Why spend billions on hospital beds when you can care for patients at home?BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1119 (Published 16 May 2023) Cite this as: BMJ 2023;381:p1119
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I would like first to thank TESSA RICHARDS for her interesting and fascinating OPINION on:
"Why spend billions on hospital beds when you can care for patients at home?"
I was amazed and encouraged after by the many supportive RAPID RESPONSES to this excellent idea: HOSPITAL AT HOME and as mentioned by :Iain Goodhart Firdaus Aden Walla and Karen Titchener....
This new way of treatment is very much unknown in the medical world and among doctors' nurses and public at large. no doubt most patients will vote for it as stated clearly in Tessa Richards's OPINION:
"which—given the chance—I bet most patients would opt for."
Patients from all Ethnic minorities would love the idea of HOSPITAL AT HOME , most
Muslim patients and Muslim women especially would fully support This new attractive way of treatment "HaH" as we will explain later.
Over the years it was noticed that many Muslim patients who were admitted to hospitals for many different illnesses were not feeling comfortable or relaxed while staying in hospitals
and they seem to develop different types of stress : "HOSPITAL ANXIETY"
for a lot of reasons:
-Difficulty and inconvenience in order to perform the 5 daily prayers with the many washing for ablution before the prayers.
Obviously, it depends on the type of illness ,to perform the formal prayers:
By :Standing Kneeling Prostrating... but many are allowed to pray while lying in bed
by using hand or eye movements.
-Some Muslim men and women do need to take showers for different occasions and in special circumstances
-Worry about the meat/food offered if is truly HALAL(permissible) and many would love to eat their own cultural dishes as they have at their houses.
-A lot of worry if they were admitted to mixed wards .
-Worry among many Muslim women regarding her Hijab(covering the hair) and the importance to dress with modesty in front of public/Staff/visitors
-And Worry and concern too in case they will be seen and examined by male doctors
-Some might have language problem
-Some Muslim patients worry about racism
-Worry about feeling lonely and isolated and away from their families and children
Muslims by and large,are family minded and love to be frequently with their own family members
And they are very keen to see more visitors from the family....
These are some of the problems and worries and stress which do affect our Muslim patients
when they are admitted to hospitals !
No doubt , HOSPITAL AT HOME is the real answer the REAL CURE and most needed to Muslim patients today as it will avoid them and prevent them from having all these stresses and worries when they are admitted to hospitals...
More: We believe ,RECOVERY AND HEALING will be faster in the HOSPITAL AT HOME
apart from the SAVING OF BILLIONS IN HOSPITAL BEDS ...!
DR MAJID KATME
Retired medical doctor(Psychiatrist)
Former President of: Islamic Medical Association/UK
Competing interests: No competing interests
NHS England’s permissive definition of virtual wards and a focus on building capacity has sparked a rapid expansion of existing services and a wave of new virtual wards across the country. These wards often function in silos and their capability, clinical focus, and value for money vary greatly. The heterogenicity is making it very difficult to benchmark and standardise measures of care. Their ability to have a positive impact on frailty and elderly care is hindered by the ongoing deficit in social care. The author of this article has given an excellent summary of the content of the 2023 WHAHC and recognised that the variation and challenges that we see within the UK are also seen across the world.
Achieving buy-in from patients and clinicians requires more than simply overcoming political scepticism, it requires trust and an understanding of the services that they are being asked to work with. With such variation across the globe, and the UK, it becomes very difficult to build this trust. There is no common currency in virtual care and as a result patients and clinicians are confused by what can be provided. The overlapping geographical territories of the wards adds further to this confusion especially for patients and GPs.
The ring-fenced funding provided specifically for virtual wards was insufficient to create trust specific, multitalented, flying squads capable of delivering the complete and comprehensive home based diagnostic and treatment services, that are showcased by some centres. While a focus on capacity created headlines and was easy to measure, now we really need to be focusing on developing capability. Maximising what can be achieved while maintaining absolute patient safety. The demand and capacity will naturally follow. Many systems across the country have now moved to a phase of building collaborative and integrated systems between neighbouring wards. Harnessing the best of what has been developed and maximising access, care, quality, and patient benefit. By working together, sharing ideas on NHS futures, and other platforms, we can massively increase the scope of what we can deliver.
