Shifting boundaries of risk-work in virtual wards in North-West England: a multisite qualitative evaluation

Virtual wards (VWs) (also referred to as hospital at home (HaH)) are a key component of National Health Service (NHS) policy in England to shift acute care from hospital to community settings. While evidence suggests these models can improve patient experience and safety, delivering acute care at home redistributes responsibility for safety across clinicians, patients and carers. The concept of risk-work captures the relational and contextual practices through which clinicians, patients and their carers interpret and mitigate risks associated with clinical care. However, there is limited evidence as to how risk-work is enacted in remote care, particularly when patients and carers undertake elements of that work.

We conducted a multisite ethnographic evaluation across four NHS VW services in North-West England (July 2024-February 2025). Data included 17 patient and five carer interviews, four patient observations, 43 staff interviews and 10 organisational level observations. Reflexive thematic analysis was guided by risk-work and Systems Thinking For Everyday Work as sensitising frameworks.

Three inter-related dimensions of risk-work were identified. Translating risk describes how clinicians balanced protocolised guidance with tacit and relational knowledge when assessing eligibility, with decisions further shaped by workforce models. Holding risk illustrates the shared elements of risk-work, with temporal gaps in oversight, particularly out of hours and variation in workforce structures, shaping how risk-work was distributed between clinicians, patients and carers. Living with and managing uncertainty highlighted how clinicians, patients/carers navigated the unpredictability of acute illness at home. Governance structures, multidisciplinary teams and informal sense-checking provided collective safety-netting, although training and communication practices varied across sites.

To our knowledge, this is the first exploration of risk-work within the context of VWs. These findings extend the previous theoretical framing of risk-work, which has focused predominantly on clinicians and in-person care. Our study demonstrates how in the context of remote acute care, risk-work is redistributed and shared with patients and carers.