fellow at the King’s Fund, considered that the virtual wards model was “not a magic bullet” and it was too early to be attaching “ambitious national targets” to their use, particularly since we did not actually know how patient outcomes were affected.
• Modelling work has shown how new services the needs of patients are poorly understood can increase workloads for existing staff and have unintended consequences in terms of risk, for example, by spreading an already stretched workforce even more thinly.
• Some have observed that reducing hospital bed days is currently the ultimate currency in healthcare, with large amounts of money being diverted from tried and tested workforces into new services, new jobs, and new technology aimed at preventing patients being admitted to hospital. While some of these new ideas could work, others have the potential to be a catastrophe.
• Virtual wards lack an evidence base, including assessment of the burden put on family carers at home.

Conclusions

Properly staffed, funded and supported virtual wards run jointly by NHS and care services could offer benefits to some patients, but like much of current government health policy, there is more wishful thinking than sound evidence underlying this current plan. Until the major issues of understaffing and underfunding are grasped at national level, all new care models are highly suspect and require robust evaluation through pilot studies before general roll out. The winter plan clearly implies a deliberate decision not to increase NHS resilience by opening and staffing more in-patient beds. It is driven by the imperative to try and reduce costs under the smokescreen of ‘unsustainable demand’ and that ‘care must be closer to home because this is what patients want’.

The government must invest much more in our NHS – to restore and expand NHS capacity; repair or rebuild crumbling hospitals; and reopen unused NHS beds. It is vital to increase overall funding, invest in workforce with new targets for recruitment, training, and increase levels of pay that would prevent the service losing staff. We also need to build a properly resourced, publicly run national care and support service, and invest in public health and policies to tackle huge and growing inequalities in health. Virtual wards are a side issue.

John Puntis
Co-chair KONP