quarterly review data serve as positive feedback to the predictive risk modelling algorithm. Future plans Pilots were conducted most notably at Croydon, Dudley, Warwickshire and Wandsworth. There are some variations in the way the virtual ward operates – for example, Warwickshire use a nurse-led model, whereas Wandsworth employ salaried GPs to manage their patients. Dudley uses what has been termed a 'collaborative' model, whereby GPs and community nurses work much more closely together, sharing the clinical workload. This collaborative approach generated both a reduction in secondary care usage, and a reduction in the GPs workload. As reductions in healthcare funding affect budgets, there has been interest in virtual wards and risk stratification, with attention to the Dudley PCT virtual ward model, developed by Brian Bostock, Carl Beet and Derek Hunter. Unlike previous virtual ward models, the Dudley model incorporates a cross-service borough wide strategy that based on initial data appears effective in achieving positive health outcomes whilst providing cost effectiveness to health budgets. NHS (England) announced in April 2022 a national ambition to have at least 40 virtual beds per 100,000 population by December 2023. This would include partnerships with independent sector healthcare providers. Second generation Once a virtual ward has been established in an area, they are usually focussed on patients with long term conditions that require complex medical management. However, use of risk stratification often generates significant numbers of patients that require more specialised management. Whilst an assertive case manager may be able to impact on some of the health needs of these more specialised cases it has been recognised that focussing the appropriately skilled and trained staff in these areas, using a virtual ward model, can be effective. Typically, these specialised areas include mental health, alcohol/drug misuse and children. Although there has been some development on risk stratification tools for some of these patients (most notably the SPARRA-MD [Scottish Patients At Risk of Re-Admission – Mental Disease] tool), specialised stratification is not essential. Development of virtual ward teams with the specialised skills to deal with these specialised cases is one area of second generation virtual wards. Not surprisingly, frequent service users are also highlighted by risk stratification, and again, are often difficult to manage by virtual wards alone. Another area that virtual wards are developing is in this specialised patient group. COVID-19 and virtual wards The 2020 COVID-19 pandemic was an incentive for trusts to use virtual