How Hospital At Home is changing outcomes for patients – Claire Ritchie

Posted on October 15, 2020

NHS Lanarkshire started out on a journey to deliver Hospital At Home to patients 10 years ago. As our organisation continues to work with NHS boards to introduce Hospital At Home, Claire Ritchie explains the journey she went on to develop the service with Graham Ellis and Trudi Marshall from NHS Lanarkshire, and the huge importance of people seeing the service in action to fully understand the benefits it brings.

Hospitals fulfil a crucial role in delivering vital care to patients. But we also know that there can be downsides to hospital care, especially for older people. They are more at risk of medication errors, they can pick up infections and delirium, and they can become institutionalised. Moreover, due to the fact that they are less likely to move around, they can become more prone to falls, and with 50% of patients not returning to their previous level of functional ability. Not to mention the emotional and psychological impact of being away from family, friends and familiar surroundings. We also know that most older people would prefer to stay at home rather than to enter hospital.

In order to help address issues like these, 10 years ago NHS Lanarkshire started out on a journey to establish a Hospital At Home service, as part of wider efforts to reshape care across the NHS board area. In essence, to deliver acute care to people in their own homes through the co-ordinated efforts of a specialist team working together to keep the patient out of hospital, at the same time as improving their health. Now, we have Hospital At Home across Lanarkshire with only two localities outstanding. On a daily basis we see the benefits to patients and their families. We keep 79% of patients at home, who would have been admitted to hospital. In addition, patients have a shorter length of stay on the Hospital At Home virtual ward, and high level of patient and family satisfaction.

Ten years starting from an exploratory week

But how did we get here?

Well, the journey started back in 2009/10. With my colleagues Graham Eliis and Trudi Marshall, we visited a geriatrician in Gwent in Wales, who’d set up Hospital At Home in Torfaen. We looked at his data and decided to spend a week carrying out a ‘try storm’, to explore if it could work in Lanarkshire – we agreed we would test a Hospital At Home service for one week to dip a toe in the water. We worked with the North Lanarkshire partnership, community teams, a couple of GPs and a district nurse to pull together a small team to work within this one area for a week, basing ourselves in a care home. We saw 10 patients that week, 8 of whom we maintained at home. The exercise really helped change the mind-set for everyone. One patient was on a deteriorating pathway towards a care home, but with care from the team that week, we changed his proposed pathway. This made us realise that the benefits were not just about keeping people out of acute care but, also changing a direction of travel for some patients going into care homes. Patients and their families were very positive about the care and the team. This also gave us some data to build on, ensuring others (GP’s, managers etc) had confidence in the expansion of the hospital at home model. Within a year we’d established a Hospital At Home service at one site.

As the service has developed to take in more parts of Lanarkshire, it has been crucial to talk to people who would be involved in the process face-to-face, and to encourage them to spend time with us to see how it really worked. Seeing the change to patients has been key to winning hearts and minds. The impact on the community and hospitals was key. The importance of closing 45 downstream hospital beds due to the impact of hospital at home cannot be overstated. This enabled further funding of the two other Hospital At Home hubs (covering Hairmyres and Wishaw localities). We invited Scottish Government officials, including Derek Feeley (who was then CEO of the NHS) who was so impressed that he tweeted his support. Gradually interest from others began to grow and support from Scottish Government grew also.

In convincing people of the merits of Hospital At Home, data has also played a key role. This was different for various groups of people. For example, for medics who wanted to ensure the model was safe, they wanted to see mortality rates, how many ambulance conveyances we avoided, how many patients we treated in a day, rates of readmission – evidence was important, and at that point there was one systematic review, which showed mortality was lower at six months, with high patient satisfaction. Management teams were keen to ensure the model was efficient, cost-effective, and didn’t have unintended consequences on other parts of the system (such as greater workload for GPs, or community teams). What has really helped to sway the argument has been the fact that we deliver acute level care at home to those who need it. Hospital At Home is not doing the work of GPs, but management of acute unwell older people delivered by the right professionals, and all working as if the bed in the home was part of a ward.

The people who have never really needed to be convinced about Hospital At Home are the patients themselves and their families. They describe the team as like the cavalry coming over the hill, ready to sort everything out: medication, treatment, social services – and with a team of specialists at our disposal, including nurses, physios, OTs and pharmacists.

The future of Hospital At Home

Even 10 years after the first test for Hospital At Home began in NHS Lanarkshire, we still find that many clinical staff are attached to the traditional model of hospital care, and we still need to promote and persuade. In a way it’s understandable. There’s a fear of the unknown at times, as well as some practical issues like recruiting staff to key posts.

