Sally Greenbrook joined the BGS in April 2019 as Policy Manager. She has more than a decade of experience in the UK health policy sector, having worked for the Department of Health and, most recently, as Policy Manager for Breast Cancer Now. She has for many years had an interest in the health and care of older people, having written her MA thesis on housing for older people. She posts on X @SallyGreenbrook.
On Monday 20 January, the BGS partnered with the Academy of Medical Sciences’ FORUM to host a workshop in Edinburgh looking at Hospital at Home services for people living with frailty. This event brought together experts from lived experience, healthcare, academia, industry and government to discuss the current evidence around Hospital at Home and where more research is needed.
The Academy of Medical Sciences will publish a full policy report in the coming months and I have no intention of pre-empting that report. However, through my policy role at the BGS, I have been aware of Hospital at Home services for some time. And while I am certainly not an expert, I am relatively well-versed in the evidence and arguments around delivering hospital-level care for someone in their own home. I therefore want to use this two-part blog to reflect on some of the discussions from the day that were new to me.
This is part one of a two-part blog post and will look at the issues discussed that are about the experience of people receiving care through Hospital at Home. Part two will look at the system-wide issues of Hospital at Home.
Lived experience
I’ve repeatedly heard from clinicians about how much patients like Hospital at Home but this was the first time I’d heard directly from people with lived experience, both as patients and as carers. While the feedback from these two groups did largely support the view of Hospital at Home being a positive experience for patients, it also raised some concerns, particularly around the experience of carers. The BGS report Bringing hospital care home details how Hospital at Home often requires significant input from carers as the person they care for needs more from them at this time. However, I hadn’t considered the stress that a carer might feel as a result of having many additional people come into one’s home. Teams should consider this when planning visits and think about whether one person could carry out several tasks on one visit. Role-blurring, which I’ll discuss later, can also help to address this.
The carer’s health is also an important consideration in Hospital at Home as carers are often spouses who are also older and may have their own health concerns. Caring for someone who is acutely unwell will take a toll on the carer and this should be considered by teams. One participant told me at the break about a patient who they had admitted to hospital, not because the Hospital at Home team couldn’t provide the care needed but because the carer would not be able to cope with the level of care they would need to provide for their loved one when they were acutely unwell.
Inequalities
‘You think you know how to do something and then you have to do it in a caravan with a dog sniffing around your trouser leg.’ This paraphrased quote from one of the participants served to remind us that not everyone has living conditions suitable to receive hospital at home. Inequalities came up several times throughout the day with a question around whether Hospital at Home could in some cases exacerbate inequalities as factors such as unsuitable living conditions could mean the service is not suitable for some people. People living in poverty or in temporary housing may not be able to be cared for at home. Financial inequalities may mean that people prefer to go to hospital as they know they won’t have to worry about extra bills from putting the heating on or grocery shopping. Use of technology such as monitoring devices may exclude some households without an internet connection or where the patient and/or carer does not feel confident in using technology. None of these issues are insurmountable but they all need to be addressed (for example, providing internet connection as part of the service when needed) if Hospital at Home is to be a true treatment option for all.
Preventing deconditioning
We know that many older people experience deconditioning in hospital which means that they are slower to recover from ill health and leave hospital requiring more care than they did previously. It was suggested during the workshop that people being cared for at home are more likely to move around, even if it’s just going to get themselves a cup of tea, moving from the bed to a chair during the day or going to the toilet. Even this small amount of physical activity can help to prevent deconditioning. However, similarly to the earlier social care point, this is an observation from clinicians for which there is minimal evidence. Future research could focus on this.
Can this care be provided in Hospital at Home?
There is currently a lack of awareness of Hospital at Home among both patients and healthcare professionals. Participants at the workshop said they want to get to a situation where patients ask, ‘can I receive this treatment at home?’ There will always be a place for hospital in older people’s healthcare as there are treatments that cannot be provided at home and people for whom treatment at home is not a desirable option. However, as Hospital at Home services grow and technology improves, it seems that more and more care can be provided in someone’s usual place of residence and awareness among the public will help to ensure that people who do not want to be admitted to hospital may be able to avoid it.
