Delivering virtual wards at scale in LMICs: What can we learn from a qualitative exploration of a national virtual ward programme in the UK (Preprint)

BACKGROUND As the potential of virtual wards to offer safe cost-effective care at distance is becoming more widely understood, their international utilisation is growing for a range of conditions, despite the lack of robust, policy level principles for their design and delivery. Policymakers, commissioners and service leads in high-income-countries have the benefit of learning from numerous if localised initiatives, for those in low-and middle-income countries there are few previous examples to draw upon. However, with growing evidence that the key challenges of providing effective and equitable digital health are shared by health systems across the globe, it is possible that important lessons for low-income countries can be learnt from the experiences of those delivering virtual ward programmes in high-income countries. OBJECTIVE To collate the experiences of policymakers, clinical innovators and service providers of delivering a national virtual ward programme in the UK and place these findings in the context of low-and-middle-income-countries specifically for the purpose of providing practicable learning for those in low-and-middle-income settings. METHODS A directed content analysis using qualitative data collected from interviews with staff involved in developing, leading and delivering a national virtual ward programme (n=58) was used to populate the domains of the Non-adoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability of technologies for health and social care (NASSS) framework. RESULTS The NASSS framework provided transferable learning for those wishing to deliver VWs at scale in Low-and-middle-income-countries across its seven domains: Condition, the importance of having a process for accommodating new clinical evidence into the existing referral and treatment criteria; Technology, the need for robust and consistent supply lines, and greater provider engagement in digital procurement; Value proposition the benefits of unified (central) messaging on need and benefit to facilitate patient understanding and organisational buy-in; Adopters the need to understand the digital capabilities of patients and their carers, and the impact of remote working, especially on co-opted, inexperienced or untrained staff; Organisation, the value of prior experience of delivering similar services and existing collaborative inter-organisational partnerships; Wider system, the importance of national policies being structured to accommodate regional priorities and of leadership cultures that share best practice; Finally in Embedding over time the need to integrate systematic evaluation to inform iterative improvement incorporating, if not driven by, patient experience. CONCLUSIONS If virtual wards in low-and-middle-income-countries are to be successfully deployed at scale they need to overcome several challenges relating to the interaction of infrastructure, technology, patients, providers, and organisations as exemplified by the experience of implementing the national virtual ward programme in the United Kingdom. Building on our findings we have developed a series of questions to inform current and future policy design for national virtual ward programmes in low-and-middle-income-countries.