Virtual wards may feel like a recent thing, but you’ll have to go back to the early 2000s to find the first version. However, these looked a lot different - powered by just a spreadsheet and a landline phone. Geraint Lewis, now Director of Population Health at Microsoft, was one of the doctors to work on this model, bringing hospital-level care into patients’ homes. And doing it for the first time.
We spoke to him about his role in creating virtual wards, key changes he’s seen over the last 20 years and how it might evolve in the next decade.
Health services around the world, including the NHS, have been aware for a long time that a small percentage of the population account for a very large proportion of hospital expenditure through unplanned admissions. So, in the early 2000s, the Department of Health commissioned a predictive risk model to calculate which patients were likely to have an unplanned admission in the next year.
Two nursing colleagues and I then used the outputs of this tool to offer hospital-level care to high-risk patients in the community. We took the systems, staffing and daily routines out of a hospital ward and used them to care for patients remotely, with the aim of reducing their risk of hospitalisation.
The predictive tool we were using was very sophisticated.
But in contrast, the actual virtual ward itself was operated with just a Microsoft Excel spreadsheet and a landline phone!
Things have moved on a lot since then.
What’s exciting about the resurgence of virtual wards 20 years later is that the majority are now tech-enabled. Algorithms and hardware are being used to pick up signs of early deterioration to improve clinical safety, allowing patients to be cared for at home who previously would have needed a hospital stay
Something I hadn’t anticipated back then was the idea of step-up and step-down virtual wards. Step-up is when a patient who is in the process of being admitted to a hospital ward is diverted into a virtual ward, rather than straight into a hospital bed. Step-down is when the patient is discharged early from hospital into a virtual ward. As with everything in healthcare, predictive models will never be 100% accurate, so the step-up/down model can be less risky from a health economics point of view as it helps patients that we know are either about to occupy a hospital bed or are already in one. There’s huge opportunity for growth here since many patients are admitted for monitoring or coordination purposes rather than hands-on care.
It's important to remember that the hospital-at-home model has been around for a very long time. There's a reason that hospitals all over the world are organised into wards - indeed ward rounds have been used for over 350 years. It’s reassuring that we are continuing to take inspiration from this tried-and-tested model of care and using it outside of hospitals. It’s the same care, just delivered in a different way.
Virtual wards as a model of care offer many benefits, including supporting patients in the community, enabling earlier discharge, and helping clinicians to manage caseloads effectively.
But I really do think we are just scratching at the surface.
A lot of in-patients are not acutely unwell, but they need input from different clinical teams which has previously made sense to coordinate in hospital. But there’s no reason some of this can’t be done at home now.
From what I've seen, virtual ward utilisation is often nowhere near the capacity of how many patients they could take. There’s huge opportunity for improving efficiency here – once staff are comfortable with more patients on the virtual wards, we’ll begin to see productivity gains.
One of the main challenges is people jumping on the bandwagon and using the term ‘virtual wards’ for things that don’t really fit the definition. Hospital wards have certain core features that without them, we wouldn’t recognise them as wards. So, in my opinion, using ‘virtual wards’ for projects that are missing core features of a ward dilutes the concept down. Patients need to be reassured that they’re getting the same level of care that they would on a hospital ward. When people misuse the term, it could result in a negative view, which will make adoption harder.
Another challenge is that virtual wards will never be appropriate for everyone, whether that’s for clinical or social reasons. It’s important that the NHS and healthcare systems internationally design services with the most disadvantaged in mind.
Not everyone will have a warm, dry home to recover in. We mustn’t let health inequality slip our minds.
Firstly, I’d like to see people think more carefully through the economics and ethics. Economically, where does it make the best sense to invest in remote patient monitoring? Preventive care is brilliant, but we need to also help those who are already unwell.
On the ethical side, we also need to be careful about continuous monitoring.
Even in a world where money was no object, we wouldn’t be monitoring every patient like we do in intensive care.
Monitoring someone for 24 hours a day can lead to inconsequential and abnormal findings, causing anxiety for the patient, or leading to unnecessary investigations or treatments.
Something I'm excited to see would be for it to come full circle. Virtual wards have learnt from hospital wards, but what can hospital wards learn from virtual ones? A good example is that on a virtual ward, technology such as that offered by Spirit Health can systematically record and track patient symptoms over time across lots of parameters through their remote monitoring platform, Clinitouch. Wouldn’t that be great if we did that in hospitals to get a richer picture of a patient’s health over time? I also expect to see innovations in how to run a virtual ward more efficiently, often through empowering patients to take on more elements of their own care, transferring back into hospital wards.
A lot can happen in 10 years and I still find it remarkable that many of us spend the bulk of our working lives on Microsoft Teams - a technology I hadn’t even heard of it four years ago.
To be honest, I don’t think we’d be sat here having this conversation if it wasn’t for the pandemic - virtual wards wouldn’t be where they are now without it. It kickstarted things that people had been talking about for many years, pushing through many health tech advancements. I look forward to seeing where the next decade takes us.
Thanks again to Geraint for an insightful conversation into the world of virtual wards. If you’re interested in reading about our remote monitoring software platform Clinitouch, which has been used to power virtual wards at scale across 16+ different health conditions, check out our case studies.