HELEN ROBERTSON
Deliver To: Amanda Pritchard,
NHS Chief Executive Officer
10 South Colonnade
Canary Wharf, London, E14 4PU
Dear Amanda Pritchard,
In 2022, your team announced the expansion of virtual wards across England to reduce demand for hospital beds. In response, Integrated Care Systems (ICSs) have been tasked with establishing 40 – 50 virtual ward ‘beds’ for every 100,000 people by December 2023 (Sollof 2022). As you know, virtual wards are care models that enable the remote provision of care at home through digital monitoring tools. Currently, ICSs have established care pathways for ‘frailty’ patients and acute respiratory patients who need short-term care for 1 to 14 days (NHS England 2023). Your team has promoted virtual wards as a safe, technology-enabled form of healthcare that will reduce hospital admission and support early discharges. However, my own experience, supported by evidence from medical anthropology literature, leads me to believe that virtual ward expansion is merely another NHS austerity measure, rather than a progressive healthcare model that will promote better patient outcomes.
The current approach to virtual wards is at odds with many of its promises of safe, effective care. Last year, I worked with a team of researchers that observed the patient and staff experience of virtual ward pilots for ‘frailty’ patients in East England (Burraway 2022). These were patients aged 65 and over that were either recently discharged from hospital or were on the verge of admission. After weeks of shadowing and interviews with staff and patients, we concluded that wards were relying on the human resilience of local staff in the absence of more structural support needed to address changes brought on by virtual wards. As a result, we witnessed increased staff burnout, care pathways that were difficult for patients to understand, and the feeling that patients were not always receiving the more intimate care that they deserved (ibid). In addition to this experience, my time in Dr Carrie Ryan’s applied medical anthropology course has reinforced my appreciation for the social and cultural complexities of delivering technology-enabled care, particularly for ageing populations. I’m writing to ask you to re-consider the rollout of virtual wards for frailty patients. Frailty patients deserve a more stable, intimate approach to care compared to the acute, short-term nature of the virtual ward. By failing to invest in the supporting infrastructure needed to run virtual wards, your approach undermines many important aspects of care and ultimately puts frailty patients at risk. I hope that you take the following considerations to heart and will re-think how a more social, cultural approach is needed to deliver meaningful care for ageing populations across England.
New ways of ‘seeing’ and knowing
A key part of virtual care is technology-enablement. As defined by NHS guidance, technology-enabled care means “the management of patients via a digital platform” where “patients measure agreed vital signs and enter data into an app or website” (NHS England 2021). While technology-enabled allows patients to stay in the comfort of their homes, an ethnographic perspective reveals other consequences of this new dynamic between patients and carers. In Care at a Distance, Jeannette Pols (2012) found that the mediation of elderly care delivery — through remote monitoring systems – forced clinicians to adopt new ways of understanding patients and their symptoms. Pols (2012) points out that “the monitoring system changed what problems were relevant to watch out for,” and “reduced the chance of spotting relevant signs.” (51). As a result, clinicians began relying on discrete information from the monitoring systems instead of more holistic information from typical face-to-face settings. This shift — from assessing the body holistically to investigating the body through disaggregated indicators — marks a new way for clinicians to ‘see’ and know patients and their symptoms. Pols’ work provides a clear example of how such technological mediation ushered in new communication dynamics and norms for approaching care while preserving the integrity of it.
In the case of virtual wards for frailty patients, how does the virtual ward model account for these shifts in knowledge flows? In examining official guidance for the virtual wards, I came across little information about how clinicians are meant to prepare for these new ways of ‘seeing.’ The guidance only suggests that staff should receive “appropriate” training to their role and “a training plan should be developed at the start of the project to identify the training needs of the staff and the resources needed to deliver this” (NHS England 2021). Such vague language indicates that the virtual ward model has not accounted for the everyday changes brought on by the digital mediation of patient-carer relations. As such, I anticipate that virtual ward staff will have to acclimate to these new learning styles without adequate support, preparation, or guidance. While remote care does have its benefits, the implicit shift in ‘seeing’ and ‘knowing’ patients put both staff and patients in compromised positions. For staff, the burden of adjusting to these new knowledge flows is cumbersome under a short time frame; and for patients, the risk of having their health condition eclipsed by this new communication dynamic is worrisome.
The Labour of (virtual) care
Not only are clinicians expected to adjust to new ways of understanding patients and their bodies. They also become responsible for setting up and maintaining the technology that enables virtual care. Virtual wards claim that technology can “reduce the burden on frontline staff by making the right information available to the right people at the right time” (NHS England 2021). Yet as Xinyuan Wang (2023) describes in an ethnography on mHealth practices in mainland China, digital care technologies often come with “a hidden workload for care workers” (19). Tasks like troubleshooting issues, manually uploading data into various platforms, and helping patients use new technology become implicit within the delivery of virtual care. Accordingly, staff remain accountable for their existing care duties alongside more implicit tasks needed to maintain the functioning of mHealth systems.
