View from the ground, by Dr Honor Merriman
Recently, I was unwell to such an extent that I stopped being able to think and became dehydrated. My nonmedical husband went to meet friends for coffee, and was given an electronic blood pressure monitor by a friend. When he got home, I tried it out to show him how it worked. My reading was surprisingly low, which fitted with being unable to stand—so I phoned work to say that I would not be in that afternoon.
My GP advised that I go to our local acute assessment unit, but I was too muddled to think how I would get there. She rang off, and about an hour later, the Hospital at Home team arrived at my house. The team consisted of an experienced medical clinician, nurses, and observers. In a few minutes, the team did several observations, inserted a cannula, and took blood samples for a near-patient testing machine. Because one of my legs was red and swollen, the doctor used ultrasound to exclude deep vein thrombosis. In a short time, I was given intravenous antibiotics. It was all done so smoothly, and everything was explained to me.
So began my recovery. Over the next few days, I was visited each day, and a further infusion of antibiotics was delivered by a nurse. The whole team was wonderful: I had been aware of our local team for some time, but to experience it in action was special.
The idea of delivering care in patients’ homes instead of admitting them to hospital is not new. The COVID-19 pandemic hastened the development of these services—solutions were required for the increased demand for acute care, and these were facilitated by improvements in remote monitoring. Hence, in 2020, 95% of integrated care systems (ICSs) received funding to develop virtual ward systems,1 and services like Hospital at Home were established to offer both acute care and monitoring of long-term conditions for defined periods.2–4 Now, home-based services are offered in most areas of England, tailored to the needs of local communities.
Studies of home-based services have found that they are cost effective, with comparable or improved outcomes for patients.5,6 However, the advantages of virtual wards are not just economic.2,5,6 Hospital admission carries risks, such as deconditioning, delirium, and hospital-acquired infection.3 Not everyone is suited to acute care.3 That said, although living alone with no family support does not necessarily exclude people from home care, hospital care may be safer.3 When considering whether a patient is suited to home care, the British Geriatrics Society suggests using the acronym ‘DOT’:3
- drink—can they get a drink on their own, or do they have someone who can get it for them?
- once a day—can they cope with a visit from the team only once a day?
- toilet—can they get to the toilet on their own, or do they have someone who can help them?
Funding is available for further development of these schemes. In England, £200 million is available to support the establishment of virtual wards in 2022/23.3 In 2023/24, an additional £250 million will be available.3 ICSs have been asked to plan for 40–50 virtual beds per 100,000 population by December 2023.3,4 A full breakdown of funding allocations by ICS is available in the letter to systems from NHS England dated 19 April 2022, which is accessible via the FutureNHS platform.7
The future of these services will depend on the needs of local populations.8 Options for acute care outside of hospital are described in the article Right time, right place: urgent community-based care for older people, and include:8
- Hospital at Home
- urgent community response
- same-day emergency care
- frailty assessment units
- virtual wards.
The article advises planners to consider what will work best for the local population, geography of the area, services already in place, and capacity available.8 Hybrid models should be considered.8 Assessments, such as those offered by the Getting It Right First Time programme, may also be helpful for providing an understanding of the services required.8,9
In future, these systems will evolve and learn from one other. I hope I will never need the Hospital at Home service again—however, I can see these services becoming a greater part of care for our ageing population.