Editorials

Hospital at home

Providing services traditionally associated with secondary care in the community is a feature of health policy both in Britain and abroad. "Hospital at home" is currently a popular response to the increasing demand for hospital beds. Cutting costs by avoiding admission and reducing length of stay in hospital is a central goal of such schemes. Changes in medical technology, improvements in housing, and an increasing emphasis on primary care have all encouraged the idea that some hospital services can be provided safely and more cheaply in the community.

A national survey of purchasing authorities in Britain shows that most authorities are either supporting, or planning to support, a hospital at home scheme (S Iliffe and A Haines, unpublished data). All 136 health authorities, commissions, and health boards were asked to report planned or operational hospital at home schemes in their district. Hospital at home was defined as the provision of a service that prevented hospital admission, or facilitated early discharge from hospital. The purchasing authorities were also asked whether they provided specialist paediatric or mental health services or supported schemes that made use of intensive technologies such as renal dialysis or home parenteral nutrition. Seventy six per cent of those surveyed replied, and they reported 139 existing and 100 planned hospital at home schemes. Of these, paediatric and mental health services made up 21% and 12% of schemes in operation, and a further 15% and 21% of planned schemes. Only 15% of existing or planned schemes were providing or planning to provide specific technological services. A more detailed profile of hospital at home in Britain is currently being prepared by the Policy Studies Institute (N Fulop, personal communication).

Broadly speaking, hospital at home schemes are community or hospital based. Community based schemes build on existing resources, including district nurses and domiciliary provision of other services such as physiotherapy and occupational therapy. Clinical responsibility is usually assumed by general practitioners. In hospital based schemes, consultants provide clinical responsibility, and services are provided on an outreach basis with varying degrees of integration with community services.

Considerable heterogeneity exists within this framework. Some schemes are designed to care for specific conditions, such as the home ventilation service provided to patients requiring long term mechanical ventilation in south London.¹ Other schemes provide specialist services, such as administration of intravenous antibiotics or parenteral nutrition.² Much more common are schemes to care for patients discharged early from hospital after surgical, especially orthopaedic, procedures.^{3 4 5 6} Some schemes have an open door policy, admitting patients with an unrestricted range of conditions.⁷

This concentration on personal, nurse led care rather than provision of technical services is in contrast to the development of home care in other countries. In North America in particular, high technology home care, such as intravenous drug administration and blood transfusion, is well established.⁸ These schemes usually have close ties with acute hospitals and may be encouraged by the different structure of incentives in insurance based systems of health care.

It is, of course, essential that new types of service provision are formally evaluated before they are widely adopted. There is little published research on the relative costs and benefits of different forms of hospital at home in comparison to traditional hospital care. There are some randomised studies of the early discharge of patients after specific surgical procedures, including hernia repair, abdominal hysterectomy, and cholecystectomy.^{9 10} However, these were published 20 years ago and their relevance today is limited, given the overall reduction in length of hospital stay, the use of day case surgery, and the introduction of minimally invasive surgery. More recent studies have suggested that hospital at home is a safe and acceptable way of delivering care to patients after repair of a fractured femur^{3 5 6 11 12} or hysterectomy.^{13 14} Another recent study, comparing patients with access to hospital at home to those with no access to the service, reported that hospital at home can be cheaper per bed day than hospital care for patients with a fractured femur.⁴ However, these studies were non-randomised and therefore prone to selection bias. One recent randomised study of elderly patients was limited by its small size.⁷ Three randomised trials of hospital at home are currently under way in Britain (UK Collaborative Group on Research and Development of Hospital at Home, North Thames Regional Health Authority),¹⁵ and the first results should be available in 1997. Until the results of these, and other, studies are available, it will be unclear whether hospital at home schemes represent a new, cost effective direction for health service provision or are merely a substitute technology of limited value and lifespan.

Research officer Health Services Research Unit, Department of Public Health and Primary Care, University of Oxford, Oxford OX2 6HE

Reader in primary care University College London Medical School, London N19 5NF

Sasha Shepperd, Steve Iliffe 

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