Schemes evolve gradually

EDITOR—In his editorial on hospital at home schemes Iliffe highlights the need for “descriptive studies of the organisational culture and practice of [such] innovative services” to supplement the findings of trials.1 In evaluating a local hospital at home scheme for orthopaedic patients2 we put our findings into context by obtaining the views of hospital and community based staff on the practicality and acceptability of such a service.3

At the outset the staff were ambivalent about the concept of early discharge. Although they were more positive about the concept once the service started, many remained negative about the practicality of running the service. Staffing and financial costs gave rise to particular concerns. Despite apprehension that general practitioners may face additional burdens, neither the reported studies 4 5 nor our own findings support this. We can also confirm Iliffe's suggestion that length of stay was sometimes prolonged by delays in arranging social services support to enable seamless care on discharge.

Controlled trials generally use dedicated teams, but this scheme had occasionally to rely on locum cover for physiotherapists and occupational therapists, with consequences for patient throughput and, potentially, continuity of care. Staff turnover was unusually high, which could partly be explained by healthcare support workers using the scheme as a stepping stone to a clinical career. Such staffing features are not necessarily accounted for in economic analyses, which makes it even more difficult for providers to interpret the currently equivocal views on cost benefit.

There was some anxiety about awareness of the roles and responsibilities of each member of the team and about encroaching on other professionals' roles. The needs for suitable training and good communication systems were highlighted. The introduction of healthcare support workers spawned a training programme that is now used for ancillary staff throughout the trust. …