Virtual Wards RES shows value of evidence synthesis for large scale transformation programmes
When partners across the Greater Manchester health system were tasked with implementing Virtual Wards across the region in 2022, experts within NIHR ARC-GM’s Evaluation Theme were commissioned by Health Innovation Manchester to undertake a Rapid Evidence Synthesis (RES) to inform the process. In the first in a series of blogs from leading figures across the health and care system involved in Virtual Wards, ARC-GM’s Dr Gill Norman offers an insight into the RES process, the outcomes, and the widespread impact of the work regionally and nationally.
The process
Our Rapid Evidence Synthesis framework has been developed to enable evidence to inform decisions around how, or if, to implement innovations in Greater Manchester. It is real-time evidence briefing that is designed to be done very quickly within the commissioning decision-making process.
We use systematic review principles and toolkits, but it is very much stripped back to produce something that can be timely enough to fit that process.
The Virtual Wards RES represented something of step change in the types of innovations we were evaluating using the RES process. We had originally focussed on single innovations, such as an app for mental health conditions. However, we've expanded to cover wider remits and Virtual Wards was the first broader programme of work that we undertook a RES for.
This project was also different because it's part of a national programme, which meant it was always going to be rolled out in some form in Greater Manchester. We were undertaking the RES to inform the implementation and then the evaluation, rather than the decision whether or not to implement it.
Defining the focus
To deliver a RES we need to first identify a set of specific answerable questions that form the focus of the evidence gathering. We worked with colleagues from Health Innovation Manchester to really drill down to what they needed to know to inform implementation.
It became clear at this stage that we were going to do the RES purely using existing evidence synthesis because there was enough evidence at that level. We had six questions to start with, which is more than we’d normally have. Typically, we would have two or three questions for a RES. But we really wanted to explore the experiences of people involved and how different types of wards might work. So, in this instance, it was right to have more questions to cover the key areas, which centred on the effectiveness and safety of Virtual Wards, patient and carer experience, barriers and facilitators, and cost-effectiveness.
What the RES told us
What became clear as I started the RES was that there is extensive literature on the ‘hospital at home’ model - which is about providing hospital level care in the home - and that well established evidence base was going to do a lot of the work of informing the RES. This was particularly relevant because Virtual Wards are mostly being used for older people with frailty and people with multiple comorbidities. In other words - people for whom hands-on care is an important component of hospital level care at home. So Virtual Wards may have a lot of virtual components, but are going to look a lot more like a ‘hospital at home’ model for many of the people who go into that treatment path because of the nature of those people's needs.
The RES showed, broadly speaking, that Virtual Wards are about as good, or possibly a little better, most of the time for most people. The approach was safe and it wasn't producing worse outcomes. However, economically speaking, the evidence around cost-effectiveness was poor.
There was some interesting evidence around what does and doesn't make for effective delivery of Virtual Wards or ‘hospital at home’ in terms of care structures at an organisational level which I hoped would be helpful to guiding implementation.
A glaring gap which made me sit up and think was the experience of the people who are caring for their relatives at home. Instead of their loved one going into hospital and being cared for there, even with the best care possible, they are themselves providing a lot of care at home. The implications of that weren’t very well explored in a lot of the literature.
For example, many of the economic studies excluded out-of-pocket costs to the patient and their carers, which could include unpaid time off work or heating their home to a standard that is acceptable for a hospital inpatient. They also excluded non-financial costs, such as the emotional burden and the risk of burnout which are hard to capture in economics.
For some carers, the model can be a good thing as it gives them the ability to stay close, to be able to communicate and to not have the problem where an elderly person goes into hospital and becomes isolated from their main source of support. But reports coming through from primary studies in qualitative reviews suggested that some people may be really struggling. This highlighted that the impact on carers needs further exploration.
Other interesting findings that came out were around patient selection. People are often selected for care in Virtual Wards or ‘hospital at home’ groups based on certain factors, such as whether they live close enough to the hospital for teams to visit them and what their home set-up is - do they have an appropriate space or somebody living with them who can look after them at home? All of this makes sense, but if admission is governed by those factors, it can have impacts on health equity because they can intersect with financial or socioeconomic status, and other equity-related factors. So, more work is also needed to explore the equity implications of hospital level care at home.
The next steps
The RES was used by Health Innovation Manchester to shape the delivery and evaluation of Virtual Wards, and it identified gaps in research around this model of care for further exploration. It has also fed into wider work and discussions beyond our region. In addition, it was the basis of the evidence section of the British Geriatrics Society’s position statement on virtual wards and hospital at home for older people.
Following completion of the RES, I worked closely with Professor Emma Vardy and Paula Bennett to submit a journal article for Age and Ageing focusing on virtual wards and implications for the care of older people, which was published earlier this year.
More recently, the work has informed a full systematic review of the components of virtual wards and what contribution they're making to effectiveness, which has now been submitted for publication – watch this space.
Dr Gill Norman, Research Fellow at NIHR ARC-GM:
"The next in our RES virtual wards blog series comes from Dr Paula Bennett, in which she explores the impact of the RES from her perspective as the Chief Nurse for Health Innovation Manchester who supported the Greater Manchester Virtual Wards Approach and Group."
Download the Virtual Wards RES at: https://arc-gm.nihr.ac.uk/rapid-evidence-synthesis