The Growing
Value of XR in Healthcare in the United Kingdom

Some XR devices contain highly sophisticated sensors that can record physiological data on a user. This can be sent either to a clinician for monitoring or directly back to the user in real-time to provide information about difficult-to-observe  functions such as breath or brain activity, with the aim of improving the user’s conscious control of these functions (biofeedback). 

These enhanced biometric sensing and communication devices enable the gathering of valuable information that can be used to help consult on, diagnose and treat a range of psychological and physical conditions. These technologies can also help validate certain approaches and enable more personalised and precise treatments for patients. 

Some headsets have integrated sensors that can not only detect traditional biometric data, including heart rate and heart rate variability, but also a user’s respiration, expression and emotion in response to live VR experiences. This data can then be output to a backend report and analysed. A range of external options are compatible with headsets, including heart rate monitors, eye-tracking add-ons, breath belts and galvanic skin response devices.  Increasingly, eye-tracking sensors are being built in to monitor eye movement and position to enable greater understanding of presence, attention and focus.

Immersive experiences can be developed on several platforms. The most popular are Unity and Unreal, which account for the vast majority of XR applications. Some startups are also offering their own platforms, which simplify the creation and distribution of XR experiences. 

WebXR technology is making access to XR experiences even easier for users. Instead of creating an application that needs to be downloaded from a store and installed locally on a user’s device, it can simply be loaded from a web browser on the user’s mobile phone or headset. This distribution model is becoming increasingly popular as it makes XR experiences quicker and simpler to access. However, it can pose a challenge where the internet is not available, not reliable, or restricted as may be the case with some hospitals. Mozilla Hubs allows users in VR or on desktop computers to access a shared virtual world together and is a good example of WebXR technology in action.

The global immersive technology market is accelerating out of the Covid-19 pandemic and reaching the tipping point of wide scale penetration in both the enterprise sectors and the public domain. Worldwide spending on AR/VR is forecast to accelerate, growing from just over $12 billion in 2020 to $72.8 billion in 2024 (IDC Nov 2020)

The pandemic has created a shift in mindset and a rapid acceptance of AR and VR in various sectors as businesses turn to a remote working business model. A greater focus on ROI and productivity and efficiency gains continues to ramp up interest in enterprise AR and VR, supported by the 2020 XR Association Study which shows that 80% of respondents in manufacturing, 75% in healthcare, 74% in education, and 70% in public safety predicted that their organisations will increase spending on XR technology over the next five years. An interview with PwC’s Jeremy Dalton on XR In Industry analysis in 2021 discovered that across the UK there are over 97 organisations using XR technologies for healthcare, and at least 119 distinct projects underway.

Initial applications mainly focused on how VR could be used within exposure therapy. This type of therapy directs people to the source of their anxiety and so has applications in the treatment of Post-Traumatic Stress Disorder (PTSD), phobias and social anxiety disorder. VR offers a way for therapists to fully control the environment and the extent of how challenging the exposure is. For example, while a fear of spiders could be treated by presenting a small spider and gradually exposing the individual to bigger and bigger spiders, there is a limit to how large spiders can get. Within VR the spider can grow to the size of a house or could start off as a cartoon and become more realistic. For PTSD where the anxiety is linked to a specific highly stressful situation, it can be hard to replicate an authentic experience in the real world but a VRsimulated event can be recreated and explored from different perspectives. Researchers have found that people who do something stressful have a very similar response when doing it in VR, both bodily and mentally – in other words, it feels real (Martens et al. 2019). Being exposed to something you are scared of or a real situation that makes you anxious can be a very intimidating experience for people and many refuse to be treated in this way. Interestingly, people are more likely to choose to be exposed in VR rather than in real life (García-Palacios, Hoffman, Kwong See, Tsai, & Botella. 2004) even if it elicits the same levels of fear. There are many potential reasons for this – it may help an individual to overcome initial reluctance by offering something they see as less distressing and where there is no actual threat. It may seem real but they know that it isn’t; a form of suspension of disbelief.

In more recent years the use of VR within psychological therapies has evolved and it is being applied to both the diagnosis (Ferrer-García & Gutiérrez-Maldonado, 2012; Sorkin, Weinshall, Modai, & Peled, 2006) and treatment of specific conditions such as psychosis, depression and anorexia nervosa. VR has often been used as a tool within a package of care with a therapist who controls the environment and works with the individual to address the problems they have faced. Some recent examples of treatments include the therapist as a virtual embodiment (Craig et al., 2018) or the individual embodying, at different times, an adult and child version of themselves (Falconer et al. 2016). In the former, a novel treatment was developed for individuals who experience persecutory auditory hallucinations but do not respond to antipsychotic medication. The individual, with the support of the therapist, develops an avatar to represent the entity that they hear, with both the face and voice being fully customisable. The therapist then takes this form on a computer screen, enabling a dialogue that can be used to help individuals overcome their fear of the entity and challenge its rhetoric. Researchers have reported that for some the hallucinations completely disappear (Leff, Williams, Huckvale, Arbuthnot, & Leff, 2014). For the treatment where an individual embodies an adult and child, the aim is to promote self-compassion in the treatment of depression. By first delivering compassionate sentences to a virtual child and then embodying the child and hearing these delivered, the individual’s self-compassion increases and self-criticism decreases, leading to a reduction in clinical depression scores. Still in its early days but with several small clinical trials demonstrating feasibility and efficacy, the provision of automated therapy within the virtual environment itself using virtual coaches or agents is being explored (Freeman et al., 2019). This promises not only to increase access, since the professionals delivering it does not need the same level of clinical training, but it may also lead to XR therapies that can be self-delivered from home. While psychological therapies will always require clinicians with appropriate training, there is the potential that XR could offer an entry point, a way of preparing the individual and supporting them towards recovery. It also could offer more targeted or specialised psychological therapies that are unavailable in some areas.

