Delivering hospital care at home

Professor Dan Lasserson has been working with Warwick Medical School (WMS) for three years and delivering alternatives to acute hospital care for over a decade. His work around bringing hospital care into the home is receiving real traction. It was the subject of a Panorama programme earlier in the year and has NHS England behind it.

He said, “There's an increasing recognition from research funders that this is an area that needs to be explored. It's a great place to be now because there's lots of innovation needed and that's really exciting.

To deliver and develop hospital care at home you need to incorporate lots of disciplines, both academic and clinical. As the objective is to include all the best bits of the hospital and leave the less good behind you need to have a diverse multidisciplinary team with different perspectives to deliver these elements of care and to study it. This includes diagnostics, intervention trials, patient experience, service evaluation and mathematical modelling such as operations research.”

There are currently a range of models operating across the UK as part of the NHS England’s Virtual Ward Programme of which Hospital At Home is one. These vary in maturity from where hospital care isn’t replaced but patients are being monitored to the more acute end of the spectrum where patient care is delivered at home or in a care home.

Hospital at Home is for all ages but often works best for patients who are older and living with frailty. Very often they will have had previous experiences of hospital care and may be at a stage where they no longer want to go to hospital for their health care, preferring to remain at home or in a care home setting. This may include patients with advanced dementia where families can often describe previous experiences of distress at being in hospital and are keen to see if alternatives can be delivered that still meet acute care needs.

Dan has also successfully treated young people with long-term conditions who have moved from paediatric medical care to adult medicine. He has seen it work well for those with acute infections, acute COVID-19 infection and for patients where, after discussion, the most intense form of treatment would be care on a medical ward because at most they would be receiving intravenous fluids, oxygen, blood products and intravenous medications which can be given at home.

“The Panorama documentary was really useful in telling patient stories, highlighting the benefits and the challenges of Hospital at Home. It’s a useful resource to point people to when they are considering whether it’s for them. It’s important for more of this work to be done so patients can make informed choices when they become acutely ill.”

Dan is part of the UK Hospital at Home Society that was set up about three years ago and has bought together innovators across the UK who are looking to join a community of practice. He said, “We aim to help healthcare professionals with their own development as well as considering how best to tackle both delivering the best outcomes for patients, and the best value to the health care system. Working with similarly engaged healthcare providers also means it is easier from a research perspective in recruiting to trials or undertaking surveys. It’s a way of helping us with our research delivery as well as getting key messages from the front line to identify what the research priorities are”.

Dan works clinically in Oxfordshire at the John Radcliffe Hospital, has links to Sandwell and West Birmingham Trust and is supporting University Hospital Coventry and Warwickshire and South Warwickshire Foundation Trust as they go on the journey to deliver hospital level care in the home and care home. His role enables him to engage and influence on a wider geographical scale beyond the boundaries of the West Midlands.

“Our local hospitals have functionality in the home currently but they want to increase capacity, the breadth of patients they can treat and a menu of interventions that they can deliver. The objective isn’t to deny hospital beds for anyone, it is to give patients a choice of where they want to be treated. NIHR funded randomised trials in this area show that it is both a clinically and cost-effective model. For every patient that you treat outside of the hospital setting you save the health and social care system around £2,500.”

At a time when the NHS seems to be in crisis more than ever it seems even increasingly important to look at different ways to treat patients in an effective way. It is, however, often difficult to introduce new approaches and models in a well-established system and they are viewed with a certain degree of scepticism. Budgetary constraints are one thing but tradition and cultural resistance are other areas that can cause tensions.

Dan revealed “In order to make Hospital at Home standardised treatment it needs to be scaled up and strategic decisions need to be made in the areas of investment, workforce development and staff training. We struggle in this country in getting workforce development strategy right and there is a huge mismatch between need and functional ability of policy and strategy. It will require a radical rethink. Not just in the context of Hospital in the Home but also planning our workforce more generally across the medical, nursing, therapies and allied health professionals. There is a question of whether the new integrated care systems can flex muscle locally and say ‘this is what we want’. It isn’t only about money but also about prioritisation and culture.”

Although the Hospital at Home Society is relatively young, their innovative work has enabled them to make rapid progress. They are now seen as equal partners on the global stage, alongside more established societies such as that of France, which has been going for 60 years. At the recent World Hospital at Home Congress in Barcelona, UK members contributed heavily to the agenda and took key speaking roles despite a UK society not having existed when the last face to face event took place in 2019.

Looking into the future, Dan would like to see Hospital at Home as a standard offering to every patient for whom it is appropriate. “It would reduce the number of patients coming into hospital and reduce progression to requiring institutional care such as in a care home. We have evidence of this from an NIHR funded randomised trial. We would change our model of detection of acute illness. For example, if you are acutely sick and you are in your home or a care home and you need a same day diagnostic so you can start treatment, currently you would largely have to go to hospital to do that. However, if we can make our diagnosis outside of the hospital, we can make decisions about treatment. You will only go to hospital if something is found that you can’t be treated for at home. In the future there will be new diagnostics and an extended range of interventions available outside of hospital as work progresses in this area.

I am looking forward to working with partners in academia to use the energy and drive of research to support moving the model forward. As well as clinical innovation we need a thriving and robust academic community in this space as well.”