Hospital at Home in Scotland evaluation: phase 1 findings report

Executive Summary

Background

Hospital at Home (H@H) is described as an intervention which provides time-limited, acute care, face-to-face to suitable people in their home, a relative’s home or in nursing homes (Public Health Scotland (PHS), 2026). This can be as an alternative to a hospital admission or early supported discharge from hospital. For the purposes of this evaluation, specified related admission alternative services which provide clinical care for patients who would otherwise have been admitted to hospital are also included within the scope. H@H aligns with the commitment within NHS Scotland’s Operational Improvement Plan, to shift the balance of care from acute hospitals to the community.

A number of different H@H services (or ‘pathways’) exist across Scotland. These include:

• Acute / Older adult services - provide care for adults, including frail or older people, suffering with acute illnesses and health conditions requiring secondary care assessment and intervention.
• Respiratory Services - specialist support to patients with breathing conditions.
• Heart Failure Services - specialist support to patients with heart failure.
• Outpatient parenteral antimicrobial therapy (OPAT) - provide IV or complex oral antimicrobial therapy for suitable patients.
• Paediatrics and Neonatal - specialist support to patients under the age of 16 years.

Given the significant financial investment to support the expansion of H@H services in Scotland^[1], and recognised gaps in existing research evidence around delivery and impact of H@H services, the Scottish Government commissioned an evaluation of H@H to support learning, continuous improvement and assess cost effectiveness.

The evaluation comprises two distinct phases. This report focusses on Phase 1, a process evaluation, exploring views of the H@H delivery and referral workforce in relation to effective processes, blockers and aspects of service delivery requiring improvement.

Methodology

Phase 1 of the evaluation comprised two distinct elements:

• An online ‘workforce survey’ which included separate questions for those delivering H@H services (i.e. ‘deliverers’) and those who refer patients into H@H (i.e. ‘referrers’). A total of 236 responses were received: 100 deliverers and 136 referrers.
• Focus groups with deliverers and referrers - 3 with deliverers (13 participants) and 3 with referrers (6 participants), plus individual/paired interviews (including with 7 deliverers and 2 referrers), meaning 28 participants in total.

Main Findings: Nature and Scope of Hospital at Home

Absence of a unified understanding of H@H

In focus groups and interviews with referrers, there was very mixed understanding of the scope, principles and practices underpinning H@H, largely because there was no one model employed across the country and no single definition available.

Among delivery staff, ambiguity around scope was also present, underpinned by a perceived disconnect between how services were labelled and their referral criteria. Similarly, some H@H pathways were delivering services consistent with other parallel pathways but under a different name.

Changes and variation linked to funding

Views were expressed by both deliverers and referrers that the service was still subject to rapid change, often on a very regular basis, linked to funding and other decisions. This was the case even in longer established services, and made it difficult to keep abreast of what H@H currently entailed.

Absence of standard protocol

Staff reflected that there was no clear guidance around how services should be set up, and much of this was left to local decision makers. As such, views were shared that some areas had decided to set up and run H@H in an almost exploratory way or in a phased way that enabled a test of change, or multiple tests of change. Feedback from interviews and focus groups suggests that a lack of standardisation in how services have historically been set up and run means there is no clear guidance for ‘new’ teams or services. For newer and developing pathways (including Paediatric and Neonatal pathways) there was also some uncertainty around how to define scope, primarily as most previous/existing services and definitions in place to guide them were for adult and older patient groups. The recent involvement of Public Health Scotland in defining H@H was mentioned as being helpful in allowing teams to refine, align and understand better what their service should look like against a standard model.

Variability of delivery models

Considerable differences in how services are being run was evident in research findings. This includes both where services are based and leadership structures within teams. Some teams had a greater focus on admission avoidance, while others focussed on early supported discharge. Variability in the maturity of different services was also evident.

Expansion of the service

Mixed views around expansion were expressed. Some respondents in well established services felt that, while they knew there was a commitment to expand the service, it was less clear if this meant increasing volume of activity, or growth into new service areas or geographical regions. It was also unclear if expansion would mean an increase in staff to help meet any increase in service provision. Unless expansion was matched with sufficient resources (both staff and materials) it was felt that existing quality of care standards could be compromised. Expansion has also not been clearly operationalised or quantified at the micro/local level.

Main Findings: Referral into Hospital at Home

Frequency of referrals

Just over a third (35%) of referrers in the workforce survey said they referred to a H@H service very or quite often, 31% ‘not often’ and 27% reported doing so ‘rarely’, ‘very rarely’ or ‘never’. A small minority (7%) responded that they were not aware of any H@H provision in their Health Board^[2]. Most referrers who took part in interviews or focus groups reported that they regularly referred into H@H. This ranged from daily (for paramedics) to weekly or monthly for GPs, showing significant variation in use of H@H between individual practitioners.