Clinicians and researchers in the UK are developing not just products but entire treatment packages that tap into the many novel capabilities of XR. While these are mainly being delivered within research environs, such as the Virtual Reality Lab at KC and O-CAP in Oxford, there are also several NHS Trusts adopting innovative XR treatments. OVR and ProReal have both worked with Oxford Health to develop Global Digital Exemplar (GDE) blueprints, which provide an implementation toolkit that other trusts can follow. This suggests that while other areas may yet be slow to embrace XR, there is a real drive within the NHS to begin using XR technologies in mental healthcare. 

 Increasing people’s engagement with XR mental health treatments can help overcome the considerable number of barriers that prevent people getting the treatment they need such as accessing the right treatment at the right time, when there may be stigma around or resistance to using mental health services. XR approaches can be used as a tool to target and reduce waiting lists.
Given the increased demand for mental health provision and support as a result of the COVID-19 pandemic, increasing support for the creation and delivery of XR mental health solutions like offering remote treatment where patients exhibit a preference to be engaged at home, has the potential to address some of the major challenges facing the UKs mental health sector today. 

VR has also demonstrated the enhanced therapeutic potential of mindfulness and meditation. Through creating relaxing environments that people can escape to, from soothing beaches to forests at sunset, with a range of gentle relaxation activities available. VR relaxation experiences have become an increasingly popular application for at home users, and increasingly in workplace, care home and healthcare settings(Sonney, J. et al, 2021). There is also arguably a use for technology in waiting rooms or hospitals and to help anxious patients prior to surgery or other stressful situations. This can drastically improve patient cooperation, and offer immediate support in helping people self soothe during challenging moments.

The use of VR has been used across care homes to reduce apathy and associated issues such as dementia. Loneliness and lack of intellectual stimuli can lead to a faster rate of cognitive decline, reduced quality of life, and high caregiver burden. In 2020, Saredakis, D. et al developed a study using VR as a tool for reminisce therapy with groups and used it to enable people to return to places of significance, alongside 360 content available on YouTube. Providing relaxing and entertaining experiences that can engage people who are frail and unable to travel far can bring extremely positive benefits. Additionally, the opportunity to bring VR to palliative care settings has been found to have extremely positive results. 

Dr. Sheila Popert, Medical Director at Prospect House Hospice, has been utilising VR over the last five years. She initially developed an experience titled Forest of Serenity, voiced by Sir David Attenbrough, as a tool for pain management. Through her implementation, she found the experience was effective in reducing anxiety, and has broadened the scope of their research and deployment to support people’s emotional wellbeing both in the hospice and at home.

“We use VR for opening up people’s worlds,” she explains. “When patients are stuck alone in a room, their world shrinks.”.
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Not only can VR improve the wellbeing of those in palliative care settings, but can directly reduce people’s fear of death. In a series of studies by VR researcher Mel Slater, specifically developed experiences were found to reduce people’s fear of death, and lead participants to become more beneficent, self accepting and concerned for the wellbeing of others. They reported a higher sense of life purpose, self reflection and a stronger belief in social justice (Bourdin et, 2017).

It is common for us [end of life doulas] to hear people who are at the end of their life say “I would love to see that place one more time”, or “I wish I could have seen...”.
If VR can provide an opportunity for people to virtually visit these places, I can see there being high demand.Emma Clare, Director of End of Life Doula UK
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A number of universities and research centres have taken interest in this field. Organisations such as StoryFutures Academy, based at Royal Holloway University, have developed a number of programmes to support new immersive projects to help health and wellbeing. They supported the Nesta X StoryFutures Immersive Wellbeing Fellowships in 2020, with projects including interventions to improve self-compassion for women of colour in workplace environments and tools for anxiety regulation to be used within school contexts. 
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These initiatives have been followed by additional programmes, which are under development and preparing for release in 2021. These include Positive Realities: XR for Youth Wellbeing, developed in collaboration with Coventry UK City of Culture, and a programme with the Roald Dahl Foundation supporting the development of augmented and mixed reality R&D prototypes exploring how immersive storytelling can improve ‘transition of care.’

Immersive technologies as a tool to improve wellbeing to benefit the wider population has had success in a range of contexts, from festivals and public spaces, to alleviating stress in the workplace, at schools and in the home. The covid pandemic saw a huge paradigm shift of health seeking behaviour. Digital services providers reported a recurring observation that demand for digital mental health support has risen, and that the nature of this demand has also changed since COVID-19, with an apparent increased presentation of anxiety and loneliness. Conversely, at the same time, referral rates to NHS primary care mental health services dropped (Inkster et al. 2021). Individuals chose quick and easy access to self care wellbeing support. XR wellbeing has an open door to occupy this space. 

The UK's immersive tech sector is based on the foundations of a thriving games, digital, creative and entertainment industry, with more and more businesses entering the virtual, augmented and mixed reality market. Since the pandemic, the games industry has witnessed a 30% increase in valuation. This is creating more opportunities for both industries to collaborate on new powerful experiences with real-world impact that can open up new markets and deliver world leading XR mental health solutions.
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The growing need to support increasing mental health demands creates new opportunities to harness the potential of technology as part of a broader holistic approach to improving health and wellbeing. Immersive technologies have the potential to play a significant role in preventative care by teaching self compassion and valuable skills in emotional regulation alongside fitness and exercise based activities that can delay or prevent the onset of a range of physical and mental health conditions.

