Hospital at Home in Scotland evaluation: phase 1 findings report

Short Summary of Findings

The high-level summary of findings set out below is based on feedback from NHS Scotland workforce involved in either delivering Hospital at Home (H@H) or referring patients into H@H services. Their views were captured through an online ‘workforce’ survey (Nov 25 - Jan 26), focus groups and interviews (March 26). Note that the brevity of this summary precludes the full breadth and depth of findings from being presented. These findings comprise Phase 1 of the H@H evaluation; the upcoming Phase 2 will produce an impact evaluation through interviews with workforce, H@H patients and their families/carers, as well as an economic analysis.

Nature and scope of Hospital at Home

The research found a very mixed understanding of the scope, principles and practices underpinning H@H. Considerable differences in how services are being delivered was evident in research findings. Feedback suggests that the heterogeneity of delivery is driven by a lack of standardisation in how services were historically set up and an absence of clear guidance on how new services should be set up, meaning much of this is/was left to local decision makers. Furthermore, views were expressed that the service was still subject to rapid change, often on a very regular basis, linked to funding and other decisions. This made it difficult to keep abreast of what H@H currently entailed, even in longer established services.

The referral process

Of referrers who completed the ‘workforce survey’ (n=136), around half described the process of referring a patient to H@H as mostly or almost always straightforward, around a third as sometimes straightforward and sometimes difficult, and a minority as mostly or almost always difficult. The findings demonstrated a clear buy-in for the H@H service among the majority of referrers, both in terms of their willingness to actively refer patients, and their confidence in the quality of patient care provided by the service. Additionally, communication from H@H teams was generally described very positively. However, referrers did raise frustrations with the referral acceptance decision process, which was perceived to be inconsistent at times. Views were also shared that the number of patients accepted into H@H might be diminished by referrals being rejected due to a lack of capacity within the H@H teams, and an absence of H@H provision out-of-hours. Another concern among some referrers was a lack of clarity on where responsibility sat - between primary care and secondary care - for a patient referred into H@H.

The delivery process

Most deliverers reflected positively that their H@H team comprised a strong mix of staff from different professional backgrounds, with different expertise. Effective delivery processes within teams and strong senior promotion of H@H were also believed to be present. Many deliverers mentioned Point of Care testing as a key strength of the H@H service, as well as access to remote monitoring. Conversely, challenges affecting optimal delivery were frequently mentioned in relation to staff shortages (including for specific or specialist staff), and staff recruitment/retention (linked to the short-term funding model). Some gaps or limitations in the availability of IT hardware and software were cited, as well as with accessing social care and community services input.

Suggestions for the future

Maximise optimal delivery by:

• Continuing to embed strong links and communication between H@H teams and their local referral pathways.
• Continuing to build teams with different professional backgrounds, expertise and specialties, with clear and robust delivery and improvement processes in place and with collegiate culture.
• Ensuring that strong senior promotion of the service remains in place, and that communication on the expansion of the service is universally received.
• Continuing to roll out expanded use of equipment enabled Point of Care testing and remote monitoring.

Alleviate existing barriers by:

• Ensuring that referral eligibility criteria are clear and well adhered to (by both delivery teams and referrers), and that referral acceptance decisions are made consistently on this basis.
• Minimising inefficient use of staff time, including through more and better-connected IT equipment, virtual assessment when appropriate, and funding for dedicated driver support.
• A funding model which supports teams to have greater and more consistent staff resource, facilitating increased capacity to take on referred patients and potentially to implement longer hours of operation and additional geographical coverage.