By Josh Burraway, Senior Consultant and Jennifer Yang-Meslet, Director, Consulting
In April 2022, NHS England and NHS Improvement asked all Integrated Care Systems (ICSs) to extend or introduce the virtual ward model.1 ICSs have been asked to deliver virtual ward capacity equivalent to 40-50 virtual ward ‘beds’ per 100,000 population (equivalent to the delivery of up to 24,000 virtual ward beds), by December 2023. In the spring of 2022, Deloitte teams supported ICSs in the East of England region in their virtual ward implementation. We adopted a distinctive approach to understand patient and staff perceptions of the virtual ward, based on applying behavioural science and inclusive research that garnered feedback from the workforce, patients and the system. Our findings upended many of our initial assumptions as well as validating others. In this blog, we showcase how applying a ‘new lens’ to our research enabled us to marry a bottom-up view of daily operations with a birds-eye perspective of the user experience.
What are virtual wards?
A virtual ward is intended to provide a safe and efficient alternative to NHS bedded care that is enabled by technology. Virtual wards support eligible patients to get the acute care, monitoring and treatment they need at home safely and conveniently, rather than being in hospital. This includes either preventing avoidable admissions or supporting early discharge out of hospital. In 2022-23, £200 million funding has been made available from the Service Development Fund to support this initiative, with a further £250 million in 2022-23, on a matched funding basis.2
Many of us will automatically think that admittance into a virtual ward is primarily dependent on technology. Indeed, virtual ward patients do use remote monitoring technologies to measure their vital signs, such as blood pressure and blood oxygen levels. This allows clinical teams to actively monitor their patients remotely and intervene if their readings are deteriorating. These technologies can be especially useful for patients who require less intense levels of physical care – like some acute respiratory infections. However, technology is not the defining feature for virtual ward patients with more complex co-morbidities, such as those living with frailty. In this latter case, patients require more hands-on multidisciplinary care from a whole host of clinical specialists visiting them multiple times a day.
Understanding what clinicians and patients on the virtual ward really think
“To the extent that ethnography is the science of observation, it is the art of paying attention”
Faced with the need to articulate their business cases and awaiting national funding to implement the virtual wards model, ICSs are asking themselves what day-to-day operations are actually like in practice for those who are delivering and receiving ‘virtual’ acute care. This is where user research can offer huge value.
User research is a multidisciplinary field that investigates human experience and behaviour in context, using insights derived from the behavioural sciences to drive product and service designs that make sense to the people who use and deliver them. Although it is not typically used in the NHS, it offers real benefits and innovative ways to improve both the care for patients and the working conditions of their care workers. As a starting point, we sought to understand what daily life on the virtual wards was like from both the patient and clinical perspective to gain a holistic understanding of the service ecosystem. We considered that the tools best suited for this goal were ethnography and inclusive design.
Ethnography involves the researcher immersing themselves in the worlds of other people to generate “insider perspectives” into what forms the fabric of their everyday lives. People, after all, do not live in vacuums. Life is messy. When that messiness collides with the rigours and intensities of clinical practice, things get even more complicated. Ethnographers seek to understand human behaviour in all its everyday messiness and complexity.
In practice, this meant shadowing clinical teams on their daily rounds, watching and listening as they interacted with colleagues and patients, as well as conducting exploratory interviews in context. We immersed ourselves in the day-to-day happenings of the virtual ward, watching events and issues unfold in real-time and then probing deeper to understand what had happened and why.
Applying new lenses
“It’s not just my car – it’s my office and my kitchen!”
The biggest frailty ward we researched spanned over 400 square miles. Accompanying staff in their cars, it was clear this wasn’t just a physical experience, but an emotional and psychological one too. We heard how working in community settings meant being “on your own.” Their car isn’t just a way of getting from A to B, but the office where staff take their calls, write their notes and liaise with their coordinators. It is also the canteen where they eat their lunch. For many, long periods alone in the car can quickly become symbolic of broader deteriorations in their sense of belonging that had already been exacerbated by the COVID-19 pandemic. In addition, compared to a clinical setting where hierarchy is often flattened by the shared experience of working together in the same space, the physical separation between coordinators and staff can, in certain circumstances, exaggerate an “us vs them” mentality. This separation manifests first in a perceived lack of transparency, then understanding, and, in the end, trust.
“My body and home are no longer my own”
From the patient’s side, our most profound observation was how staff were able to help patients re-establish new relationships with their homes, bodies and selves. Virtual ward patients experience their changing health situations in disconcerting ways, losing a sense of control over their own bodies. This reality becomes mapped onto the home as it fills with medical personnel and equipment, radically disrupting their sense or routine, privacy and normality. One elderly patient had fallen outside his home and broken his knee. The virtual ward team didn’t just help him rebuild confidence in his knee, but confidence in himself and his surroundings. They leveraged his goal to walk unattended at a relative’s wedding as a kind of moral, future-orientated narrative to structure his rehabilitation. This culminated in him walking outside with his carers, unattended, to the very part of the curb that he had tripped on, allowing him to regain the sense of control and future possibility that his fall had stripped from him.
In parallel, we carried out an exclusion mapping workshop, focused on patients who had experienced precarious housing, digital exclusion, and literacy issues. We subsequently examined barriers that other excluded patient groups might face in their movement across the virtual ward pathway, identifying possible interventions and isolating important areas for further research. For example, we uncovered that patients with literacy issues or who could not speak English would encounter major barriers in fully utilising the remote monitoring technologies. By identifying these blind spots within the journey, we helped the virtual ward team develop a more proactive clinical protocol in relation to patients who suffered from complex patterns of exclusion.
Resilience at the forefront of virtual wards
Time and time again we witnessed the extraordinary levels of wrap-around care that patients can receive through this virtual ward model. The challenge, however, was that much of the workforce were at the limit of their practical and emotional capacity, relying on levels of resilience that were already stretched, plunging many into the realm of burnout. Having identified key operational pain points and infrastructural issues (in particular around staffing, technology and clinical governance) through our ethnography and inclusive design workshop, we concluded that cultivating system-level resilience is crucial if the virtual ward model is to meet the expansion goals outlined in the new national guidance.3 Consequently, we developed a framework for how ’Resilience Interventions’ could be applied across the main system challenges identified through our research (Figure 1).
Figure 1. Identifying system challenges
Source: Deloitte research and analysis.
Because this framework was developed from observations of daily life on the virtual wards, we explored not just what is done but how and why things are done. Our methods made visible the contextual and cultural factors that shape daily operations on virtual wards. Consequently, we traced a line between individual and system challenges, ensuring that our recommended resilience interventions resonated with the lived experience of staff and patients alike. Looking forward both to the future and the coming winter pressures, optimising the success of virtual wards requires resilience structures to be embedded from the outset, driving new interdisciplinary collaborations, and translating qualitative data into practical adjustments in the everyday provision of services.
For more information on user research methodologies applied to health and care settings, please contact Jennifer Yang-Meslet at firstname.lastname@example.org.