Brennan Spiegel lays out the beneficial effects of VR for pain management in his book VRx (2020), Spiegel posits

‍“VR lowers the perception of pain in at least three different ways. First, it distracts the brain from noxious signals rising up from the body. Second, it creates an illusion of time acceleration, effectively shortening the length of pain episodes. And third, it nips signals in the bud at their origin, blocking pain from reaching the brain. The combination of these effects supports the ability of immersion to fight pain.”

VR has been used to manage pain and distress associated with a wide variety of known painful medical procedures and conditions. It has been used in acute pain such as childbirth, episiotomy repair, burn dressing management, cancer pain, colonoscopy, and a range of other routine medical procedures. It has also been applied in chronic pain for conditions including fibromyalgia, neck pain, back pain or chronic regional pain syndrome, although to date only a few studies have investigated VR for chronic pain management and the data is preliminary. 

In clinical settings and a number of UK and international trials (Li A, Montaño Z, Chen VJ, Gold JI. 2011), participants immersed in VR experiences demonstrated reduced levels of pain, general distress/unpleasantness and reported a desire to use VR to help manage the pain. A growing body of evidence points to VR acting as a non pharmacologic form of analgesia that exerts an array of emotional affective, emotion-based cognitive and attentional processes on the body’s intricate pain modulation system. Potential benefits include a reduction in opiate addiction, illness or reduction in deaths; decreased medical bills and subsidies to pharmaceutical companies and perhaps the most compelling reasons to use VR for patients are:, no side effects from medication, a less painful experience of surgery and ability to manage their own pain symptoms. 

Often, minor surgeries requiring local anesthetic can be anxiety inducing, and can lead to delayed procedures, or even rescheduling surgery. Possible future applications of VR in pain management and distraction include VR for dental procedures, and vaccination anxiety, and other minor surgeries requiring a local anaesthetic. In 2019, Torbay and South Devon NHS Foundation Trust used VR as a distraction tool for patients experiencing anxiety during toenail removal. Podiatrists noted a drop in patient anxiety and pain experienced during the toe-nail removal procedure (Ghatnekar, P 2021).

Whether it is for the management of burns, long term conditions, podiatry or a range of other pain issues, VR presents a compelling, non pharmacological, scalable digital intervention that can reach more patients and improve quality and consistency.
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Early intervention in general, and early treatment by physiotherapists in particular, for common musculoskeletal problems can reduce the amount of time people are off sick and can prevent acute problems becoming chronic(Neilson, A.R et al, (2019) The pain and discomfort of current therapeutic exercises can reduce compliance and, therefore, the range of motion patients achieve. This increases the risk of chronic pain and can reduce patients' confidence in the care team. Tackling rehabilitation pain and treatment adherence is important to succeed in long-term outcomes for this population ( Threapleton, et al, 2016).

Repeated sessions could potentially enhance the prospect of good and/or complete recovery with the optimal restoration of function, and by using the VR in clinic and at home, patients could achieve this. Benefits include speedier recovery and earlier return to work/school. Clinicians would benefit from patients needing fewer clinic appointments through patients’ improved adherence to their rehabilitation protocols, with the attendant savings to the NHS.

The first publications in adult rehabilitation focused on people post-stroke (Piron. et al, 2001) and in pediatrics, primarily focused on children with cerebral palsy (Sandlund et al, 2009). The works of Deutsch et al.(2008); Laver et al.(2017); Lohse et al (2014) and Saposnik et al.(2011) demonstrated VR’s promising results using upper limb rehabilitation in adults. The works of Jannink et al. (2008); Sharan et al. (2012) and Sun(2012) reported the positive effect of using non-immersive VR game training on physical motor rehabilitation in children. However, a review looking at VR for stroke rehabilitation in adults suggests that immersive VR using head-mounted displays (HMD) is more effective for upper limb motor recovery compared to non-immersive VR (Henderson. et al, 2007). This is supported by the fact that the level of immersion (presence) in the environment contributes to enhance learning efficacy and support the following transfer of knowledge and skills. That plays an essential role in providing an optimal condition for task practice, as does the meaningfulness of the task to the participant. 
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Currently, research has mainly focused on the application of VR as a motivational enhancer that increases the level of participation and reduces the pain experienced during exercise performance due to its immersive power. In this sense many commercial games, such as exergames, have been used to enhance children's enjoyment and engagement. Increasingly, research is being conducted that could further help physiotherapist and occupational therapies to better deliver their interventions by developing immersive and interactive VR scenarios.

Possible future applications of VR in rehabilitation include its use for home therapy. Home rehabilitation allows patients to reduce therapy time, but many patients report difficulty in following rehabilitation at home due to a lack of motivation to exercise on their own (Jolly et al, 2007). VR systems available for use at home could help solve this problem, improving patient participation and enjoyment. This in addition to having other benefits, such as cost savings, reducing patient transportation to appointments, reducing home visits or providing patients with self-care/self-management, which could be beneficial for the long-term management of their conditions (Threapleton, et al, 2016). In addition, home rehabilitation in emergency COVID-19 situations presents itself as more relevant than ever to help reduce care pressure (Salawu, et al, 2020).

