The current evidence base for virtual ward models of service delivery is limited and heterogeneous. Evidence on the added value of virtual ward platform technologies is inconclusive, and therefore their use should be accompanied by ongoing and systematic data collection.
When NHS boards implement virtual wards supported by virtual ward platform technologies, they should be offered as an optional alternative to either hospital admission or in support of earlier discharge. Virtual wards should be used only for patients who require ongoing monitoring and are clinically suitable for remote monitoring. Participation should be based on informed patient choice and consideration of patients’ circumstances, including the potential burden on carers. This should be supported by clear and comprehensive discussions between clinicians and patients about risks, benefits and available alternatives.
In delivering virtual ward services, NHS boards should assess the suitability of a patient’s home environment for this purpose, the availability of informal support, digital access and literacy, and any assistance required to use the technology. This is necessary to ensure the intervention is appropriate and that resources are used effectively.
Virtual ward platform technologies should not be expected to deliver benefit in isolation and should be implemented as an integral element of service delivery.
Remote monitoring devices used must be validated for use across diverse populations, including people with a range of skin tones. Clinical decision making should be informed by multiple measures rather than relying on a single data point.
The introduction of virtual wards should be supported by a structured evaluation framework to enable consistent and meaningful data collection. These data will be critical for assessing clinical and cost effectiveness and for informing future decisions on the scale and scope of national implementation.
NHSScotland is required to consider the Scottish Health Technologies Group (SHTG) recommendations.
1. The Council recognised the complexity of the topic and the associated evidence base. In particular, the substantial variation in virtual ward delivery models was recognised as limiting the interpretability of the evidence and complicating the formulation of clear, generalisable recommendations.
2. The Council heard expert input from two clinical topic experts from NHS England and a representative of the Roy Castle Lung Cancer Foundation.
3. A clinical expert described how remote monitoring can take many different forms depending on the clinical context, the condition being monitored and the technologies used. Monitoring may be continuous or intermittent. The expert highlighted that the term ‘virtual ward’ is not consistently understood and may be confusing for patients in terms of what the model involves in practice.
4. Clinical experts questioned the suitability of the NHSScotland virtual ward model for widespread application across patient groups. They noted that hospital admissions are rarely for monitoring alone and more commonly reflect multiple clinical needs. From this perspective, experts advised that remote monitoring may be better framed as one of several enabling approaches supporting a broader shift away from hospital‑centred care towards care delivered in community settings.
5. The Council noted expert advice on the importance of the type of technology used for remote monitoring, particularly the distinction between active and passive approaches. Active technologies require patients or their carers to take physiological measurements (such as blood pressure or oxygen saturation) and to enter or transmit the data themselves. This can place additional demands on patients and carers, relies on correct technique, and may increase the risk of missing or inaccurate data, especially for people with limited digital confidence, cognitive impairment or fluctuating health status. In contrast, passive technologies such as wearable electrocardiogram (ECG) or physiological monitoring patches, require minimal active input from patients. These technologies may therefore be more acceptable and accessible for some patients and carers, reduce the burden of self-management and lower the risk of errors in data collection or reporting.
6. The representative from the Roy Castle Lung Cancer Foundation highlighted the vulnerability and anxiety experienced by many patients following discharge after lung cancer surgery. Virtual ward monitoring was described as having the potential to provide reassurance, reduce feelings of isolation and support patients, many of whom will have co‑existing chronic conditions, through the remote monitoring of vital signs. Technologies enabling early identification of complications and timely intervention were valued by patients and carers and may help reduce avoidable readmissions.
7. The Council noted that informal carers often play an important role in supporting people who use virtual ward platform technologies. Carers may assist with monitoring signs and symptoms, as well as facilitating communication with healthcare teams. The Council recognised that this support may increase caregiver burden and requires appropriate consideration, training and support within service design.
8. The Council agreed that the value of virtual ward platform technologies is likely to depend on how effectively they are implemented and integrated into service delivery. The Council drew on insights from the evaluation of the NHS Borders respiratory virtual ward pilot, noting that technologies should not be expected to deliver benefits in isolation and must be:
a) aligned with service needs
b) embedded within clearly defined care pathways
c) supported by appropriate clinical oversight, sufficient workforce capacity and robust operational processes.
