Why I… work in hospital at home

Dr Shazia Din, MBChB, MRCGP MRCP (Edin) DFSRH previously worked as a GP and accredited Trainer in Edinburgh. She is currently working in Medicine for the Elderly in Dundee and Co-Leads the Dundee Enhanced Community Support Acute (DECS-A) Team which aligns itself to hospital at home. Her interests include advanced care planning, patient-centred care and frailty, and she continues to keep her hand in General Practice as a locum. She has recently been appointed as the Interface representative for the BGS Community and Primary Care Group (CPCG) and is a committee member on the UK Hospital at Home Society and BGS Scotland Council. She tweets @ShaziaDin2

I knocked on the door. From behind the entrance Alan appeared weary and yet relieved to see a familiar face. I sat down with him and revisited our meeting a week prior when he came to see me complaining of widespread joint pain and weight loss for which no cause had been identified by the hospital specialists. He was known to have Rheumatoid Arthritis amongst multiple other conditions and was attending to discuss what could be the cause as he was now becoming frail, tired, and perplexed at why he wasn’t improving.

Just a few weeks before I had become the Practice Lead for the ‘Headroom’ initiative funded by the Scottish Government, looking at health conditions that were impacting our local population and how our Practice could be supported to find solutions. For me, one area of interest was multi-morbidity in older adults, and ensuring we had anticipatory care plans developed in sync with each patient’s situation.

I felt Alan could benefit and discussed this with him and he was open to being a part of the intervention. This would be an extended initial appointment with up to 2-3 review visits. We agreed that I would meet him at home.

I sat with him in the kitchen when a woman, whom I assumed to be his wife, entered, pacing the room and firing questions at him. I could see Alan was becoming flustered. The doorbell rang and it was a support worker who had arrived to take Alan’s wife out for her scheduled walk. Alan’s wife had Alzheimer’s disease and was physically robust but had started to become disinhibited in the last few months.

I revisited our initial discussion from the previous week but had begun my information gathering as soon as I passed the threshold. Alan was in his eighties and was tall yet frail and weighed no more than 55kg. He was the main carer for his wife but had his own disabling health concerns. There was no package of care, and he was struggling as he walked along the hallway. It was a beautiful semi-detached Victorian house but had little in the way of adaptations to accommodate his mobility issues.

He sat down once his wife and her support worker had departed and he became emotional when I asked him how he was managing. Listening to him made me appreciate how much he loved his wife and how proud and fearless he was as an individual. He was running around looking after her but had become exhausted by the end of each night and too tired to feed himself. This had become a vicious cycle and his weight was dropping further and further.

As he realised the cause of his weight loss and it all sunk in, I hugged him and he wept and thanked me for listening. He was finding it increasingly difficult to care for his wife but was loath to even consider giving up on her. His biggest fear was going into hospital himself - who would look after her? How would she manage and would she become more confused without him around? He couldn’t ever contemplate leaving her. I was overwhelmed by Alan’s sense of protection towards his wife and privileged that he saw me as a confidante. We came to an agreement that he would allow me to refer him for an urgent social care package to support them both and involve the physiotherapist, occupational therapist and dietician in his management to improve his mobility and to ensure he did not lose any further weight.

Alan was one of the first patients who made me reflect on my work as a GP.

It had become a running joke with the reception staff that I was often the last to leave, and that was after spending long hours in my room trying to care for patients as fully as possible. I was grateful for the opportunity to be involved in the ‘Headroom’ initiative but wondered how many ‘Alans’ were out there who were afraid of being admitted to hospital because they were the main carer for someone else or felt an admission was not in their best interest? As a GP on a tight schedule under constant time pressure, sometimes admission was the only safe environment I could find. Was I failing them? Had I enough protected time to manage these patients and coordinate their specialist medical needs and perhaps own a magic wand to conjure up a chair lift and carers and get them over their acute illness in a safe manner, it might have felt different, but time was really the clinching factor.

I moved to Dundee five years ago and I took the opportunity to shake things up. Having not worked in hospital medicine for ten years, I initially worked in Acute Medicine but was later given the opportunity to launch Dundee Enhanced Community Support Acute Team (DECS-A Team) in January 2018 to all the GP Clusters in Dundee with the aim of preventing frail patients over the age of 65  being admitted to hospital and instead managing them safely at home.

We are a very small, yet dedicated team, assessing 20 referrals per month and have fortunately secured funding from Scottish Government to develop our service. We now operate with the support of an MDT involving physiotherapists, occupational therapists and a social care coordinator with a pharmacist attending weekly.

These days, I come home at the end of the day and wonder why I didn’t take the plunge earlier. I feel as if I have found my niche and knowing that I have been able to observe someone’s wishes makes it all the more worthwhile. I often think of Alan. To keep our focus on what matters most to the people we serve, we are signed up to Care Opinion to ensure we are hearing directly both what we do well, but also how to improve.

Please note: Names and settings have been changed to protect the individual's identity