There is huge potential for XR training in health and care. The exploration of XR technologies in healthcare education and training is being driven by a number of factors. The time afforded to training within clinical settings is stagnant or decreasing, partly due to the acknowledgement that excessive working hours increase the risk of making clinical errors and compromises patient safety. This has had the untoward effect of reducing clinical exposure which has been the backbone of training to date. There is also a national mismatch between the supply of healthcare professionals and the demand for their services, which produces greater pressure on limited training time. In addition, the2018 Kings Fund report The healthcare workforce in England: make or break? highlights that 30-50% of the frontline workforce is due to retire by 2030. 

Education and training also places a significant financial burden on the healthcare system and more cost-effective, remote and accessible solutions are constantly being sought.However, current approval and governance processes are not dynamic enough to allow for the acceleration of deployment of XR training and education solutions to meet the latent demand. This is slowing down the ability to develop the broad range of XR solutions required to meet future health and care training requirements.

XR enhances and extends existing pedagogical approaches to traditional health and care training. Many health careers are vocational and as such XR offers ways to practice and train before a clinician sees a patient. While the tools should support and supplement existing learning curriculums using active and collaborative simulation techniques, there are clear advantages that are afforded by their use. 

Many XR technologies remove the temporal and geographical barriers to training. This enables healthcare professionals to learn in their own time, at their own pace and unconstrained by physical locations such as the hospital. In addition, they facilitate the dissemination of knowledge and skills from centres of excellence ensuring democratisation and accessibility in training across the NHS. These technologies also provide a unique opportunity for replication of dangerous, difficult and inconvenient locations. This has the potential to improve accessibility, reduce inequalities in training and improve patient safety. 

This report recognises the significant potential of this training method, particularly during COVID-19, where alternative means of education and training have been sought. It is apparent from the use cases discussed and the developing evidence base, that XR technologies will have a huge impact on healthcare education and training over the next decade, particularly in the delivery of clinical skills training outside of hospital environments, more cost effectively with more impact and less risk. XR provides an opportunity to support the training recovery of the health and care workforce, particularly as there has been so much disruption to training due to the pandemic.

The future design, implementation and evaluation of XR technologies will require a collaborative approach with stakeholders from a range of industries. The approach will require a combination of contemporary evidence-based practice, real world use cases and dissemination of best practice. Five main elements should be factored into the design and implementation of XR technologies in healthcare education and training: learning needs, technological capabilities, wider needs assessment, simulation and evaluation.

There is high demand from governments and healthcare organisations worldwide for new ways to deliver high quality education and training in healthcare for growing and ageing populations (Healthcare UK Annual Review 2019-20), providing significant market opportunities. Due to the UK’s strong global reputation in healthcare education and training, the country is well positioned to offer XR multidisciplinary clinical education and training, healthcare leadership and management training, and bespoke education and training to an international market. 

Understanding patient perspectives and narratives are critical in medical education and training. Experiencing the lived conditions, feelings and emotions of a person can help healthcare workers empathise with patients. Empathy is the ability to connect and appreciate with the patients’ experience and communicate using this understanding. Within the context of healthcare, empathy is a skill that can help affect the quality of the relationship between the patient and healthcare professional. This in turn can translate into a better conversation, supporting an essential “what’s important to you?” approach to care. As an intervention in this context, a change of perspective - or “seeing through the patients’ eyes'' - provides a valuable moment of reflection and consideration for the health and social care workforce. Such an opportunity to “experience” a different perspective can help empower effective and meaningful care by enhancing the relationship and engagement between parties. A shared appreciation of a condition or lived narrative can help engagement with a treatment or care plan, having positive implications on patient outcomes. 

Empathy training and, in the wider context, a continuation of humanities focused teaching, is a vital ingredient in healthcare education and training. However, due to burn out, lack of consistent training, and system pressures, combined with the challenges of teaching humanities focused curriculum as a consistent key skill, leads to a reduction in protected time where practitioners can reflect on their experience and empathise with patients.

The introduction in 2015 of patient perspective 360-degree video scenario content, created at Torbay and South Devon NHS Foundation Trust, has provided unique insights and reflective learning for trainees to access as part of their educational simulation training. This has complemented the teaching as an additional interactive experience, delivered in both VR and as a desktop experience. 

Image: Courtesy of Torbay Hospital, Torbay and South Devon NHS Foundation Trust

The role of virtual, mixed and immersive reality has long held promise for autistic groups to support communication needs, social skills development, educational outcomes, practicing skills (like crossing a road safely) and vocational outcomes such as job coaching (Smith et al. 2014). VR can help to simulate real-world situations and contexts in safe and predictable ways (Bradley and Newbutt, 2018), and has the ability to control, shape, and tailor VR interventions to participant needs and local contexts. The role of immersive technologies has therefore been considered with autistic groups and research demonstrates that VR head-mounted displays (HMDs) are viewed as comfortable, acceptable and usable by this group (Newbutt et al. 2020). It has been used across a range of environments and scenarios including social development, transitions to employment, travel training and general educational materials. 

Further research by Newbutt and colleagues in 2020 discovered that through the co-creation of educational experiences in classrooms for autistic children, VR helped them to relax, remain calm and opened opportunities for previewing a real-world experience in VR. Additional research by Brossonboek et al (2019) discovered that Deep, a breath controlled VR experience, helped reduce disruptive classroom behaviour. This finding, alongside data suggesting that high-end head mounted devices were preferred by this population, is starting to shed light on the potential that VR could have for neurodiverse young people; mainly reducing anxiety, promoting calm and visiting places virtually before a physical visit. 

