Hospital at Home in Scotland evaluation: phase 1 findings report

Key learning and areas for consideration

Phase 1 of the evaluation focussed on how H@H services are currently operating in Scotland, to identify what was working well, what was working less well, and where improvements could potentially be made. The research revealed a number of effective processes and practices currently in place, and service elements which could usefully be replicated or standardised nationally to maximise efficiency and impact. The research also revealed a number of challenges and aspects of service delivery requiring improvement from the perspective of the workforce, as well as learning linked to the geography, maturity and nature of the different services being offered. This chapter summarises key learning in each regard.

Key learning: Nature and Scope of H@H

• A wide range of different H@H service models are in place. In the absence of guidance around what services should look like or how they should be set up, services have developed to meet local needs. Funding and availability of staff both seem to be driving factors in service development.
• A lack of clarity around the scope of H@H exists, linked to the introduction of new pathways at different points in time under the H@H umbrella. This is compounded by issues around nomenclature, lack of a nationally unified definition (until recently), differing service provision in different Health Boards, and ever-changing nature of services over time (often linked to funding instability).
• The number and diversity of alternative referral pathways that exist alongside H@H creates a complex landscape for referrers when considered alongside the multiple different pathways that sit within H@H and their different operating arrangements in different areas.The absence of a standard model or operating protocol means that services often rely on iterative learning to influence service delivery in real time.
• While leadership promotion and support for H@H is evident at the macro level, improved communication around funding and local expansion intentions was encouraged between leaders and those delivering H@H services on the ground.
• While there is good awareness that expansion is required, there is less clarity around what this might look like in the immediate future and what it might mean for existing staff and resourcing allocated to teams.

Key learning: Referral

• Referrers generally appear to buy into the concept of H@H, show willingness to utilise the service, and have confidence that H@H services provide a high quality of patient care.
• H@H teams appear to be engaging well with professionals who refer into their services to raise awareness and build local rapport. However, not all communication from H@H teams may be being absorbed by busy practitioners.
• Delivery staff suggested that referral criteria are not necessarily adhered to, whilst some referrers perceived there to be inconsistency in referral acceptance decisions within services.
• A perceived lack of capacity in H@H services was reported among referrers as something which may influence decisions around whether or not to refer into the service, as well as potentially hindering the number of referrals they were able to make
• Lack of up-to-date information about services’ capacity to accept referrals was also cited as a hinderance, and it was suggested that existing operating hours limited the number of patients that could be referred.
• Some issues exist around shared understanding of where responsibility sits for patients at different points during their H@H care.

Key learning: Delivery

• Participants reported that their H@H team comprised a strong staff mix and attract confidence of referrers that they provide a high quality of patient care.
• Staff recruitment and retention was reported as one of the main challenges facing H@H teams, an issue often linked to short-term funding cycles. This lack of stability affects planning for future service delivery improvements and change. There may also be a need for more/more ready access to specialist staff to help support service delivery.
• Most deliverers appear to have access to the essential medical equipment that they need. Ability to offer services such as point of care blood testing are seen as strengths of the service (where available).
• Similarly, while deliverers appear to have access to the basic IT facilities required to deliver H@H services, access to more IT equipment, more robust Wi-Fi-connections, and integrated IT systems were encouraged.
• Remote monitoring was seen as a strength of the service.
• While H@H appears to integrate well with wider health and social care services, the absence of equitable access to social care support for patients is evident and may be impacting upon referral and delivery decisions, as well as care provision.

Geographical variations

Many of the findings presented above were generalisable across services of different levels of maturity, and in different geographical areas. Qualitative feedback did, however, reveal some nuanced differences in experiences that were linked to geography, as follows:

• Those in remote and rural areas reported finding it challenging to deliver services ‘in person’ in some cases due to the wide geographical spread of patients. A reliance on technology in these areas is perhaps greater than other areas but this can be hindered by issues linked to digital connectivity.
• Absence of POC testing can be more challenging for services in rural areas where distance and travel time requirements prohibit the ability to get routine samples to hospital and respond back in the patient’s home on the same day.
• Travel is an issue affecting both urban and rural teams, with either excessive travel times to patients’ homes, or problems associated with congestion in urban areas acting as a barrier to service efficiency.

