Organisational aspects of hospital at home schemes
In his editorial on hospital at home schemes, Iliffe(1) highlights the need for 'descriptive studies of the organisational culture and practice of [such] innovative services' to supplement the findings of trials. In evaluating a local hospital at home scheme for orthopaedic patients (2), we took the opportunity to contextualise our findings 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 somewhat ambivalent about the concept of early discharge. Although the staff were more positive about the concept once the service got underway, many remained quite negative about the practicality of running the service.
There were particular concerns about manpower and financial costs. However, despite apprehensions that general practitioners may face additional burdens, neither the reported studies (4-5) , nor our own findings(6) 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.
Whilst controlled trials generally use dedicated teams, this scheme on occasion had to rely upon locum cover for physiotherapists and occupational therapists, with consequences for patient throughput and, potentially, continuity of care. Staff turnover was unusually great, explained in part by health care support workers using the scheme as a stepping stone to a clinical career. Such staffing features are not necessarily accounted for in economic analyses making 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 caution in encroaching onto other professionals' roles. The needs for suitable training and good communication systems were highlighted. The introduction of health care support workers spawned a training programme that is now used trust-wide for ancillary staff. As the scheme has evolved, responsibility for discharge co-ordination by one team member, the involvement of a specific geriatrician, and the integration of the scheme into a broader intermediate care programme have occurred. However, these measures alone cannot be expected to offset the challenges of operating a multi-disciplinary, multi-agency service, with salient inter-professional tensions. Regular monitoring via audit is needed. We echo Iliffe's call for further reporting of the organisational arrangements associated with hospital at home schemes, to support service development and promote good practice.
Jane Sims, Elizabeth Rink
Lecturers in Primary Health Care Sciences
1. Iliffe S Hospital at home: from red to amber? BMJ 1998; 316: 1761-1762.
2. Rink, E.M., Sims, J., Walker, R., Pickard, L. Hospital care at home: an evaluation of a scheme for orthopaedic patients Health and Social Care in the Community 1998; 6 (3): 158-163.
3. Sims, J., Rink, E.M., Walker, R., Pickard, L. The introduction of a hospital at home service: a staff perspective J Interprofessional Care 1997; 11(2): 217-224.
4. Shepperd S Harwood D Jenkinson C Gray A Vessey M Morgan P Randomised controlled trial comparing hospital at home care with inpatient hospital care 1: three month follow-up of health outcomes BMJ 1998; 316: 1786-1791.
5. Richards S H Coast J Gunnell DJ Peters TJ Pounsford J Darlow M-A Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care BMJ 1998; 316: 1796-1801.
6. Sims, J. (1997) The Impact of the Going Home Service on General Practice in Wandsworth. A report prepared for Merton Sutton & Wandsworth MAST.
Competing interests: No competing interests