You are free to subscribe to the cynical position that virtual wards aim to evict patients from hospital and deliver healthcare on the cheap while grabbing headlines claiming expansion in NHS capacity or you can recognise that the way we deliver healthcare needs to change. Continuous remote monitoring means that our virtual patients can be more closely watched than most of our inpatients. Through the virtual wards programme, we clinicians, can radically redefine health care provision, empowering our patients, liberating them, and delivering true individualised care. We need hospitals but their design, purpose and focus must evolve. It is my opinion that technology enabled virtual care, with patient focused monitoring, should become the backbone of the modern NHS. Hospitals should be used for inpatient treatment and be redesigned to provide versatile environments that minimise harm and support wellbeing and recovery. We must work together; we must share expertise and resource. We must listen to our patients and give them what they need to enable them to have true quality of life throughout life.
Competing interests: Cambridge and Peterborough ICS Clinical Led for virtual wards. CUH Clinical Director for Virtual Wards. Development Director of ePAQ Systems Ltd an NHS Technology spin out company.
Read Tessa Richards' article with interest and a touch of envy as I was unable to attend the world Hospital at Home (H@H) conference.
We have been providing a service to our local community for over 15 years as have a number of other well-established H@H services across the country. Providing acute medical care in people’s homes has been gaining momentum and received an impetus with the advent of Covid 19 and the development of Covid “virtual wards”. This helped the setting up of H@H services beyond the context of acute respiratory infections. The rapid expansion of this field encompasses all ages and a variety of clinical conditions most of which one would see presenting to the front door of an acute hospital. There is no doubt that the older frail population are most vulnerable to the adverse effects of hospitalisation and benefit most from having their medical care provided at home. Even though our service accepts referrals for all adults, the average age of patients on our caseload is 80 years.
Most of frailty is out in the community with the frailest of the frail in our care homes but the resources to look after this group of people are in hospital. Therefore, it is of no surprise that they gravitate to secondary care at the time of crisis. This imbalance does need to be addressed and H@H services working with GPs, paramedics and other community teams are best placed to provide the level of care needed to look after these patients safely in the community. The atypical and relatively slow evolution of frailty crisis, the move to virtual consultations and the lack of time and expertise in the community leads to a delay in investigation, diagnosis and treatment. In the meanwhile, the patient deconditions in the community and their social infrastructure falls apart even before they enter a hospital ward. The window of opportunity to reverse a crisis in a frail older person is small and any delay will have serious consequences on potential recovery.
A H@H service is well placed to respond to a crisis but needs a senior clinician with a dedicated team that can work extended hours. They need to be capable of responding quickly and carrying out traditional hospital based investigations and treatments in the community. Remote monitoring for the older person has a very limited role and the care provided needs to be very “hands on”. Different terminologies to describe this service has not helped, least of all the term “Virtual ward” used in England, when there is nothing virtual about looking after this group of patients.
Modern medicine is expensive business and I think “billions” will continued to be spent on hospitals. However, if we embrace the principles of H@H and change attitudes and culture in the hospital and community including educating the public and politicians then hospital beds will be readily available for the very sick, those needing urgent cancer care, surgery for chronic disabling conditions etc. In addition, paramedics will be on the roads responding in time to emergencies instead of parked outside A/Es.
A final thought on those providing this sort of care. From my experience the job satisfaction of seeing a frail older person not only getting medically better but seeing their whole life coming together with their family in support sure beats standing beside a hospital bed having to hear the perennial plea from a frail older person, “Doctor, can I go home?”
Competing interests: No competing interests
Thank you so much for this encouraging article. I myself presented at the World Hosptial at Home Conference and was very excited and motivated to here how the pandemic had accelerated the growth of hospital at home programmes. Having built several programmes in the UK before moving to the USA to build programmes, I have clearly seen the benefit to both the patient and the health systems.