Ease of referrals

Around half (51%) of workforce survey referrers who had previously completed a referral said that the referral process was mostly or almost always straightforward, whilst 15% said that it was mostly or almost always difficult. A third (34%) reported the process was sometimes straightforward and sometimes difficult.

Those working in General Practice were the most likely to describe the referral process as mostly or almost always straightforward (62%) compared to those working in emergency medicine and primary care out-of-hours.

Those who rated the referral process as always or mostly straightforward were significantly more likely to agree or strongly agree (compared to others) that: they had confidence in the quality of H@H care given to patients (93%, compared to 68%), the H@H team(s) in their area actively engaged with them to share patient referral criteria (67%, compared to 37%) and they had a clear understanding of the H@H referral criteria in their area (88% compared to 65%).

Referral: What works well

Buy in and utilisation of H@H

A clear majority of workforce survey referrers agreed (46%) or strongly agreed (48%) that, where clinically appropriate, they would actively seek to refer a patient to an available H@H service. Furthermore, around three in four agreed (38%) or strongly agreed (39%) they were confident that the H@H services in their area provide a high quality of patient care.

Qualitative responses from referrers also evidenced a positive view of the service, particularly aligned to the aim of reducing hospital admissions, sometimes in spite of a view that the existing delivery processes could be improved. A small number of staff explicitly indicated that they felt the scope and range of services offered could be expanded. Some workforce survey respondents suggested widening criteria for existing pathway(s), introducing new pathways or reintroducing pathways no longer in operation locally.

Engagement between H@H teams and referrers

Three quarters (75%) of workforce survey deliverers agreed or strongly agreed that their service proactively engaged with their referral pathways, whilst a smaller proportion of referrers (49%) agreed or strongly agreed that the H@H team(s) in their Health Board actively engaged with them/their team to share their patient referral criteria.

Communication from H@H teams was generally described in very positive terms by referrers who took part in interviews and focus groups. Face-to-face contact with teams was suggested as the best way to ensure that practitioners engaged in learning about the service.

Referral: Existing challenges

Capacity to accept referrals

Numerous referrers raised frustrations about a perceived lack of capacity in H@H services, which hindered the number of referrals they were able to make. Calls were made for real-time information around services’ capacity, to reduce time spent referring a patient to H@H only for the referral to be rejected due to lack of capacity.

Limited visibility over service capacity was further exacerbated by there being multiple referral routes into H@H, i.e. via a Flow Navigation Centre, from GPs directly, from hospitals for early discharge and from the ambulance service.

Adherence to referral criteria

Some delivery staff reported that inappropriate referrals were being made (i.e. outwith criteria). In such cases, these patients were nonetheless sometimes accepted, whilst other times not. This corroborated a view from referrers that inconsistency in acceptance decisions was present.

Issues with the referral process were also raised by delivery staff in relation to the timing, volume and spread of referrals received at different points in the day. This affected decisions around which patients could and could not be accepted.

Referral decision process

Another common frustration aired by referral staff was around the decision-making process for referral acceptance or rejection decisions, specifically, inconsistent approaches taken by whoever answered the call in the local H@H team, leading to confusion for referrers. The wide range of other referral options that sit alongside H@H were also described as making the referral pathway landscape confusing for GPs/primary care clinicians. Qualitative feedback revealed views that the eligibility rules and scope for H@H could be too rigid in some cases.

Out-of-hours provision

Lack of out-of-hours^[3] provision was consistently raised as something which diminished the volume of referrals that services can receive. Similarly, in interviews and focus groups, a common theme to emerge from delivery staff was frustrations that services could not take more referrals due to lack of senior staff availability outside of their core operating hours.

Clarity on responsibility for the patient

A frequently cited concern among referrer focus group and interview participants was around who had overall responsibility for a patient at various points in their H@H journey and risks attached to ambiguity in responsibility. Others expressed concern for the sufficiency of expertise to cover the needs of all patients accepted, including non-specialist staff looking after patients in a non-hospital environment.

Main Findings: Delivery of Hospital at Home

Delivery: what works well

Delivery teams’ skills and experience

In the workforce survey, 67% of deliverers agreed or strongly agreed that the skill set in their team was sufficient to meet requirements. In interviews and focus groups, most delivery staff also reflected that their local H@H teams comprised a strong mix of staff from different professional backgrounds, and with different expertise, and considered this a strength of the H@H model.

Point of Care testing and equipment for specialist treatment

A large number of deliverers across the survey and focus groups mentioned Point of Care (POC) testing as a key strength of the H@H service, as well as being able to provide intravenous antibiotics or fluids, and oxygen.

Remote monitoring

Access to remote monitoring^[4] was praised as assisting delivery of H@H, and was perceived as largely welcomed by patients as a way of helping them to retain ownership over their care (although it was recognised that some patients and their families/carers could experience challenges with the equipment).