In a way, the pandemic has helped the case for Hospital At Home. There’s been a greater acceptance of the need for creativity in relation to solving health and care problems, and there’s a need now to retain that creativity as we begin to restart services that were paused.

In the future, I’d like to see Hospital At Home in every NHS board, perhaps supported by flow hubs, as well as the service being used for a wider range of conditions: heart failure, respiratory problems, renal, oncology. But the main future I’d like to see is for the patients themselves: more people getting the care they need while continuing to live their lives in their favoured surroundings and with their loved ones nearby. True person-centred care in action for all.

Claire Ritchie was an AHP Rehabilitation Consultant for Older People at NHS Lanarkshire, at the time of developing Hospital at Home. She is now Acute Site Director for Ayr Hospital in NHS Ayrshire and Arran.

More information

Healthcare Improvement Scotland’s ihub is working with NHS boards to introduce and develop Hospital At Home services.

Visit the ihub website for more information on Hospital at Home

Categories: DCRS

Death Certification Review – latest annual report shows the service is on the right track – George Fernie

Posted on October 13, 2020

This year marked the fifth year of Scotland’s Death Certification Review Service, created to ensure the accuracy of death certificates. As the service’s latest Annual Report is published, George Fernie, Senior Medical Reviewer, reflects on the year past and the service’s plans for the future.

I am genuinely delighted to be presenting my fifth annual report for the Death Certification Review Service, a significant milestone. It’s an opportune moment to reflect back on progress made over this period. It’s especially satisfying to consider what has been achieved, particularly when the process and content of the Medical Certificate of Cause of Death (MCCD) has assumed much greater public prominence due to the COVID-19 disease pandemic.

We have attained a reduction in the ‘not in order’ rate, which is the measurement the Certification of Death (Scotland) Act 20113 states best demonstrates the quality and accuracy of an MCCD. Over half of all MCCDs reviewed when the service commenced required some change, compared to now, whereby some NHS boards have a sustained improvement and a ‘not in order’ percentage rate in the ‘teens’.

A conscientious approach

Whilst there remains room for improvement, this suggests we are on the right track.

Had I predicted we would have effected this so quickly, I would have been concerned about over-optimism. However, the conscientious approach adopted by the team who have progressed the reviews in an educative and supportive manner, coupled with a responsive group of certifying doctors in Scotland, have helped us surpass our initial ambition.

We have continued to review MCCDs and improve:

quality and accuracy, giving public confidence in the death registration process in Scotland,
public health information about causes of death in Scotland, supporting consistency in recording that will help resources to be directed to the right areas in a more timely way,
clinical governance, helping to improve standards in reporting deaths across Scotland.

Although quality improvement is the main reason the service exists within Healthcare Improvement Scotland, the fact we have demonstrated sustained improvement over this timespan very much justifies our existence. This is at a time when the importance of the quality and accuracy within MCCDs has attracted great attention due to the consequences from infection by such a devastating Coronavirus.

Last year, we identified some areas we would like to focus on to support the continued improvement of certificates and the review process. I am pleased to report, we have completed some of this work and have made good progress in all other areas.

We have:

reviewed how we manage enquiry calls to the service,
increased awareness of the death certification review process across Scotland,
improved the ‘not in order’ rate in all NHS boards,
improved the speed with which the outcomes of cases reported to the Procurator Fiscal are dealt with.

Although there has been a heightened awareness by the team, especially of prescribing issues identified in the Gosport inquiry, no such systematic failings have been identified in Scottish territorial boards, although a watching brief has been maintained.

Public health benefits

Work continues on wider public health benefits where the service has co-operated with Public Health Scotland, particularly in considering the implications from the COVID-19 pandemic.

Analysis of administrative and process errors by certifying doctors and transcription errors by registrars is underway. The main impediment to completing reviews within the service level agreement is the unavailability of certifying doctors. However, the breached rate remains reassuringly low.

We also have new plans for the year ahead. We plan to complete piloting work to introduce the eMCCD into secondary care which will bring a number of benefits to families bereaved, NHS boards and registrars; and work with NHS Boards to reduce the number of clinical errors on MCCDs, including appropriate reporting to the Procurator Fiscal.

I’d like to sign off by thanking the DCRS team for all their hard work and to the NHS in Scotland for their dedication to improving the system. It’s the continued teamwork that will bring about further successes in the years ahead.

George Fernie is Senior Medical Reviewer with Healthcare Improvement Scotland’s Death Certification Review Service.