9. The Council acknowledged that the term ‘virtual ward’ is used inconsistently and has the potential to cause confusion, particularly for patients and the public. It was also recognised that virtual ward platform technologies are already in use in NHSScotland, including within hospital at home pathways, adding complexity to decision making in this area.
10. The Council discussed sustainability considerations and sought the views of the clinical experts. Experts advised that some remote monitoring devices can be reused following appropriate decontamination, depending on device type. They also noted that virtual ward models may contribute to reduced carbon dioxide emissions, primarily through reduced patient travel and fewer emissions associated with inpatient hospital stays.
11. The Council discussed the findings of the Citizen’s Panel survey and highlighted the value it added to this work. The demographics of respondents were considered, with the Council acknowledging that the use of an electronic survey may have led to an over‑representation of individuals who are already comfortable using digital technology. This limitation was recognised by the authors of the Citizen’s Panel report. The Council also noted the under‑representation of respondents aged under 45, and of those living in social or private rented accommodation, while recognising that survey responses were weighted by age and housing tenure to mitigate this imbalance.
12. The Council acknowledged the lack of robust economic evidence to inform its considerations. This was viewed in the context of the heterogeneity of service models and the difficulty of defining discrete models from which costs and cost effectiveness can be reliably estimated. The Council highlighted the importance of further evidence generation to support future decision making in this area.
Background
In NHSScotland, a virtual ward is a service delivery model in which patients are monitored at home with minimal face‑to‑face contact with healthcare professionals. It is used as either an alternative to hospital admission or to support earlier discharge. Virtual wards require dedicated and appropriately trained staff. Consultations with healthcare professionals are primarily conducted by telephone or online platforms. A range of virtual ward platform technologies is available to support this model of service delivery. These technologies typically consist of a patient‑facing app or website associated with medical devices for recording symptoms and physiological measures, with a digital interface linking to healthcare professionals.
2. In NHSScotland, ‘hospital at home’ and ‘virtual wards’ are distinct service delivery models. This is different to the wider literature and NHS England where the terms are used interchangeably. In NHSScotland, hospital at home is an established model delivering short‑term, acute‑level hospital care in a patient’s home or a home‑like environment. In contrast, virtual wards are generally less intensive service delivery models, focusing on remote monitoring with escalation of care when clinically required. This SHTG Recommendation is about the virtual ward platform technologies used to support virtual ward models of service delivery.
Clinical evidence
3. The current evidence base for virtual wards supported by virtual ward platform technologies is limited in both quantity and quality. Although the models described in the literature broadly align with the NHSScotland definition of a virtual ward, no two studies evaluated the same service delivery model. There was considerable variation across studies in virtual ward service design, components, and the type and intensity of monitoring provided. This heterogeneity makes it difficult to attribute outcomes to specific elements of the service model, particularly the contribution of the virtual ward platform technologies themselves. Interpretation of the evidence is further complicated by inconsistent terminology, most notably the interchangeable use of the terms ‘virtual ward’ and ‘hospital at home’.
4. Most of the studies focused on outcomes such as hospital admissions, readmissions, length of stay and mortality. Clear or consistent patient selection criteria are lacking. The studies primarily involved patients with respiratory or other acute conditions, limiting generalisability. While the limited evidence suggests that outcomes for patients managed in virtual wards appear comparable to those for patients managed in hospital wards, the specific added value of virtual ward platform technologies remains unclear. This reflects the fact that studies generally assessed whole models of service delivery, making it difficult to isolate the effects of the platforms from other components of care.
5. A comprehensive systematic review of 69 studies (describing 63 interventions) found low-certainty evidence indicating no difference in hospital readmission rates between patients receiving technology enabled care at home and those receiving inpatient hospital care.1 Similarly, limited mortality data suggested no difference in survival. The review stated that it remains unclear whether virtual ward platforms offer additional benefits compared with telephone or video conferencing within home-based care models.
6. The National Institute for Health and Care Excellence (NICE) guidance published in 2023 on virtual ward platform technologies for people with acute respiratory infections was based on 19 studies encompassing 6,129 people. Sixteen studies were case series and 17 were on people with COVID-19.