Gold et al. (2021), have explored the role of VR to support autistic patients for preoperative anxiety in addition to improved patient, caregiver, and healthcare satisfaction of a preoperative experience. Results here suggest that patients reported decreased anxiety along with feeling less scared of visiting a hospital for preoperative care. These results provide a compelling argument for the continued examination of VR applied to autistic people; be they young children at school or people accessing healthcare or cultural experiences.

VR experiences can encourage communication between patients and health workers and provide answers for questions that may be stressful for the patient. For example, human anatomy or health conditions can be presented as visuals in immersive environments. Patients may be able to better understand their condition, how the clinical procedures will be performed and visualise the role played by the procedure in solving their problems. The use of VR as a visual aid for improving patients’ understanding of procedures is now growing. House et al. (2020) have used XR to educate patients on pre-operative education before epilepsy surgery (stereotactic electrode implantation). Migoya-Borja et al. (2020) have used VR to help educate patients on pre-operative education and depressive symptoms, respectively.

Anxiety can have significant implications in the lead up to and during clinical procedures. This can extend the time taken to complete the procedure, may require attention from multiple healthcare staff/general anaesthetics or the procedure may even need to be cancelled to be repeated at a later date. This can have a domino effect on other patients’ schedules and incur a cost to the healthcare system. In this context, work utilising XR technologies (i.e. Koo et al. 2020) includes an interactive 360-degree video that has been explored and deployed in various healthcare pathways to reduce anxiety and better educate the patients on what to expect. One accessible example of this is a journey app that incorporates 360-degree video and instructional design (explainer graphics) to assist children and their parents ease the fear of attending an MRI scan (Ashmore, et al, 2019). In addition Yang et al. (2019) have used VR for pre-operative anxiety management in patients undergoing arthroscopy to positive effect.

Empathy and compassion focused education should be at the core of non-technical skills education for healthcare workers and students. VR can deliver powerful experiences that are filmed or created from a first person perspective, offering users an opportunity to stand in someone else’s shoes. This has clear applications to support healthcare workers in developing empathy with patients or colleagues. Participants should then be given an opportunity to reflect upon and discuss the experiences, and come up with solutions for improving the experience. At Torbay and South Devon NHS Foundation Trust, empathy education is a critical component of soft-skills education for health workers. As part of simulation education, medical students from year three onwards participate in humanities workshops. The students are shown first-person perspective films from the patient's point of view, using VR HMDs. Examples include the patient’s journey through to ICU and the different communication styles experienced by the patient along the way, from paramedics, nurses and doctors. A more recent experience allows participants to see a simulated patient perspective during COVID-19, observing the effect PPE has on communication and the patient journey.

In recent years there has been a change in the familiarity and prevalence of VR technology in the UK population. This change includes much wider consumer purchase of Head-Mounted Displays (HMDs) and haptic controllers for video games, and use of AR through smartphone games such as Pokémon Go. HMDs as personal technologies have improved in comfort and many now have embedded computing power so that a separate PC is no longer required. There are also variants of HMDs that use a smartphone as the screen, although the recent introduction of cheaper untethered all-in-one HMDs are already replacing the former in many applications.

Compared to 25 years ago when more comfortable VR equipment was first becoming available, although still mainly used in research, a liquid crystal HMD with electromagnetic tracking system for the head and hands and a suitable PC would have cost more than £10,000 in total, which at today’s prices with an annual uplift of 3% would be £20,000. In comparison, a PC based VR system in the 2020s is 10 times less. The newer consumer level all-in-one untethered HMDs with two controllers are even cheaper with Oculus Quest, for example, retailing to consumers at around £300, while smartphone-ready headsets are cheaper still at £30-£50. If we consider a lifetime of two years and 262 working days in a year, plus the addition of a small amount per use for a disposable liner or cleaning materials, the cost per day of a PC based system is now only around £5 per day over its lifetime based on hardware alone. Similarly, replacement costs of devices or batteries for portable equipment are much lower in the 2020s.

Per-person cost is further reduced if devices are used more than once a day with different patients. Higher utilisation is more practical than ever due to improved weight and portability of equipment that can be carried by professionals into different healthcare settings, including the home, hospices, care homes and training venues. It is clear that the price of purchasing or leasing the equipment to deploy VR is now a relatively low proportion of overall cost in comparison to staff costs. This all means that capital outlay and consumables are likely to be judged affordable to start using VR more readily in more settings. 

At the time of writing, typical offerings on the market for HMD based-VR health are in the range of £400-£4000. At the low end, this consists of HMD, software and internet capability with minimal support, and at the high end includes a fully supported and maintained system in a protective case with more choice of virtual environments, backend outcomes data acquisition and storage, and enhancements such as an accompanying tablet for third party viewing, and 360 camera.

One of the biggest drivers within the NHS is to provide value for money – as a free health service the funding provided through tax is reinvested to best benefit the healthcare needs of the UK population. Identifying the most cost-effective return on investment can be complex but here we present four case studies that demonstrate savings across various services and in several ways. Although two of the four presented are not UK-specific, they emphasise the potential that XR offers in supporting healthcare services to deliver highly effective outcomes in a more cost-effective way. 

