Understanding facilitators and challenges to establishing the NHS Northumbria Healthcare Trust Step-Down Virtual Ward
Context
Virtual wards (VWs) became popular in England in 2022 to help reduce hospital crowding and improve patient health.
They allow patients to receive hospital-level care at home. Virtual ward care is managed using digital systems and delivered by multidisciplinary teams (MDTs).
VWs can be ‘step-up’ wards to prevent admissions or ‘step-down’ wards to support early patient discharge.
Evaluations suggest high acceptability among patients and staff, improved satisfaction, reduced infection risk, and lower likelihood of delirium amongst VW patients.
NHS commissioners have flagged challenges with establishing virtual wards, partly because this format of care does not align with established primary or secondary care services.
This study explores the facilitators and challenges experienced in establishing step-down virtual wards across Northumbria Healthcare NHS Foundation Trust (NHT-VWs).
NHT-VWs provide step-down care to patients from various hospital wards, including respiratory, frailty, cardiology, oncology, and more.
Patients are managed via hospital-based IT systems (Nervecentre). The Trust has yet to adopt digital technologies for remote monitoring for patients.
The NHT-VW team works closely with hospital wards and clinical leads to identify suitable patients and support their transfer to virtual ward care.
The research
Researchers conducted interviews with patients, family members, and staff including core management team leads, clinical leads, and practitioners delivering virtual ward (VW) care.
They then analysed the interviews using Normalisation Process Theory (NPT) to understand how this new approach was implemented, integrated, and sustained.
The findings provide key learning to inform virtual wards policymakers, commissioners, service leads and providers.
Policy briefs covering the findings and key recommendations can also be downloaded at the end of this page
Findings
Key facilitators:
Prioritising staff engagement and buy-in
The virtual ward leadership team prioritised engaging staff and securing their buy-in. They co-developed the NHT-VW model and procedures with staff and shared case studies to build trust in this new approach. Unlike the usual focus on building digital systems first, the team believed that engaging staff was key to successfully implementing virtual wards.
Service leads felt their emphasis on engagement helped to overcome resistance and foster a sense of ownership among staff.
“Everyone else has gone technology first. I can understand why, that was the ask, but I’m glad we took that step back. Because you’ve got to have the pathways. You’ve got to build those relationships. And now we’re bringing the remote kit in.” – Service Lead
Strong leadership and coordination
Staff across NHT-VWs emphasised the crucial role of the core NHT-VW management team in setting up and maintaining virtual ward care. The team coordinated the setup, engaged clinical leads, supported patient identification and referrals, and managed patient care on virtual wards. This strong leadership ensured that the virtual wards were well-organized and effectively managed.
“The core management team has just been so good, they are spot on with their assessment of the patients. They’ll stick to what’s appropriate and they will very clearly say, ‘No, this patient is not appropriate for this reason,’ or ‘Yes, absolutely. We can deliver x, y, z. Not a problem,’ and then the team will facilitate it” – Service Lead
Recognition of benefits
Both staff and patients recognised the benefits of virtual wards.
Patients appreciated being able to return to the comfort of their own homes and routines, with the support needed to do so safely. They valued the additional care provided by visiting practitioners to aid their recovery.
Staff noted that virtual ward care improved patient satisfaction, outcomes, and reduced hospital stays and readmissions. Some staff also reported increased job satisfaction from their roles in developing and delivering virtual ward care. These positive views helped build support for virtual wards and encouraged wider adoption.
“I felt safe. I mean, you come home and you’re just left to get on, but it wasn’t like that. Virtual ward care was completely different. It was like you had somebody there on your shoulder.” – Patient
Using established digital systems for patient management
NHT-VW coordinated virtual ward patient care using Nervecentre, a system familiar to hospital-based clinical leads responsible for VW patients.
Although this made it harder to coordinate pharmacy and community care input, as their systems weren’t linked with Nervecentre, the NHT-VW core team believed it encouraged clinical leads to admit and oversee their patients in VW care.
“Acute have always used Clinical Noting. The argument I put forward was, ‘These patients are under the consultant’s name. If everything goes wrong, it will be the consultant in the coroner’s court. They need to be able to see what’s going on with their patients all the time. It’s the only way we’re going to get the trust. It’s the only way we’re going to get involvement” – Service Lead
Developing safe and straightforward referral processes
Creating safe and simple referral processes, along with effective triage by virtual ward leads, helped manage risks and ensure patient safety. These processes made sure patients received appropriate and timely care.
Continuous reflection and refinement
The NHT-VW core management team emphasised that regularly reflecting on virtual ward processes and outcomes, and developing the model to support more patients, were crucial for improving the service.
Effective multi-disciplinary team (MDT) working
Effective MDT collaboration between the NT-VW team and hospital staff, along with local district nursing teams and community services, improved service delivery.
This teamwork ensured comprehensive care for patients, aiding their recovery and self-management at home.
By working together, the teams provided more holistic and coordinated care.