This hidden workload is symptomatic of similar ‘silver bullet’ solutions, or top-down health interventions that governments frequently implement to quickly address a complex health issue. While such interventions – like vaccines, health campaigns, or in this case, digital health initiatives – may seem like an attractive and innovative solution, they often fail to consider the underlying social, cultural, and economic determinants of health that are often more complex to solve. By neglecting these fundamental considerations, silver bullet solutions often leave a trail of other secondary consequences behind. In the case of virtual wards, the invisible labour of (virtual) care for staff is immense and contingent on their participation to keep the wards up and running. This extra burden comes at a time when the NHS workforce is already incredibly stretched and overworked. As one GP put it, “doctors want to innovate and see the potential benefits that could come with virtual wards, but we can’t do that if the Government hasn’t got the basics right: bolstering the workforce” (Colivicchi 2023). Mediating healthcare through digital technology may appear innovative and efficient, as displayed in the promotion of the virtual wards. Yet the current approach will only exacerbate existing workforce pressure, not alleviate it.
Disrupted social relations
The final aspect of the virtual ward model worth highlighting is the increasing de-humanisation of care. As demonstrated in medical anthropology, healthcare is an increasingly institutionalised practice that is more attuned to discrete medical solutions and individual interventions than the social aspects that make up the health of a person (Sokolovsky 2020). Care for ‘ageing’ or ‘frail’ patients is no different, as demonstrated in the language of the virtual ward model: providing short-term care for an acute set of symptoms. By confining the scope of care to discrete aspects of the physical body, the virtual ward model undermines important social aspects of care for ageing people, such as social relationships, intimacy, and physical touch. This oversight of the value of physical, embodied care is reminiscent of James Wright’s study on Japanese care homes. Wright (2018) observed the adoption of robotic lifting devices called ‘the Hug’ that promised to alleviate the physical burden of care caused by constantly lifting patients. Yet users felt that ‘the Hug’ disrupted the connection between carer and patients, and ultimately the device failed to gain traction (ibid). Wright extends this failure to the integral role of physical touch in developing trust and compassion within carer-patient relationships. Touch not only symbolises the “‘co-suffering’ embodied” in physical transfer, but it also “establishes the value of care labour” that is deeply tied to physical touch (Wright 2018, 35).
By reducing care to a short-term and routinised pathway, virtual wards undermine the social, personal, and often physical aspects of healthcare, especially for ageing individuals. Instead of using technology as a silver bullet, virtual wards need to recognise that “technology is human, and humans are technology” (Wang 2023, 21). Technology cannot replace human care, but it should be used to make care more human. If the virtual ward frailty pathway is not willing to invest in the necessary workforce and human infrastructures alongside the technology, then it will inevitably fail.
Health starts with meeting people where they really are. Instead of investing in digital transformations and ambitious rollout plans, I urge you to listen to the experiences of everyday clinicians and older patients. NHS staff are the backbone of healthcare delivery. They cannot implement the virtual ward if they are not supported in doing it, and the ward cannot support ‘frailty’ patients if you do not integrate the intimate, social aspects of care into a technology-enabled agenda.
Sincerely,
Helen Robertson
References
“A guide to setting up technology-enabled virtual wards.” NHS England. 21 December 2021.
Burraway, Josh and Jennifer Yang-Meslet. “Are virtual wards truly “virtual”? The case for
resilience.” 1 July 2022. https://blogs.deloitte.co.uk/health/2022/07/are-virtual-wards-truly-virtual-the-case-for-resilience.html.
Colivicchi, Anna. “Plans for GPs to support 10,000 ‘virtual ward’ beds ‘will put patient safety
at risk.” Pulse Today. 14 February 2023.
Lamb, Sarah Jessica Robbins-Ruszkowski, and Anna I. Corwin. “Introduction: Successful
Aging as a Twenty-first-Century Obsession.” Successful Aging as a Contemporary Obsession: Global Perspectives. Rutgers University Press. 2017. https://www.jstor.
org/stable/j.ctt1q1cqw5.5.
Lupton, Deborah. “Quantifying the Body: Monitoring and Measuring Health in the Age
of mHealth Technologies.” Critical public health 23, 4, 393–403. 2013.
Pols, Jeannette. Care at a Distance: On the Closeness of Technology. Amsterdam University
Press, 2012. http://www.jstor.org/stable/j.ctt6wp5zw.
Sollof, Jordon. “NHS England Guidance Asks ICSs to Extend or Introduce Virtual Wards.”
Digital Health. 9 May 2022. https://www.digitalhealth.net/2022/05/nhs-england-ics-virtual-wards-guidance/.
Solovosky, Jay. The Cultural Context of Ageing: Worldwide Perspectives (4th Edition).
Praeger, 2022.
“Supporting Clinical Leadership in Virtual Wards – A Guide for Integrated Care System
Clinical Leaders.” NHS England. 8 February 2023. https://doi.org/https://
http://www.england.nhs.uk/long-read/supporting-clinical-leadership
-in-virtual-wards-a-guide-for-integrated-care-system-clinical-leaders/.
Wang, Xinyuan. “The smartphone and the ‘Human Plus’: an ethnographic review of mHealth
practices in mainland China.” Unpublished manuscript. 2023.
Wright, James. “Tactile Care, Mechanical Hugs: Japanese caregivers and robotic lifting
devices.” Asian Anthropology, 17:1, 24-39. 2018. DOI:
10.1080/1683478X.2017.1406576.