Hospital at Home in Scotland evaluation: phase 1 findings report

Nature and Scope of Hospital at Home

This chapter explores the main feedback provided by delivery and referral staff in the workforce survey and interviews and focus groups around their understanding of the nature and scope of H@H. The sub-sections are based on salient key themes within the findings and the chapter also includes views given in relation to expansion of H@H services.

Absence of a unified understanding of H@H

Among referrers into H@H, there was very mixed feedback in engagement sessions in relation to a common understanding of the scope, principles and practices underpinning H@H. This was largely because there was no one model employed across the country and therefore no single definition available:

“I feel I’ve never really had a really clear definition told to me, if that makes sense. It’s more just kind of from, you know, word of mouth and kind of experience of finding out what they can and can’t do and things like that. That’s just how I’ve kind of come to get to where I’m at, if that makes sense.” (Referrer: Allied Health Professional)

“They seem to all be on subtly different levels, some quite dramatically different and some are looking at hospital admission avoidance, others are looking at facilitating discharge and some do both. Some will take referrals from hospital staff or from GPs and, again, there’s variation in practice.” (Referrer: Other)

While most referrers were aware of their main local service(s) some felt that there was potentially more breadth to the scope of the service(s) than they were fully aware of.

Among delivery staff, ambiguity around what was formally and informally in scope for H@H was understood to be driven by a perceived disconnect between how services were labelled and what their official referral criteria were:

“I think on the ground, there’s still lots of debate across services about what that looks like and who we can best help…for example, [local service] is specific to older people living with frailty, it’s set at older people. But the frailty aspect of that hasn’t been one of the admission and referral criteria and therefore there’s sometimes uncertainty as to, should we be taking older adults who are not frail? Or should we preferentially focus on those living with moderate to severe frailty?” (Deliverer: Other)

Similarly, some H@H pathways were delivering services consistent with other parallel pathways but under a different name. For example, Intravenous (IV) drug/antibiotic treatment or prolonged oral antibiotic treatment and patients with respiratory and heart failure conditions being cared for via the Acute/Older adult service, rather than dedicated services for these. Thus, while staff in some areas might describe offering, for example, respiratory services as part of H@H, this was not a dedicated Respiratory pathway.

A lack of clarity around the integration of specialist OPAT services into the wider H@H service was noted elsewhere:

“…there’s now this blurring where it gets quite confusing when our OPAT colleagues are coming under the umbrella and we’re saying, we’re delivering Hospital at Home bed numbers through OPAT. Whereas, actually, what is happening is that they’re coming into our outpatient services for antibiotics or…they’re living at home and going into a community hospital using a PIP line, having their antibiotics, then going home. And there’s a bit of a mismatch or scratching of heads between the definitions now. It was quite simple beforehand but then they start to throw in other services.” (Deliverer: Consultant)

In a different area, there was a suggestion that a broad raft of community services were being delivered which were perhaps not accurately being labelled as H@H:

“…the health board gets credit for that if we say, well, this is part of Hospital at Home, even if, actually, the services are totally unrelated…it just ends up blurring the edges of what Hospital at Home actually is and I guess there’s also an incentive to deliver things that aren’t really Hospital at Home services. The definition involves being Consultant led…but again, there’s a push to say that, actually, people with very remote medical supervision are delivering a Hospital at Home service because that looks good on the kind of reports from government. I think that’s a fairly big issue cos it dilutes what Hospital at Home kind of actually is.” (Deliverer: Consultant)

Comments were also made about the wide range of other referral options that sat alongside H@H, which made the referral pathway landscape confusing for GPs and other primary care clinicians when directing patients. It was suggested that confusion around H@H was simply subsumed into wider challenges presented by growing and ever-evolving referral routes presented to primary care.

