Facing up to home truths

Reducing the time patients spend in a hospital bed they don’t need is crucial as the NHS tries to meet savings targets and improve care.

An extra night in hospital is likely to cost the NHS at least £250. In 2011, the benefits of early discharge to home were calculated at £1.3bn and 14,500 bed days, while other patients could be better cared for at lower cost in a supported environment such as a care home.

‘Jacqui Lyttle says virtual community wards “take the professional to the patient rather than forcing the patient into hospital’

As well as the financial benefits of discharging patients from hospital earlier, there are benefits for the patient, too. Some patients may be particularly suitable for care at home – those who are in hospital primarily because they need intravenous antibiotics, for example, are often well enough to go home. Administering antibiotics at home can save bed days and get the patient back to their normal life more quickly.

Dr Paula Franklin, Bupa’s medical director, says patients benefit from being in a home environment: “It can make a huge difference to their quality of life,” she argues.

“I was recently out with one of our nurses who was supporting an elderly gentlemen with a chronic condition. We are supporting him in managing his IV line and various other elements of care. If he did not have this done at home he would be in hospital for a long time.”

Being in their home environment often enhances patients’ quality of life and supports them towards regaining independence. “We have to see it as an ongoing continuum and come back to what the goal is – restoring maximum independence,” says Johnny Marshall, policy director at the NHS Confederation.

But not all patients who could currently benefit from early discharge either straight to home or to a step-down environment have such an option.

In some cases this will be because there is not enough capacity in the local NHS – be that in the form of beds in a residential setting or staff with the required specialist skills to support patients at home. It is not surprising, then, that many NHS organisations are now looking at independent providers to support them in this regard, whether on a short term or longer term basis.

One approach that could support earlier discharge from hospital is the virtual community ward. This brings together staff with different skillsets to support patients in the setting that’s right for them. For some patients this will be discharge straight to their home, but with a package of support which could include nursing and therapy services. For others, a care home environment is appropriate.

‘We have the capability to deliver healthcare across a number of settings. If we add that all together we can help many more patients’

Whatever the setting, the idea is that healthcare professionals deliver closely coordinated care. This can include multidisciplinary meetings to discuss the progress of patients and to adjust care accordingly.

Jacqui Lyttle, who advises a number of CCGs on commissioning, says virtual community wards “take the professional to the patient rather than forcing the patient into hospital”.

They need to be backed up with teams of professionals who can provide access to good domiciliary care. Some patients with specialist needs may require care from specialist nurses, which can often be delivered in the home.

She says patients in need of IV antibiotics are one group who could be cared for at home relatively easily. Despite the benefits of such an approach, take-up has been sporadic. This can be down to a lack of resources to support such a shift in approach, as well as the lack of a model to shift the culture and operation of the local NHS towards a new approach. Although barriers exist, there is clear opportunity to develop such models more widely.

Bupa has been working with the NHS in a large number of health economies to support this shift towards care outside hospital. According to Tiffany Hall, managing director of Bupa Home Healthcare, this virtual ward approach is already helping patients on IV antibiotics, parenteral nutrition, or chemotherapy to leave hospital and have their care delivered at home.

The emphasis has to be on what is clinically appropriate for the individual patient – and can complement what is already available in the local community. Bupa Home Healthcare sometimes provides services for patients who are some distance from a hospital, while the hospital’s own outreach team deals with those who live closer, for example.

It may be that some patients will need additional support after they leave hospital, and so are best cared for in a residential setting before going home. Transferring patients to this setting, with an emphasis on reablement, frees up NHS capacity but it requires a joined up approach between commissioners and providers across both health and social care. Coordination is also needed between staff in the care home and those in the hospital.

Andrew Cannon, managing director of Bupa Care Services UK, says that, as average lengths of stay have come down, patients being discharged have higher levels of dependence.

“We have seen a very dramatic acceleration of that over the last 18 months. The whole mix of what we are doing has changed.”

This can often involve working alongside NHS organisations which may provide dedicated occupational and physiotherapy staff to support patients in a care home setting.

However, the reablement approach goes deeper than that and involves all the staff in encouraging patients to regain mobility, functional skills and confidence.

When patients are ready to leave the residential setting, they can return home but with support that helps them gradually maximise their independence and that may reduce costly readmissions. Tiffany Hall, managing director of Bupa Home Healthcare explains: “We have the capability to deliver healthcare across a number of settings. If we add that all together we can help many more patients.”

A good out of hospital service needs planning, communication between partners, and a focus on identifying patients who will benefit from different settings - all of which can be hard to do.

But carefully designed and delivered schemes offer the chance to improve patient experience and quality of care, while also meeting the NHS’s need for savings. And they could offer a way for early discharge to become the norm and average length of stay to reduce.

Find out more

• Turning Vision Into a Reality: a practical guide to moving care out of hospital
• Taking the Pressure Off: the opportunity for home healthcare in today’s NHS