A published economic model that looked at VR as an alternative to opioids in US hospital settings demonstrated savings of over USD5 per patient, due to a reduction in length of stay, which when scaled to 15,000 admissions per year with one in seven patients using it, would cover the cost of 30 software licenses at USD3500 and USD47,030 to employ a VR specialist (Delshad, 2018). Considering the health benefits of reduction in opioid use, this digital solution to pain management offers far more than just cost savings.

Another published economic evaluation, from Spain, investigated the benefits of delivering VR interventions for balance recovery after stroke remotely to the home, rather than in the clinic. It found that it reduced not only transport costs but also the contact hours of physiotherapists. This resulted in a 56% saving compared to usual care (Lloréns, 2015). This is a good example of the potential for increasing the home use of XR in healthcare.

At the heart of the UK health and social care economy is a commitment to deliver health outcomes that can improve the population’s quality of life. In the following case studies, several examples are explored where XR has shown promise in providing affordable improvements to existing services. 

The cost of avoidable errors within the NHS has been estimated at £2.5 billion and within the UK one in ten new medical graduates feel poorly prepared. XR has the potential to offer innovative ways of supplementing clinical skills training and research has demonstrated that it can work as well as, or potentially even better than, existing training. A recent meta-analysis of its use in training for laparoscopic surgery showed improvements in practice and quality including reduced error rates (Portelli et al. 2020). Twenty-four separate randomised controlled trials across different VR systems showed that VR led to faster operative times, better handling and OSATS scores (scores across seven parameters of skill) compared to apprenticeship training. One recent study suggested that improvement in overall surgical performance may potentially be as high as 230% versus traditional training methods (Blumstein et al., 2020). 

Over the next few years it is clear that it will be necessary to implement more efficient healthcare services as we face not only the cost of an aging population but the repercussions of a global pandemic. The impact on workforce, elective care and training has been discussed previously and here we outline several use cases that demonstrate measurable potential in scaling up the delivery of existing care and education to ensure that the NHS can meet demand. 

30 participants assessed use of VR versus paper floor plans of the hospital to prepare nurses for wayfinding in a new hospital building. Cost analysis showed that a VR approach was more expensive to develop but during implementation it reduced staff time needed for practicing wayfinding skills. The paper approach development cost was USD40,000 and implementation was USD530,000, while the virtual world development cost was USD220,000 and implementation was USD201,000,(Halfer, 2014).

The pandemic has increased the number of people seeking information on careers in healthcare two-fold. This increase in interest may help us to meet the unprecedented demand within the NHS but, despite significant investment in upskilling and from HEE to ensure that training is available, there are logistical issues that may remain post-Covid. For instance, opportunities for learning, such as ward rounds, may become more restricted due to social distancing needs. Technology is unlikely to completely replace more traditional methods but can perhaps help HEE meet their commitment to increase the workforce in key areas, such as mental health, significantly. 

During the pandemic it was important for staff and patients to be protected. Imperial College Healthcare NHS Trust worked in partnership with Imperial College London and Microsoft to introduce HoloLens onto wards treating COVID-19 patients. Healthcare teams could see what the doctor was seeing over a secure live video feed without having to be on the ward with him. This led to staff spending up to 83% less time in high risk areas and reduced the need for PPE, potentially by 700 items a week. The cost of PPE is around £1 for surgical gloves and up to £3.50 for an FFP2/3 mask (Walters, 2020) which suggests savings of up to £2450. The HoloLens has now been scaled up for use in teaching and training, with doctors leading virtual ward rounds and surgical teaching so that students still have access to the clinical experiences and exposure that are needed. Professor Amir Sam, Head of the School of Medicine at Imperial College London, also highlights the parity of access that this can provide students:

“Teaching with the HoloLens allows us to guarantee a level of exposure for our students to a far greater range of patients and medical conditions than ever before.”

Fear of Heights is a VR treatment where Nic, the virtual coach, guides people through the different levels of a shopping mall to help them overcome their fear through exposure therapy. Many people in the UK with a fear of heights do not engage with treatment as it is intense and difficult. A randomised controlled trial found that not only did Fear of Heights reduce fear but also increased engagement (Freeman et al., 2018). By providing a VR solution it enabled people to undertake intensive treatment in a shorter time and with less input from a therapist, thereby increasing access. 

Although initial development costs were high when the intervention is deployed there are significantly lower costs than standard treatment as it does not require a therapist and can be delivered through inexpensive consumer VR equipment. Outcomes may also be significantly more improved with fewer dropouts and effect sizes higher than those found in a meta-analysis of therapist-assisted exposure therapy using real heights (Wolitzky-Taylor et al., 2008). Participants also reported significant changes in their approach to heights, with one reporting:
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“I’ve just finished my sessions, I did four in total. Last week, after my third session, I went up to the Westgate [a shopping centre]; the difference in my mental capacity to deal with heights was amazing. Previously I wouldn’t go anywhere near the edges, I was almost hanging right off, looking vertically down. The sessions I’ve had here have given me a lot to think about, and certainly with regards to my fear of heights it feels like it’s helped a lot. So, very worthwhile doing.” (p.631)

Leading from the adoption of Fear of Heights within talking therapy (IAPT) services, Oxford Health NHS Foundation Trust has produced a Global Digital Exemplar blueprint to help other trusts to deliver Fear of Heights more quickly and cost effectively by providing a structured collection of resources and information to support implementation e.g. standard operating procedures, proformas, key decision areas, etc. 

Credit: Courtesy of Health Education England Technology Enhanced Learning

Despite a proven track record in delivering outcomes and many use cases to demonstrate its applicability and acceptability, XR products are not yet commonplace within healthcare settings. Many of the barriers that were seen in the early days of VR, such as cost, have been overcome but many also remain. Currently the pilots of XR in the NHS are fragmented. 