If governments took seriously the impact Hospital at home programmes could have on their burgeoning capacity issues they could stop building hospitals and transfer more acute care to the community. However, the only way that this will work is for Hospital at Home programmes to grow their capacity to truly reflect a minimum of 4 acute inpatient units. 80-100 patients on the programme at any given time. Hospital at home needs to combine clinical and technology capabilities and expertise to ensure they are able to safely care for patients in the home without overburdening the patient or care givers. If leaders get this combination correct the growth potential for Hospital at home will be both transformative to the current weak community services and be a true collaborator with acute hospitals to appropriately care for "inpatient" level patients in their home rather than hospital. Hospital at Home is the way forward for all health care systems in terms of cost reduction and capacity constraints.
Competing interests: No competing interests
"No doubt some patients could benefit from virtual wards, selection being critical." ; those final three words of this quote from John Puntis balanced piece 'says it all'. Such a strategy should not become some top-down policy, it could only have a chance of success by ownership, design and implementation by those who know the problems at the sharp end. It would inevitably require additional resource and would certainly require ongoing careful assessment; none of which should be a barrier to cautious trialling. 'Democracy at Work' in the NHS (BMJ 2023;381:p783) is a prerequisite.
Competing interests: Doctors for the NHS, Keep Our NHS Public, Patients Association
At the start of her enthusiastic account of the World Hospital at Home (HaH) Congress, Tessa Richards poses the question: ‘Why spend billions on hospital beds when you can care for patients at home?’ implying that HaH would save billions of pounds. Not surprisingly, this meeting attracted enthusiasts, but there are many reasons for being cautious about seeing ‘virtual wards’ as a way out of our current crisis in healthcare. To quote the article: “Skilled (mostly) nurses and paramedics, provide hands on care in patients’ homes…….teams work alongside the patient's carers and supports them to be active team members”. If this is really about providing hospital level care at home (but without the economies of scale), will it really be cheaper? In making carers ‘active team members’, how much of the burden of care falls to them and what do they think about it? What if you don’t have friends or relatives to act as carers? What happens when remote monitoring shows you are deteriorating in the middle of the night? Most challenging of all, where will the team members actually come from given the NHS is in the midst of its worst staffing problems ever? (1).
Although the article states that HaH services generally deliver as good or better outcomes than inpatient care, the systematic review on which these claims are based (2) speaks otherwise. Conclusions about outcomes were limited by small sample sizes and heterogeneous measurement tools in the primary studies. The authors state that for both Admission Avoidance and Early Supported Discharge models, several outcomes and process indicators still require further clarification, including caregiver outcomes, cost-effectiveness and clinical complications! Note too, that just as with the World HaH Congress, the views of patients and public were not part of this research evaluation.
No doubt some patients could benefit from virtual wards, selection being critical. NHS England wants 40 virtual beds/100,000 population by December 2023. Jeremy Hunt claimed misleadingly in a radio interview that this was equivalent to seven new district hospitals (‘virtual hospitals’ perhaps, as in the unrealised New Hospitals Building Programme?)(3). Guidance from NHS England clearly sees virtual wards as a great opportunity for the private sector (4) but does not include a clear definition of what virtual wards are for, what they can and cannot be expected to achieve, minimum investment required in terms of staff (including necessary skill mix) and equipment required (5). £450m is being provided but only for the first two years, and initial funding works out as only around £1.5m per acute trust. Other than a lucrative opportunity for the independent health tech sector, it is inconceivable that virtual wards could make up for the additional 13,000 beds called for by the Royal College of Emergency Medicine (6).
Too many people believe that technical ‘solutions’ offer a simple answer to chronic underinvestment (7,8). HaH similarly pushes technology, but is also dependent on community staff who currently are just not there. The Japanese invented an experimental nursing-care robot from which we all might learn: their real-life abilities trailed far behind the expectations shaped by their hyped-up image, ending with them being locked away in a cupboard (9). For the tech enthusiasts, the words of Iona Heath are apposite: “Care happens in the space between people, in an unhurried encounter. Only humans in interaction can care” (7).
2. Leong MQ, Lim CW, Lai YF. Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open 2021;11:e043285. doi: 10.1136/bmjopen-2020-043285. pmid: 33514582
7. Heath I, Montori VM. Responding to the crisis of care. BMJ 2023;380:p464
Competing interests: I am co-chair of Keep Our NHS Public