Hospital at Home (12 May 2025)

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Dr Aoife Duignan (AD): Hello and welcome to this episode of Clinical Conversations, which is brought to you by the Royal College of Physicians of Edinburgh Trainees and Members Committee. My name is Aoife Duignan and I'm a member of the Trainees and Members Committee and a Registrar in Geriatric Medicine in Edinburgh. Today I am delighted to be joined by two guests to talk about hospital at home. Dr Claire Steel who is President of the UK Hospital at Home Society, Consultant Physician and Clinical Lead of the Hospital at Home Service in NHS Lanarkshire. We're also joined by Dr Shelagh O’Riordan, who is a Consultant Physician and Lead for the Hospital at Home Service in East Kent. She is President-elect of the Hospital at Home Society and is National Clinical Lead for Virtual Awards with NHS England. Welcome Claire and Shelagh.  

Dr Claire Steel (CS): Thank you.  

AD: Be good to start by talking about what is hospital at home? And to get your perspectives on how it's set up around the country and what differences there are, if any, when we're talking about hospital at home and virtual wards.  

CS: Okay, I'll maybe start. Thank you very much, Aoife and the Royal College for inviting us to speak in this podcast. Hospital at home has been going around for kind of twenty-five years in some countries and I think when we're trying to look at what is hospital at home, there has been some definitions And with our, myself and Shelagh, you know, in the UK Hospital at Home Society, we've looked at a definition for Hospital at Home. So, I probably thought it'd be useful just to kind of go through what is Hospital at Home and what do we mean by Hospital at Home? What we say is that it's an acute short-term intervention for patients that would otherwise require admission to hospital. So looked after mainly kind of by secondary care, I suppose treatments and conditions that would otherwise require admission to hospital. And I suppose when we talk about who's the responsible officer, it does vary across countries, both, you know, across our four nations. Certainly, in Scotland, the responsible officer in Scotland is a medical consultant, but I think that's something that can be discussed and it's not something that's set in stone. But I think it is important to say that, you know, with hospital home, we're looking at more like secondary care is not enhanced community care. We're not there to look after patients that would otherwise be managed by the specialist in primary care. So that certainly when we're talking about hospital home, that's what we're looking at. It's short term, usually kind of between four and eight days. Does depend on the patient population that you're looking after. But I don't know, certainly in NHS England, you've used a different name rather than a different definition, and I thought that's probably something that has caused a bit of confusion in the hospital world, but I think that's probably important if Shelagh could just go through what we're talking about with regards to the virtual world, because what they are doing in England is very similar. It's just using a different term. Shelagh.  

Dr Shelagh O’Riordan (SO): Thanks, Claire. Yeah, so I didn't choose the term virtual ward. The term virtual ward came to us and just as we came out of COVID, there was this idea that there were huge numbers of people in hospital. Want for a bit of remote monitoring could be at home and of course in COVID to a certain extent that was you could see if people were getting better or maybe you would identify that they weren't and then you could quickly escalate them back to hospital. So instead of keeping them in hospital, you could have done that. Now, of course, as we came out of COVID, that turned out not to be the case at all. And there weren't huge numbers of those, but that term virtual ward then has gone to be used in exactly the same way as Claire has used. Just said, so I always say, so you're sick enough to go to hospital. You can have your hospital treatment in what we might call a bricks and mortar hospital, or you can have this hospital treatment in your home. Or you're still sick enough to stay in hospital to have further treatment or you can have that treatment at home. So I think that's a nice way of thinking about it, but just because in England we call it Virtual wards does not mean it's not the same thing. People are working absolutely towards exactly the same principles. And I think that it's quite nice to look at the definition which said that it has the staff, the equipment, the technologies, the medication, and the skills. To provide that care in your home and that it should be consultant delivered. In the England space, that consultant delivery could be A consultant, medic, physician, whoever, or it could also be a consultant practitioner or a GP with a special interest in that area. So it's slightly broader in that sense. And in England, they've gone a bit more down the line of having, so like a frailty hospital at home or virtual ward, a respiratory one, which Often focuses on early discharge of people with pneumonias and COPD and bronchiectasis and that sort of a thing. And there's a really growing heart failure versions of this. Either, you know, people never going to hospital and getting their intravenous treatments. And then a general medicine type one are the sort of big ones that are around. And we mustn't forget that the paediatric ones have been around for a while and absolutely fantastic. The evidence base for them is really good. And there's a strong but small population of hospital at home for paediatrics around the country. All over the place.  