“You’ve got that bigger picture when you’re in a patient’s home. For example, I’ve done referrals to Age UK for our patients who are lonely and have got no family support. If I feel like they need extra little bit of support, there are loads of different avenues that I can go down, so that’s really beneficial.” – Practitioner delivering VW Care
Challenges
Initial resistance and scepticism
Establishing virtual wards faced significant initial resistance and scepticism from some clinicians, who felt unsure about the feasibility and value of virtual wards.
Overcoming this resistance required substantial effort from the core management team in demonstrating the benefits and safety of virtual wards.
“Initially, the majority of staff were very nervous about virtual wards. They felt, ‘Oh, gosh, these are going to be really complex patients, these are going to be patients additional to what I already have. How on earth are we going to cope with this?’” – Clinician
Resource constraints
Limited staffing and medical equipment posed challenges during the initiation phase of NHT-VWs. Ensuring adequate resources was essential for a smooth start and ongoing operation.
Geographical Challenges
Providing consistent care across urban and rural areas was difficult due to logistical issues. The large geographical area covered by the trust made it challenging to provide efficient care.
Digital System Integration
Integrating different IT systems from primary and secondary care for VW patient management was a major challenge for NHT-VW staff. Using multiple digital systems and duplicating information increased the workload and highlighted the need for better integration and interoperability.
Governance, risk management and evaluation
Establishing clear governance structures and permissions for virtual ward care was challenging and required significant effort from service leads.
Staff noted that the additional care transfers in virtual ward care increased the potential for errors, necessitating careful monitoring and management to ensure patient safety.
The lack of national criteria for evaluating the effectiveness and outcomes of virtual ward care also made it difficult to measure success and identify areas for improvement.
“We’ve all been asked to pilot and invest, and then prove the case, but there isn’t a national framework for how best to evaluate and how to do the cost modelling of whether it is cost-effective and whether the investment’s worth it.” – Service Lead
Patient and family understanding
Some patients and their families were unaware they were on a virtual ward, or were confused about what virtual ward care entailed. Ensuring they understood the concept and knew who to contact for support was an ongoing challenge.
Families sometimes felt uneasy about patients being cared for at home, questioning if they should be in the hospital instead. Managing family concerns and ensuring their confidence in virtual ward care was essential.
Potential inequalities in virtual ward care
Some clinicians expressed concerns about potential inequalities in patients’ access to and experience of virtual ward care. They suggested that patients from higher socioeconomic backgrounds and those with strong family support were more likely to be admitted to virtual ward services.
Clinicians also highlighted a ‘postcode lottery’ in available community services supporting virtual ward care, and potential exclusion of patients living in remote areas.
Additionally, with plans to implement digital home-monitoring and consultations, many NHT-VW staff flagged concerns about digital exclusion for patients without access to or literacy in digital technologies.
Recommendations for policy and practice
This research provides key learning to inform virtual wards policymakers, commissioners, service leads and providers:
- Prioritise staff engagement and buy-in when establishing a virtual ward by co-producing service design and sharing positive case studies with staff.
- Promote multi-disciplinary team collaboration to ensure patients receive the necessary input for their recovery at home.
- A core management team can promote strong leadership and coordination of virtual ward set-up and operations. Continued funding of this resource is an important consideration in sustaining virtual ward care.
- Allocate additional resources effectively, including managing travel demands. Virtual wards require additional resourcing beyond established primary and secondary care services.
- Support patient and family understanding of the virtual ward concept, benefits, and processes through national awareness campaigns and clear patient information.
- Consider the acceptability of digital technologies to patients and staff when implementing remote digital monitoring in virtual wards.
- Develop safe and straightforward referral, management, and governance processes, integrate digital systems, and continuously refine virtual ward designs.
- Ensure consistent patient oversight and clarify clinical ownership of patients and test results.
- Identify and address potential inequalities in virtual ward care, including geographical challenges, socio-economic disparities, lack of family support, and digital exclusion.
- Establish nationally agreed evaluation criteria to monitor virtual ward processes and outcomes, and clarify key priorities in virtual ward care.
For more information, contact lead researcher, Dr Beth Bareham
E: beth.bareham@newcastle.ac.uk
Partners involved in this work
Northumbria Healthcare NHS Foundation Trust
Advanced Care Research Centre (ACRC)
Funding
This research was funded by the NIHR Applied Research Collaboration (ARC) North East and North Cumbria (NENC). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. This work was also funded by the Legal & General Group (research grant to establish the independent Advanced Care Research Centre (ACRC) at University of Edinburgh). The funder had no role in conduct of the study or interpretation. The views expressed are those of the authors and not necessarily those of Legal & General.
The work was led by researchers from Newcastle University. It involved Northumbria Healthcare NHS Foundation Trust.
Research team
Newcastle University: Dr Beth Bareham, Dr Jan Healey, Dr Jenny Liddle, Dr Matt Breckons, Professor Amy O’Donnell, Professor Eileen Kaner, Professor Barbara Hanratty.