Variability of delivery models

Feedback from across the different research elements suggests that there are considerable differences in how services are being run. This includes both where services are based, e.g. by staff in the community or by staff based within hospitals, and who is leading the service, e.g. Consultant led services and those led by other clinicians such as ANPs or Allied Health Professionals. Some teams also had a much greater focus on admission avoidance, while others had a focus on early supported discharge.

There were no strong views around what ‘type’ of model worked best. Having a community-based team was seen as being beneficial for admission avoidance, since there would be engagement from primary care from the beginning of the process. Similarly, having Consultant led teams in the community was seen as a strength where it meant that there was always direct patient engagement:

“…there’s that option, with the majority of patients having been seen by a Consultant or at least discussed with a Consultant, so they are getting not a dissimilar level to if they were in the hospital. So, I think that - I would see that as a very positive thing in our service.” (Deliverer: Consultant)

Feedback in relation to some of the newer or developing pathways, including Paediatrics and Neonatal services, suggests that these were also, necessarily, running slightly differently from adult services. Neonatal services, for example, were necessarily focused on early discharge rather than admission avoidance, since infants born prematurely were starting their life in the hospital, rather than in the community. Similarly, many sick children required an initial stay in hospital and the main aim for some Paediatric services was therefore early discharge smoothly and safely back to the home. While having a slightly unique model of operation, the fundamental principles for these newer pathways were still the same, i.e. to provide acute hospital level care within the home.

The different research elements show that there is also great variability in the maturity of different services

Changes and variation linked to funding

Even in longer established services, which precede the recent push to expand services and the commitment to deliver 2,000 beds in the Operational Improvement Plan (Scottish Government, 2025) , 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 made it difficult to keep abreast of what H@H currently entailed:

“My understanding of what the scope of Hospital at Home is, is something that changes every day. When I say every day, I really do mean the scope can change…You’ve also got various different ways of bending the rules or shaping the rules to suit yourself. So, as far as the scope is, the scope’s quite clear in that we’re looking to care after people at home, but what the criteria is and what the guidelines are change very, very rapidly…It’s a very, very changeable environment, you know - I’m back at work tomorrow - I can go back in tomorrow and find a lot of things have changed.” (Deliverer: Other)

Two referrers who worked across multiple HSCPs^[14] cautioned that, as each HSCP had autonomy to decide what they were going to fund and how, this was resulting in variability of provision and inequitable access to the service, i.e. a postcode lottery. One of these perceived that differences in referral practices attached to different services may inadvertently exacerbate health inequalities:

“If you don’t have a national kind of agreed level of service, then what we’re doing is just creating this sort of health inequality between certain HSCPs where, you know, particularly frail, elderly patients have access to a certain degree of care and not in other HSCPs.” (Referrer: GP)

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:

“I don’t think there is something out there to say what you should be doing and what your capacity should be, and that’s something that we’re probably finding really tricky when we’re taking new patients on…” (Deliverer: Other)

“The whole thing has been a learning curve and a massive quality improvement project with lots of tests of change. We started off doing supported discharge from hospital, just it was easier because we were based in the hospital and the patients had been assessed, so it allowed us to test…our assessment documentation and our pathways. But we developed lots of communication and networking with General Practice and the Scottish Ambulance Service and our A&E. So, we now have quite robust admission avoidance pathway.” (Deliverer: Nurse)

Comments were made that while the recent PHS clarity around H@H was helpful in setting boundaries and providing definitions, there were still some issues with making practice entirely consistent with the definition. Primarily, this was related to the need for services to be delivered ‘face-to-face’. This was often not possible in very rural or remote areas, and lack of access/connectivity to technology and the internet in some places (discussed more below) meant that even virtual ‘face-to-face’ was not achievable.

Interestingly, in a different area where all initial consultations were currently undertaken face-to-face, one practitioner questioned if it might be more efficient to use virtual consultations, since not all patients needed to be seen ‘in person’.

A lack of standardisation in how services had historically been set up and run also meant that there was no clear guidance for teams who were only recently being set up. 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.