NICE concluded that there was no significant difference in outcomes (including length of stay, admissions, readmissions and escalation of care) between patients monitored on virtual wards compared with hospital wards. Mortality rates were low and there was no indication of safety concerns. NICE noted that the evidence base was limited by a lack of robust, comparative data from the United Kingdom (UK), and generalisability of the findings was constrained because of study heterogeneity and a predominant focus on people with COVID-19.
7. We identified six additional primary studies published since the NICE guidance and the systematic review (ranging in size from 46 participants to over 3,000). Five were observational studies and one was a mixed‑methods evaluation. The studies varied in size and quality and only two included a comparison group. Two studies included a clinically mixed patient population. The participants in the remaining studies were people with acute heart failure, atrial fibrillation, post‑surgical patients or people with COVID‑19. Reported outcomes included hospital readmissions, mortality, length of stay and escalation of care. Although the methodological limitations of these studies mean that firm conclusions cannot be drawn, their findings are broadly consistent with the secondary evidence, suggesting that outcomes for people monitored on virtual wards may be comparable to those for people monitored in hospital wards.
8. NHS Borders piloted a virtual ward for patients with respiratory disease from January to March 2024. The ward supported 50 people over a 10‑week period. Patients were monitored remotely using wearable devices and a clinical dashboard, with daily virtual reviews. Despite some implementation challenges (for example, a reliance of locum staff and limited operating hours), feedback from patients and staff was positive. An estimated 236 hospital bed days were avoided and 84% of patients reported feeling safe and well supported at home.
Economic evidence
9. The available economic evidence for virtual wards is limited and firm conclusions on cost effectiveness cannot currently be drawn. Available studies suggest that virtual wards could potentially enable more efficient use of resources, based on patients being discharged sooner from hospital and lower readmission rates, but further data are required to assess costs and benefits robustly.
Public perception, patient experience and equality issues
10. We used a survey to gather public perceptions of virtual wards in Scotland. The survey was sent to 963 people. Of the 377 respondents, most understood the concept of virtual wards (82%) and felt confident using technology with appropriate support (78%). The majority (65%) were comfortable with home based monitoring.
If given a choice, 44% of respondents said they would prefer virtual ward monitoring at home versus 25% who would prefer monitoring within hospital, with 31% unsure. Those preferring virtual wards valued being at home with clinical oversight. Those favouring hospital care emphasised safety and immediate access to staff. Respondents who were unsure indicated that their preference would depend on the condition and the reliability of support.
11. From the literature, virtual ward technologies are generally well accepted by patients, with perceived benefits including greater comfort, autonomy and a reduced risk of hospital associated complications. Virtual ward models of service delivery are not suitable for everyone and individual preferences, home environments and levels of support must be carefully considered. Qualitative evidence highlights the importance of clinician interaction, as well as the need for training and support for patients and their carers to address digital exclusion and reduce anxiety about using remote monitoring technologies.
12. Virtual ward models of service delivery may risk disproportionately excluding groups such as older adults, people experiencing homelessness, those with low income or disabilities, and individuals with either limited digital access or skills. Additional considerations include cultural or language barriers.
13. There are known limitations of certain monitoring devices, for example pulse oximeters may be less accurate in people with medium to dark skin tones. This underlines the importance of device validation across diverse populations and the use of multiple measures to inform clinical decisions.
Implementation considerations
14. A 2025 qualitative systematic review identified key factors influencing virtual ward implementation, including the need for skilled remote working staff, clear protocols, sufficient resources, strong leadership and supportive professional culture.11 The NICE early value assessment highlighted poor interoperability with electronic patient records as a key implementation barrier and similar challenges may be relevant within NHSScotland.
What were we asked to look at?
We have been asked to evaluate the clinical effectiveness, cost effectiveness, safety, and patient experience associated with the use of virtual ward platform technologies to manage patients who would traditionally require inpatient monitoring, either to support transition to the home setting or to avoid hospital admission
Why is this important?
Virtual ward platform technologies enable hospital-level monitoring at home, with the potential to improve patient comfort, reduce infection risk and support recovery. At a system level, they may help ease the demand on inpatient beds and could contribute to more efficient use of resources by offering a potentially flexible approach to service provision. As only limited, local trials of virtual wards have taken place within NHSScotland, a robust assessment of the evidence is important in informing future decisions about the role and value of virtual ward models of service delivery.