Suggestions for the future

Based on direct feedback from both the workforce survey respondents and qualitative engagement participants, and with reference to the H@H logic model (see Appendix A), the main areas where there is scope to optimise and improve the delivery of H@H to maximise referrals, efficiency and effectiveness appear to be:

Maximise optimal delivery by:

• Continuing to circulate and embed an awareness of the PHS H@H definition, to support more standardised understanding and application of service protocols.
• 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.
• Building on existing good practice to further raise awareness of the breadth/reach of H@H services among GPs, other primary care colleagues and non-NHS staff, as well as the general population, to help meet associated H@H outcomes set out in the logic model (Outputs 5 and 8).
• Building on existing good practice to facilitate even more collaboration between teams/multi-disciplinary approaches.

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. This may help to reduce some existing lack of clarity among referrers and increase the number of accepted referrals into H@H (as per Outputs 2, 3 and 8 of the logic model).
• Providing more transparent, accessible and up-to-date information around service capacity to allow referrers to decide early on if H@H is a viable option for presenting patients. Simpler or quicker referral processes could also be considered, including the ability to make digital/remote referrals and the use of central or single points of contact.
• Minimising inefficient use of staff time, including through more and better-connected IT equipment, virtual assessment when appropriate, and funding for dedicated driver support.
• Delivering a funding model which supports teams to have greater and more consistent staff resource, facilitating increased capacity to take on referred patients (in line with Output 3 of the logic model) and potentially to implement longer hours of operation (in line with Output 13 of the logic model) and additional geographical coverage (in line with Output 4 of the logic model).
• Exploring opportunities for joint working/sharing of caseloads between specialists to allow more referrals to be accepted and more nuanced patient needs to be met (see Outputs 9 and 10 of the logic model).
• Improved admission and discharge information/communication to ensure that responsibilities for the patient are clearly understood by medical professionals, patients and their families. This includes expediting and streamlining documentation and handover processes.
• Improving access to more and better-connected technology and reduction in the reliance on paper-based record keeping. Linked to this, a need to readdress the need for ‘in person’ assessment (and whether alternative virtual assessment may be appropriate) (in line with Output 11).
• Improving access to more medical and rehabilitative equipment and materials, with improved portability/usability of the same (also in line with Output 11).
• Better access to pharmacy resource for teams, to help meet patient’s medical needs more speedily and create parity with acute hospital care in terms of access to medicines.
• More investment in staff upskilling/dedicated training (especially for nurse practitioners) and protection of time for staff to engage in networking, skills share, reflective practice and upskilling. This will assist with meeting the intended H@H outcome in the logic model around increased availability and take up of continuous professional development (Output 12).
• Achieving parity with inpatients for access to wider social care support to assist vulnerable patients to remain in the home, as well as improved collaboration with social care and equitable access to community rehabilitation teams that do not require people to be physically admitted to hospital (see Output 6 and Outcome 9 of the logic model).

Next Steps

The findings presented here reflect learning from Phase 1 of the evaluation of H@H. The next steps for the research will be to engage with patients, their families and carers to understand directly how they perceive H@H and how it has impacted on their health and wellbeing. While this research has also uncovered some early learning around impacts of H@H, more engagement with the workforce involved in delivering H@H and their primary care colleagues is needed to explore in more detail what impacts they perceive the service is having (on themselves, the wider health and social care system, and their patients). Better understanding of the cost effectiveness of H@H is also required. Each of these will be pursued as the research moves to Phase 2 and will be reported in due course. Learning from the research, alongside other existing and forthcoming evidence on the activity of H@H teams being gathered by PHS will be used to ensure that future development and delivery of H@H is evidence led.