The care at home revolution that Lord Carter forgot about

Lord Carter’s recently published review has called on NHS acute trusts to take steps to tackle what he termed unwarranted variations in quality and finances. He lists a number of measures that could be taken to achieve this.  

Clinical homecare is alluded to only in the briefest terms. An opportunity missed, in my view.

There is a growing evidence base which suggests that hospital services delivered in a home setting under appropriate supervision can enhance patients’ quality of life, in addition to providing potential cost savings for the system.

These services include dispensing and delivering medication to patients’ homes with or without associated nursing services, as well as the treatment of higher acuity patients using virtual wards or complex home cancer care.

Expert panel

I have encountered such services in pilots, or at small scale, in many of the commissioning roles I have held throughout my career, and always thought they merited further expansion.

‘We looked at how clinical care in the home can lead to better medicines adherence levels’

Last year I chaired an independent expert panel, which sought to build the case for clinical care in the home.

Assisted by NHS clinicians and managers, private healthcare providers, colleagues from NHS England, and the pharmaceutical manufacturing sector, we looked at how clinical care in the home can lead to better medicines adherence levels, reablement, and patient activation.

The indications are that clinical home care services can comfortably meet the 3 per cent efficiency saving prescribed in the Five Year Forward View.

Personalised care

The opportunity for patients to be treated in their usual place of residence offers them and their carers a greater sense of control, comfort and convenience during their period of care.

‘Evidence suggests that care in the home is associated with better health outcomes’

It demonstrates that care can be designed to meet individual needs, not conform to organisational boundaries.

Evidence suggests that care in the home is associated with better health outcomes for patients.

Not only does it reduce inconvenient and sometimes stressful travel, particularly for elderly patients, care in the home has fewer iatrogenic complications and instances of functional decline.

A 2009 Cochrane meta-analysis found that care in “hospital at home” programmes was associated with a 38 per cent reduction in mortality at six months, compared with hospital treatment.

Greater independence

Clinical homecare can mitigate clinical and psychological risks. By eliminating care transition gaps, both patients and carers encounter a seamless care experience with enhanced control over their treatment.

This greater sense of independence is a significant outcome for both carer and patient.

Home cancer care poses particular challenges. Cancer treatment can be an exhausting process.

‘Treatments that can be administered in the home include injectable chemotherapy’

On top of regular travel to and from hospital, there is the impact of the therapy itself.

If homecare is to be part of the patient’s treatment pathway, it is vital that all stakeholders responsible for the care of the patient are working as part of an integrated plan.

Treatments that can be administered in the home include injectable or oral chemotherapy.

To operate at scale, effective, home cancer care needs to be configured with a cancer centre or unit, ensuring it makes economic sense for the trust, while also being in the best interest of patients.

Hospital capacity

Selecting regimens that require a shorter duration, as well as patients who live in a defined geographic area enables services to operate effectively at scale, freeing up hospital capacity.

Biologics, which have emerged as an important advance in the treatment of inflammatory diseases, are well suited to the clinical homecare model, as required frequency of administration makes it more convenient for patients to have them delivered to their home.

Healthcare at Home delivers biologic medicine to 80,000 patients every year. Patients remain under the care of the consultant at the referring hospital.

‘Virtual wards support integrated care models by allowing GPs to retain responsibility’

The biologics manufacturer commissions the service.

Patients can consult with a specialist nurse who is in regular contact with the referring hospital. The nurse can identify barriers to treatment, which may result in intentional or unintentional non-adherence.

Virtual wards

Virtual wards support integrated care models by allowing hospital consultants and GPs to retain clinical responsibility for their patients, undertaking their care planning and monitoring, while nurse led multidisciplinary teams provide care in the person’s usual place of residence.

It can either be through a recovery at home, or admission avoidance model.

Patients typically supported by admission avoidance schemes are those with exacerbations of long term conditions, people presenting with ambulatory emergency care conditions, or people in care homes who may be dehydrated, or have low level infections.   

‘Financial savings are only a part of the contribution clinical care at home can make’

Though researchers are reluctant to put a figure on the impact of integrating care in terms of cost savings, Monitor has noted that in the long run, well designed schemes that are suited to their local health economy and run efficiently could offer equal or better care than local acute hospitals, at lower cost per patient.

Financial savings are only a part of the contribution clinical care at home can make to NHS modernisation.

Bridging the gap

Bigger system benefits are where the real value is to be found. This includes helping patients to manage their condition, and be treated in a more favourable environment, enabling health systems to function optimally, lowering readmissions, reallocating beds and wards for more appropriate patients.

It also bridges the gap between health and social care provision so that acute and community hospitals can maintain sufficient capacity and flow.

Christine Outram is chair of the Christie Foundation Trust and a consultant on leadership and change. She is chair of the independent inquiry panel on clinical home care, whose report Building the Case for Clinical Care in the Home at Scale report was published in October 2014. www.christie.nhs.uk