In a survey of VR and AR companies the top challenge identified was monetary and funding issues. This was followed in second place by technical limitations (e.g. lack of immersion offered by mobile VR), clinical organisational issues (e.g. interoperability), lack of understanding of VR and AR as medical technologies and finally a lack of research studies. This report has demonstrated that there is a clear trajectory in three of those areas – the technical functionality and capacity, how well it is understood, and the research and evidence underpinning its use in healthcare. Conversations during the writing of this report have identified concerns particularly at the level of funding available but also at some of the barriers to embedding products within clinical settings. These are particularly notable for their potential to jeopardise the sustainability and scaling up of XR products.

Industry has consistently highlighted the challenges of NHS procurement for innovative and boundary pushing technologies such as these. One of the significant opportunities within XR is that there are several components involved, with some more affordable or potentially optional, enabling buyers to customise the offer to best suit their budget and needs. The hardware needed to access immersive applications range from basic add-on headsets that work with smartphones to the simulation or training suites that require more space and expertise to run. Equipment can be purchased as capital or leased but consideration needs to be made as to whether there is sufficient knowhow to run and manage them – this will of course be easier with the more ubiquitous technologies.

There are many freely available wellbeing applications available through stores such as Oculus that can be downloaded and used in the ways discussed in the wellbeing section. However, for interventions that require a more clinical approach (e.g. training) and require more immersive or interactive features (e.g. automation) the costs are higher. Developing software for the latter can be significantly more expensive. Many companies offer packages that can be tailored to include subscriptions to their software, devices and/or support.

Several of the products described within this report have relied considerably on charitable donations to purchase equipment. This is positive in that it demonstrates increasing interest and, for simpler technologies, appears to be practical. However, technical support must be provided in-house and this model often relies on an individual champion with a vested interest. A more commercial model, with a company and provision structure, necessitates an understanding of both XR and the complex healthcare economy. For instance, as mentioned in this section, PRinVR has behind it a clinician who also happens to be an inventor – this is the only VR system offered currently available through the Digital Marketplace.

More immersive technologies require more investment within their design and development e.g. in the case of Oxford VR’s products. Often these are reliant on funding from bodies such as NIHR and there are often significant gaps in investment between development, research, and finally procurement within the NHS. Very few healthcare services will have a dedicated VR lab like Torbay’s, so these independent organisations must attempt to sustain themselves through these stages at the same time as understanding how best to embed themselves within services that can differ significantly across the nation. It is also important to consider who will be buying the product. Enthusiastic clinicians or patients may demonstrate its value at these levels but it will be commissioners, providers or other businesses that hold the purse strings. Understanding their needs and how a product can meet them is essential.

It is disappointing that currently NICE does not include guidance on the use of XR within any of the clinical pathways despite the evidence available, particularly within mental healthcare where its efficacy has been demonstrated. Furthermore, there are only three GDE blueprints based on XR technology, two within mental health while, as we have seen, VR is already deployed in a variety of NHS and social care settings. Frameworks such as the NICE Evidence Standards Framework for Digital Health Technologies and the NHSX Digital Technology Assessment Criteria should help industry and healthcare organisations alike to identify those products that have the potential to be both usable and useful within the sector, as well as those that necessitate a higher level of oversight within the MHRA medical device regulations. However, more is needed to ensure that XR products that demonstrate they are safe, operable, secure and effective can be more easily procured. This will also help to ensure that the industry can continue to take advantage of this forward momentum so that current and future XR innovations have a route to their realisation within healthcare.

The pandemic has led to a sea change in how the NHS uses digital technologies with more consultations and appointments conducted remotely and many users of social care services provided with tablets and other devices to enable their access to support and advice from a distance. NHSX has taken a significant role in publishing guidance and offering funding to support the changes being made due to the Coronavirus outbreak. This important development in digital transformation that has accelerated out of necessity will surely endure. 

This report has demonstrated clear benefits that can be realised from the use of XR within healthcare, along with the many use cases that showcase its affordability, flexibility and acceptability amongst patients and clinicians alike. XR, and especially VR, has already found a place in the NHS and this was seen in the many examples above that are showing its role in reducing the costs of service delivery, improving outcomes for patients and staff, and demonstrating its potential to increase access to treatments and training. While there are few formal health economic assessments of VR, this chapter has shown there are good examples of both cash-releasing cost savings and cost-effectiveness, and others that are low cost or close to cost neutrality where the saving to the healthcare system could be usefully examined further. Emerging innovations in AR and MR are yet to have health economic assessments.

It will be important to continue building an offering for XR, and digital health in general that works within the existing infrastructure and information governance but most importantly, that will work for the broadest spectrum of service users. This means using co-design and taking steps to ensure that digital exclusion is addressed and the widening of health inequalities is prevented. The future of digital health in the NHS will require a specific emphasis on XR to make the most of the innovation happening in this space, developing its use beyond small scale pilots. It will be important to grow the number of Future NHS GDE blueprints for deploying XR in different healthcare settings.

As has been seen for remote monitoring during the pandemic through the Innovation Collaboratives (another part of Future NHS), a structured approach to supporting scaling by the sharing of knowledge about appropriate rapid study designs and an emphasis on calculating benefits for XR, including health economic assessments, would be very useful. Alongside this, use case templates of XR in both the NICE evidence framework and for the NHSX DTAC would be helpful tools. The funding of health economic evaluations of XR deployments in the NHS would support the case for scaling the successful ones. The procurement framework must consider the capital and IT costs associated with XR and ensure that, when costed, it recognises the investment within the development of interventions, which involves the design of high-quality virtual environments. 

