Taking patients out of the hospital and successfully providing their care at home is certainly achievable, and Mehmood Syed looks at steps commissioners and providers can take to ensure home is where the health is.
Home healthcare is rapidly becoming a much more readily used option for shifting care out of hospital. While it has been historically perceived as a distribution activity – a man in a van delivering medication to patients’ homes – it now covers a wide range of therapy areas as well as home nursing provided by healthcare professionals (see list).
Home therapy areas
- Continuing care
- Cystic fibrosis
- Dermatology
- Erythropoietin stimulating agents
- End of life care
- Fertility-assisted conception
- Growth hormone
- Highly active anti-retroviral therapy (for HIV)
- Haemophilia
- Hepatitis B
- Hepatitis C
- Intravenous antibiotics
- Intravenous chemotherapy for cancer
- Intravenous immunoglobulin – immunology
- Management of long term conditions, for example, chronic obstructive pulmonary disease
- Multiple sclerosis
- Oral oncology
- Parenteral nutrition
- Parkinson’s disease
- Post transplant – immunosuppressants
- Pulmonary arterial hypertension
- Rheumatoid arthritis
- Schizophrenia
- Thalassaemia
The opportunity presented by tackling waiting lists and bed blocking is well known. In November a report by Bupa Home Healthcare analysed hospital episodes statistics and identified that more than 1.3 million people were staying in hospital unnecessarily, particularly due to infections and musculoskeletal conditions. Up to £1.7bn of efficiency savings could be made if the NHS tackled the length of time people were staying in hospital (see table).
However, reducing patient bed days and generating these savings will only happen if changes are made at local level. The question remains – how do commissioners and providers put in place the services and processes in their local health service to actually make this change happen?
A number of factors need to be taken into account when looking to shift patient care out of the hospital setting. These range from designing the service itself to identifying which patients could be discharged from hospital to a home healthcare service, to developing the clinical governance protocols and the feedback process necessary to ensure high levels of patient safety.
NHS savings potential for early discharge
| Conditions | Savings (£m) | Bed days saved (000s) |
|---|---|---|
| Musculoskeletal | 235 | 2,120 |
| Infections | 223 | 2,804 |
| General medicine | 204 | 3,050 |
| Neurology | 177 | 1,776 |
| General surgery | 164 | 1,362 |
| Gastroenterology | 149 | 1,949 |
| Plastic surgery | 101 | 611 |
| Ear, nose and throat | 343 | 165 |
| Urology | 315 | 283 |
| Cardiothoracic | 283 | 276 |
| Gynaeocology | 117 | 276 |
| Total | 1,360 | 14,500 |
A new era
There is no one solution to the challenges faced by the NHS of increasingly stretched resources and an ageing population with rising rates of chronic disease. However, it is clear that change is needed to continue achieving the high standards set by the NHS nationally and locally.
Healthcare can be delivered in various locations, including patients’ homes. As new and existing service providers try to stand out, new business models evolve, offering better value to customers or, in the case of healthcare, patients.
Case study: providing an intravenous antibiotic service in the home
Bupa Home Healthcare has worked with the London Chest Hospital, (part of Barts and The London Trust) to provide a home intravenous antibiotic service for over 12 years. There are two aspects to the service: acting essentially as a patient triage service, reducing admissions by providing treatment at home; and providing a means to discharge patients earlier from hospital, where clinically appropriate, to receive treatment at home.
Some 150 patients are managed by the London Chest Hospital, many of whom receive their IV treatment at home. This can ease capacity pressures and offers patients an often preferable, alternative treatment option. This choice has meant the hospital has become a more attractive referring centre and has helped to increase patient referrals, thereby providing additional income for the trust.
Patients providing feedback to the hospital feel they are able to live a much more normal life. With many of them living up to three hours away from the hospital, the option to have treatment at home is a major benefit.
Home healthcare is one such innovation but making it happen requires a partnership approach to working between the commissioner of a service, clinicians and managers in the local hospital, and a provider on the ground delivering the service. As with any local health economy, the needs, requirements and challenges to making each project a success will always be different.
The steps outlined here are built on a core set of processes and protocols that focus on clinical governance, staff management and communications. These give confidence to all parties involved in providing the service so the individual patient – who should always be front and centre of these services – gets the best quality care.
Case study: Cornwall and Isles of Scilly
Bupa Home Healthcare has a partnership with NHS Cornwall and Isles of Scilly to provide care for 15 patients who have complex and continuing care needs. The rural setting lends itself very well to home healthcare providers and the primary care trust’s use of home healthcare has grown over the last 10 years.
All patients receiving home healthcare are grouped into three categories: children requiring long term ventilation, children with life limiting conditions in the end of life phase, and children with challenging behaviour.
“The reality is that many of the children using the service would otherwise be in a specialised care environment, which is often more expensive. A specialist school in the region with a package of healthcare would be in the region of £150,000 per child. The cost in an acute sector hospital would be around £328,500 per year,” says Leah Parker, associate director for women and children’s continuing care commissioning, NHS Cornwall and Isles of Scilly.
The key factors that go into making this service work revolve around three areas – governance, staff training and staff management. There is an agreed set of clinical governance protocols in place that are bespoke to each child and designed around their needs. Each of these packages gives the commissioner of the service and the responsible doctor at the local trust clarity over the care processes that are being followed.
Staff training and management is a major focus. The nursing skills required to provide care in the home can be very different from the skills that a nurse would use in a medical facility. For example, home healthcare nurses are required to work independently and autonomously, as well as adapting to working within the home environment. Staff management plays a crucial role in maintaining high quality care and ensuring clinical standards are met throughout the community based teams.
Around this goes a huge amount of engagement between parents, carers and medical professionals, ensuring regular and open communication between all of them.
“When dealing with children with such high medical needs, this kind of communication is vital to make sure that both sides are happy and confident in the care being provided to the child,” says Nicky Houghton, children’s continuing care commissioning manager, NHS Cornwall and Isles of Scilly. “Regular two-way communication and feedback from the home healthcare provider are fundamental to instil confidence in us as commissioners of the service.”
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