Hospital at home, virtual wards and turning care in the community on its head

Last week I attended the second annual Hospital at Home (H@H) conference. It was online as they are nowadays and representatives joined from the Four Nations as well as Singapore and Australia.

H@H or, if you are living in England, Virtual Wards are the NHS’s latest thing.

Somewhere in Whitehall it recently dawned on the mandarins that we couldn’t keep doing what we have been doing and expect, to survive.

Apologies for the convoluted cliché.

Building more and bigger hospitals in a society that is ageing, in a health and social care service that is supporting more and more people with chronic, long-term conditions, pretending we are still living in the 1960’s is unsustainable.

Not only can the system not continue as it is (trying checking-out the A&E waiting times near you), it has reached a point where the benefits in many instances outweigh the harms.

No one has particularly challenged me over this, although I think it is apposite to mention, my thesis does not extend to shutting-down all the hospitals, rather, it extends to a repurposing of what goes on in a hospital and how the patients are treated.

As an example, were I to develop a brain tumour, let’s go for something relatively benign like a pre-frontal meningioma. If I had one of those, I’d want the neurosurgeon to drill into my brain in the most sophisticated hi-tec operating theatre in the country. I’d hope for cutting-edge diagnostics and infection-free facilities. I would accept spending time in a hospital to gain access to this care and support.

If, however, I was 90 and I fell at home or in my care home and I had a minor bump on my head, the very last place I would like to be taken is hospital. Care in my home, with doctors, nurses, therapists and everyone else I might require to support my recovery and return to independence, would be better in my little house.

You see, there is no Covid in my home, the floors aren’t slippery, I have my favourite mugs and all my clothes. Sure, Blake the dog might get in the way although we could train him. No one would obsess over my length of stay and there would be little chance of a confused fellow patient climbing into my bed in the middle of the night or all the lights on a ward being switched-on at 6am for ‘drug rounds and observations’.

We talk about a health service (which is very good) that is based upon person-centred principles, with the person aka the patient at the core of everything we do, and yet, when you draw graphs of the organisational structures of health and social care organisations, and examine the ebb and flow of money, hospitals tend to sit in the centre (financially if not diagrammatically).

H@H sees an inversion of this.

The plan for Virtual Wards does too.

The proposal is (from memory) 20 beds per 100,000 population, equating to a 50-bedded virtual ward in Rotherham, and lots, lots more in the bigger cities

I haven’t really explained what I mean by H@H.

I’ll give an example of the current state and one which might evolve.

Let’s imagine Albert, 89 years old.

Albert has a new Covid infection, in his late 80’s with all the associated conditions –diabetes, COPD, hypertension, underactive thyroid and ischaemic heart disease.

He has had all three vaccines currently available on the NHS and despite the Covid he isn’t too unwell.

His son asks for a home visit because he has noticed they have become delirious and a little chesty.

As a doctor working outside of hospital you are quite limited by what you can do.

Checking heart rate, oxygen saturations, blood pressure and so on are straightforward.

You can talk with the patient and their family. (If you are a GP you have to rush back to the surgery in 20 minutes to sort all your other patients.)

You can determine a diagnosis and work-out what to do.

The options would are either, wait and see what happens or, call an ambulance (there are in-betweens, for the purpose of this blog, please bear-with).

The doctor calling the ambulance rationalises their actions, ‘I don’t know what will happen to their chest (NB not ‘Albert’, but his chest – a lapse into pathology and medical-speak helps the doctor distance themselves emotionally and psychologically) – it (their chest) might get much worse tonight, he is a little wheezy, could be the start of Covid pneumonitis, I don’t know if he has become dehydrated, sure, he can drink at home, but there is no access to IV fluids, and what if he needs intravenous antibiotics, and, then there is the confusion, and his CRP (test of infection/inflammation) what is that doing? Sure, if he gets much, much worse, he wouldn’t want to go on a ventilator (he told me), yet, he is still quite fit (for an 89 year old with all his health conditions), and, how will he manage, what if he falls?

Just a soupcon of a doctor’s internal dialogue.

The doctor further rationalises, ‘Well, if I call the ambulance and they take him to hospital and A&E check him over (do bloods and an x-ray) and he is fine they can send him home’ (doctor, internally not wanting to concede that trip to hospital will take four hours (ambulance are very, very busy), A&E is rammed, it will take eight hours for him to be seen by a doctor and by the time the bloods and x-ray are back, even if they are all normal it will be too late at night to send him home’) (So, yes, although not openly admitting, ‘ambulance’ means, move to medical ward for a period of time.) (Oh, and, as he has Covid, that is, the Covid ward. No visitors.)

In the conference a team from Northern Ireland presented cases of patients they had supported at home.

One was a man similar to Albert.

He didn’t want to go to hospital, he said he would rather die than go. The H@H went to him.

They provided oxygen, intravenous antibiotics, steroids, Remdesivir. They monitored his fluids his blood pressure and provided extra support for him and his wife. It was a wraparound in the community.

He recovered – he was so grateful he even made a You Tube thank you (played at the conference).

Some of you reading this might be thinking, ‘Ah, but the cost, the logistics!’ and, yes, that care was expensive, and not likely the intensity most patients require who will be supported at home, yet for this man, the alternative would have been death. And, again, ‘Well, if he wasn’t willing to go to hospital he should have been left to die,’ Some might think (but not say), and yes, there is a resource and an economic argument within the ethics of all of that, and yet.

And yet, research recently conducted on H@H has shown that it is overall less expensive than hospital care (which has multitudes of hidden costs) – the saving being, in the region of £2,000 per patient (supported at home rather than hospital).

‘What?! Why aren’t we already doing this!’

Well, a major factor is the model of care we have inherited from the last century, the medico-centric, bigger and better hospitals concept (What was it that BJ said about building 40 new hospitals?)

If we change the focus, the movement of the money, the staff and the resources from hospitals into the community, to develop community services we can achieve the miraculous.

Have a good week.

the sick child

Published by rodkersh1948

Trying to understand the world, one emotion at a time.

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