Funding bodies should continue to help researchers develop and generate evidence for XR in healthcare. Research projects like those funded by UKRI (including Innovate UK) or NIHR (e.g. the i4i programme that is supporting the development and trial of novel XR therapies like gameChange) are beginning to enter the next stages of implementation and an emphasis on sustainability should be supported, as well as investing in the development of new technologies and applications in healthcare.

While this section of the report has mostly focused on highlighting the breadth of work being done to show the value of XR within the UK and in the NHS, there are other organisations in different countries working in this field, sometimes for longer, so there is good potential for international collaboration. 

This chapter was written by Dr. Michael Craven, Principal Research Fellow and Dr Aislinn Bergin, Research Fellow - NIHR Mental Health MedTech Cooperative (MindTech) & The University of Nottingham.

The UK healthcare sector is facing challenging times in terms of workforce retention, development and training as a result of the impact of Covid-19 and due to the fact that 30%-50% of frontline healthcare workers are due to retire by 2030.

There are significant opportunities for the UK to maximise the use of AR and VR in training and workforce development, maintaining the quality of provision and delivering at scale, with lower costs and greater accessibility.

The UK is seen as a global leader in workforce training and education in healthcare. 

There is a high demand from organisations worldwide for new ways to deliver high quality education and training in healthcare for growing and aging populations (Healthcare UK Annual Review 2019-20). Due to the UK’s strong global reputation in healthcare education and training and a growing XR sector, the UK could be well positioned to become an International world leader and market in virtual training.

Some of the most interesting use cases of XR solutions in wellbeing and mental health have come from alliances between creative games companies, the XR sector, clinicians and academics. The UK games sector reached a record £7bn in 2020 (UKIE 2020). XR businesses are exploring new markets and opportunities and the creative sector makes a vital and varied contribution to the health and wellbeing of society. According to the charity Mind, one in four people experience mental health problems of some kind each year, and the impact of Covid-19 and lockdown is accelerating an already significant problem for the UK and globally. Strategic support to bring together the creative, technical and story based skillsets of the creative, games and XR sector with clinicians and researchers could fast track new R&D and solutions to address the mental health and wellbeing needs of the UK population.

There is a lack of clarity regarding how to categorise XR hardware and software as Medical Devices or Software as a Medical Device (SaMDs) from regulators, companies and healthcare providers. Regulatory approval can take a number of years, representing an inhibitory factor to development and deployment. Compliance in regulation is reported as very difficult for businesses to navigate, understand and apply within business. 

In 2020, the FDA and Department of Health and Human Services in the United States held a public workshop to discuss medical extended reality and best evaluation practices. A similar strategy is needed within the UK so we can better understand how XR can work best within the existing system, rather than seeing it as something outside of it. We are yet to see any specific guidance from NICE or MHRA on XR. Regulators must collaborate with stakeholders, into an alliance structure to meaningfully problem solve where emerging technologies like XR fit into existing governance structures. It should be made clear that any product that can be classified as a medical device must have MHRA approval and that failure to do so runs the risk that unsafe XR technologies could be deployed within the NHS.

The National Institute for Health and Care Excellence (NICE) have worked with partners to develop standards that ensure new technologies are clinically effective and offer economic value. The NICE standards can be used with XR and the Digital Technology Assessment Criteria (DTAC) should be completed for every digital technology product within the NHS, even if organisations are piloting or trialling it. NICE created the standards as part of a working group led by NHS England. This group also includes Public Health England, MedCity and DigitalHealth.London, all of which can be found here. 

Asset management of XR devices presents an unique set of logistical concerns for a system with a wide deployment. Administrative oversight and maintenance procedures may vary based on the geographical location and skillset of the users. Therefore, XR devices must be maintained and configured to ensure functional alignment across locations.

XR equipment is frequently expensive and the structures of NHS procurement processes make it hard or timely to purchase. If a piece of XR equipment is rented or otherwise shared among multiple users, hygiene and disinfection of the equipment are imperative as part of a common system-wide maintenance and asset management system. Various healthcare and education facilities have developed hygiene protocols to address this issue but must be uniformly published and adopted.

Interoperability is also a unique consideration in procuring the appropriate assets. In order to achieve worldwide deployment of XR technology, the XR equipment must be interoperable and available for deployment across distributed ecosystems. NHS IT is tightly controlled in terms of what can be downloaded or which devices can access wi-fi, for example. This can mean long delays or simply not being able to access hardware or software on local NHS Trust networks, inhibiting or ceasing progress of projects or studies.

XR devices can generate and process large amounts of highly personal data including metadata and health inferences across various geolocations. XR expands the definition of personal information that must be protected, including biometrically-inferred data, which is especially prevalent in XR data pipelines. 

There are numerous examples of data unique to XR applications, including cameras that continuously capture a patient's gaze, handheld controllers and other body sensors, video and audio recordings. The collected data includes methods of positively identifying an individual, biometrically inferred data, behavioural data, room data, mood, gender presentation, sexual orientation, and unique physical attributes not generally captured during clinical interactions. Current regulatory definitions of PII (Personally Identifiable Data /Personal Data) and PHI (Personal Health Information) may need to be expanded to incorporate and govern the unique types of data created and used by XR applications.