Two delivery staff in different areas (one urban and one rural) explained that the recent involvement of PHS in defining H@H had been a huge help to teams in allowing them to refine, align and understand better what their service should look like against a standard model. Having such a definition was also seen as key in allowing any research around H@H to be more robust.

Expansion of the service

A lack of clarity around the expansion of H@H services was identified during interviews and focus groups with both deliverers and referrers. Some delivery participants 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 the number of beds/places available for existing teams/services, growth into new areas, for example, neonatal care and paediatrics or different geographical regions. They were also unsure what expansion would mean for existing teams and whether there would be an increase in staff to help meet any increase in bed spaces.

In addition, there were questions over what it might mean for staff roles/responsibilities and working hours, for example, were staff being asked to cover a longer working day, weekends, evenings, etc. Specific concerns were also raised around whether the existing Consultant resource input to teams could handle any planned expansion. There was a sense that while ‘expansion’ was widely discussed and accepted as the future direction for H@H, this had not been clearly operationalised or quantified at the micro/local level. As one respondent framed it, “How big is big?” Additionally, in the workforce survey, views were shared that leaders also were not communicating clearly with teams what future expansion plans might mean.

Unless expansion was matched with sufficient resources (both staff and materials) it was felt that existing quality of care standards could also be compromised:

“So, I think things are always done backwards. They expect you to increase the numbers [of patients] without increasing the number of staff, and you get the number of staff if you kind of meet those numbers. But the concerns that I have in relation to that is you’re pushing the existing staff harder and harder and potentially leading those members of staff to burn out because the focus is on increasing numbers with what’s existing rather than putting kind of extra people in place to increase the numbers.” (Deliverer: Advanced Nurse Practitioner)

Other foreseeable challenges with the expansion of H@H mentioned by participants included whether there would be a blurring of boundaries between different pathways, for example, to help meet the needs of patients with related co-morbidities. The close association between respiratory and heart failure problems, for example, might mean that areas offering both pathways may encounter challenges around clear criteria for which pathway would benefit the patient most. There was also a risk that referral decisions may become based on local availability and capacity of different pathways, rather than being led by medical priorities.

The push from the Scottish Government, supported by investment, was seen as helping to drive H@H forward and ensure that it maintained momentum in recent years. Despite some concerns around the short-term nature of funding, there were views that H@H was seen as very much “in vogue” and was therefore attracting significant support from, and investment by, the Scottish Government which was a fundamental enabler.

Feedback was, however, received from referral participants which questioned the cost-effectiveness and evidence base for the service. This included comments which hinted that the funding of H@H services was sometimes seen to be at the expense of other services or investment in other areas across the NHS. This did not always sit well, and was seen as misguided by some.

One respondent explicitly questioned the extent to which the effectiveness of H@H had been fully evidenced before its roll out and expansion. Specifically, they posited that there may be some false underlying assumptions regarding the current main measurement of success, i.e. saving hospital bed spaces:

“…it’s not clear to me that this is a sensible thing for the Scottish Government to be embarking on because I think that there’s a lack of randomised control trials looking at outcomes and there’s a lack of solid cost-effectiveness data and that the evidence that I have seen has been dodgy in terms of it tries to translate patients in Hospital at Home as hospital beds they’ve saved and I think that’s a very unsafe, unsound assumption to make.” (Referrer: Consultant)

The view was that GPs were referring patients who were ‘at risk’ of referral to hospital but who would not necessarily or definitively end up being admitted. As such, there were views that it was unsound to assume that just because a patient was accepted into H@H that this meant they had avoided admission or that this had ‘saved a hospital bed’ in all cases.

Some others also questioned the cost-effectiveness of H@H per se, and felt that there was not sufficient evidence to show that it presented savings to the tax payer.

It should be noted that perceptions of cost-effectiveness were very much linked to the roles that people held, with some Allied Health Professionals perceiving that H@H provided excellent value for money for their area own practice.