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.
This is part two of a two-part blog post reflecting on a workshop BGS ran in partnership with the Academy of Medical Sciences’ FORUM and will look at the system-wide issues affecting Hospital at Home services. Part one is about the experiences of people receiving care through Hospital at Home and can be found here.
Reducing demand on social care
Much of the discussion of the day was around gaps in the research evidence and potential research questions. One that stood out for me was whether Hospital at Home services can reduce demand on social care, and help patients maintain their independence for longer. Participants in the workshop commented that, in their experience, very few patients are discharged from Hospital at Home with an increased care package while this is quite a common outcome of a hospital admission. However, it was acknowledged that this was purely observation by clinicians working within the service and there is currently minimal research to support this claim. The crisis in social care has been an enduring theme for the last few decades and while no one is pretending that Hospital at Home is the solution (and indeed, if Hospital at Home is being used to replace social care then it’s not being used correctly), any reduction in demand must surely be a good thing, if it can be proven.
Workforce
Workforce issues are a continuous theme when discussing Hospital at Home – the people who work in these services have to come from somewhere and there currently isn’t spare capacity in the healthcare system. While Hospital at Home services may relieve some pressure on hospitals, inpatient hospital care will always be needed and moving staff from hospitals to work in Hospital at Home without other reforms to the way care is provided across the system could result in further workforce shortages in hospitals.
This means the deployment of people across multidisciplinary Hospital at Home teams needs to be smart. Many participants at the workshop discussed ‘role-blurring’ where teams can all do similar tasks so that a patient receiving care through a Hospital at Home doesn’t have multiple visits by different professionals. This is less disruptive for patients and carers, as well as being more efficient for the team. However, it is important to ensure that the expertise of each profession is not lost and to recognise when the specialist skills of a physiotherapist, occupational therapist, or other healthcare professional are needed. There are also concerns that not all allied health professionals are able to prescribe, limiting their ability to work independently in Hospital at Home services.
Participants at the workshop discussed whether Hospital at Home is/should be a medical specialty. It is not currently recognised as a medical specialty and while those working in frailty Hospital at Home services have specific expertise in older people’s healthcare, there are Hospital at Home services across a range of disease areas. There seems to be no doubt that that clinicians working within Hospital at Home have specific skills and knowledge, such as around risk management and delivering care in a home environment, that could be tested. There was also discussion of the possibility of a Diploma in Hospital at Home to enable clinicians across the multidisciplinary team to have their skills in this space recognised.
Links with other services
Hospital at Home clinicians should repeatedly be asking themselves ‘is this truly replacing hospital care? If we weren’t here, would this person be in hospital?’ If the answer is no, then the patient should be discharged from a Hospital at Home service and cared for by another part of the health and care system. Clinicians at the workshop described how hard this can be – patients can still be unwell, and it is always tempting to keep them ‘on the books’ for just another day. However, participants were very clear that if patients are not unwell enough to be in hospital, then they are not unwell enough to be in Hospital at Home. These patients still require care of some description, and this is where referrals to other services are especially important to ensure that patients continue to be supported in their recovery.
Conclusion
After a really interesting day of discussion with some of the experts in the field, I came away feeling enthused about the potential of Hospital at Home for older people with frailty. The day felt ambitious, yet realistic. No one was under any illusions that Hospital at Home could or should replace inpatient hospital treatment. Indeed, everyone was very clear that older people who can benefit from hospital treatment should have access to this. But there is certainly a role for Hospital at Home within the system and for appropriate patients, it is clearly very beneficial.