Senior leadership promotion and support

Deliverers indicated in survey responses that they felt there was some (38%) or strong promotion (44%) of H@H by their senior leaders. Those who reported strong promotion were significantly more likely than others to agree or strongly agree with a number of statements about their team, including that: they had the required medical equipment (79% compared to 51%), they were able to fill vacancies quickly and effectively (51% compared to 16%) and they had enough staff in their team (46% compared to 25%).

In interviews and focus groups, most referral staff also noted that there appeared to be strong leadership promotion of the service. However, among delivery staff, there was consensus that information about expectations, changes to the service and future plans were not always sufficiently well communicated to teams.

Teamwork, processes and training

Workforce survey findings suggest that deliverers felt that their teams’ had appropriate processes in place, including relevant training and professional development opportunities (69%), clear goals and strategies for improving efficiency and expanding their service (59%), clearly defined and agreed referral criteria (81%) and clear processes for gathering and responding to feedback (78%).

Others cited a strong sense of ‘team’ and the collegiate nature of the approach that had built up locally among the practitioners. Calls were made, however, for more career development and training opportunities for staff, including protected ‘time out’ for this.

Engagement and collaboration

Most H@H teams felt that their services integrated well with wider health and social care services in their area. Effective partnership working was also identified, underpinned by multidisciplinary and collaborative teamwork and communication.

Patient awareness and understanding

Awareness of H@H among the patient population was seen to be reasonably strong. It was perceived though that not all patients had sufficient clarity around their admission to H@H in terms of who was managing their care and that more could be done to raise awareness among the public.

Delivery of Hospital at Home: Existing barriers

Staffing levels, recruitment and retention

Over half (56%) of workforce survey delivery respondents disagreed or strongly disagreed that there were enough staff in their team to meet the level of demand. Half of delivery respondents also disagreed or strongly disagreed that their team was able to fill vacancies quickly and effectively.

Similarly, staff shortages, problems with staff recruitment/retention (including protracted recruitment processes), and gaps in specific or specialist staff input affecting delivery were prominent qualitative themes.

Medical equipment availability

Delivery participants felt that, while generally well provided for, some gaps remained in equipment availability. This included insufficient: supplies/cartridges for POC testing, ultrasound machines, portable x-rays and equipment for bladder scans. Access to equipment that was easier to manoeuvre was also encouraged.

IT equipment availability and remote working

Only 49% of workforce survey delivery respondents agreed or strongly agreed that they had the required IT equipment to undertake their work effectively. Many highlighted a need for additional IT equipment (especially laptops for all staff to enable real‑time information gathering), as well as a more efficient remote working environment and streamlined software infrastructure that allows key medical documentation to be accessed promptly. Poor connectivity was also a problem reported by some.

Funding structures

A lack of specificity and certainty regarding funding was seen to impact teams’ planning. It was felt that while the overall Scottish Government funding allows Boards to tailor services to local needs, having a clear stipulation on what proportion of money should be dedicated to H@H (including potential new pathways) was seen as something which might be helpful.

Again, staff shortages were seen as being linked to short-term funding for H@H, acting as a barrier to recruitment and retention. Among referral staff qualitative feedback hinted at perceptions that the funding of H@H services was sometimes at the expense of other services across the NHS.

Travel and transport

Time spent travelling was identified as an inefficiency by deliverers in different teams and contexts (i.e. rural areas with long distances between sites, and urban areas where traffic congestion could cause delays). Suggested solutions included funding for dedicated driver support.

Access to social care and community services

Limited availability and inequitable access to wider social care was raised, i.e. to support relevant individuals at home whilst experiencing acute illness, even when H@H was in place to meet the patient’s acute medical needs. Difficulties in accessing services provided by community rehabilitation teams and physiotherapists was also raised as a current barrier to effective delivery.

Reliance on families and carers

Success of H@H was also described as being very much dependent on the home environment in which the patient lived and the wider support available to them (i.e. those living with family or carers may be more likely to have support to enable them to complete an episode of H@H care than those who lived alone). However, in cases where patients were reluctant to engage with H@H, this was typically seen as being linked to the patient’s view that it may impact negatively on their family/loved ones.

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.
• Continuing to roll out expanded use of equipment enabled Point of Care testing and remote monitoring.
• Ensuring that strong senior promotion of the service remains in place, and that communication on the expansion of the service is universally received.

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.

Conclusion

Phase 1 of the evaluation revealed a number of effective processes and practices currently in place, and service elements which could usefully be replicated nationally. The research also revealed a number of challenges from the perspective of the workforce, as well as learning linked to the geography, maturity and nature of the different services being offered. These point to a range of possible improvements that could be implemented.