AD: That's an age population I've not really thought about so much for hospital at home, I suppose, living at the other end of the spectrum. You mentioned the evidence base for hospital at home there and I wonder If either of you would like to expand a little bit on, I suppose, what the evidence base is for a hospital at home, I suppose, for patients, for their carers and How the impacts on costs and things like that as well when we're thinking about advantages and challenges of hospital at home.  

CS: Yeah, I'll start with that. We know that Hospital at Home has been around for years, but it wasn't until, I mean, Just for people who aren't aware, there was a big randomized controlled trial back a number of years ago and that was kind of run out of nine hospital home services across the UK. Across all four nations, Northern Ireland, Scotland, England and Wales. And that covered over a thousand patients. Now that mainly was patients that were stepped down from the medical admissions unit. It was quite hard to try and recruit patients in already established hospital homes when you were saying to them at home, You might get a chance you would have to go into hospital. Now, a lot of patients say, well, I don't want to risk that chance. So certainly most of the patients were recruited from the medical admissions unit, but you know, these are kind of front door patients. When they did, the main thing when they looked at the evidence was, is this something that's safe? Because that's something that in trying to get people Taking on board what hospital home is, whether it's clinicians or patients, we need to make sure that it's something that's safe. And certainly from that randomized control trial, it said there was no increased mortality from Being in the hospital home service, they did look at also reduced limb to stay, so these patients were more likely to get out of hospital quicker. They looked at reduced institutionalization, so these patients, less patients, were likely to be in, into a care home. And then out of that randomized controlled trial, they also looked at the economic analysis, because we have to say, Yes, it's proven that it is as safe, but is it beneficial with regards to cost? And certainly that showed it was more cost effective. And since then, they have, you know, they've done some Cochrane reviews last year looking at, you know, the fact that it is, you know, it's more cost effective. We know that patient satisfaction is excellent. I suppose the thing that probably needs to be looked at a bit more is looking at carer strain and burden because we know that when patients are at home In some cases, you know, they are going to need more carer support and that's usually by the unpaid carer. But generally from the evidence, patient satisfaction and carer satisfaction is generally good. I think the thing that we're probably not there yet is, you know, we know it's cost effective. We know it's clinically beneficial to mainly the elderly population because that's where the studies have mainly been with. But it's then looking at how do we then scale up and have sustainability. So that's where that's probably where we need to look at in more research. There is some research into the paediatric side of things, but I'm not quite as aware of as a geriatrician by background, but certainly that's something, as Shelagh alluded to, that the paediatric world, certainly down in the south of England are really embracing that and there's certainly evidence out there for the paediatric side. 

SO: Aoife, there's a publication done in the southeast of England, so it's an NHS region which includes about ten integrated And they looked at the step up version. So the people didn't ever go to hospital. They stayed at home. So they looked at all of those and they worked out what the predicted number of admissions would have been in comparison to the actual number of admissions. In the places that had these step-up hospital home, again, mostly frailty, but not completely. So they had medical, they had The spirit tree and heart failure as well. And that was really interesting because it showed that in places where it was running at scale and that had an established service, you could see an absolutely strong correlation between A reduction in admission from what would be predicted versus what actually happened as these scaled up. And so that really implies that if you get your patients right, so you actually genuinely see people who would have been in hospital. You make an, it's sort of obvious, isn't it? But people don't necessarily believe us. So it would make an obvious difference to the number of admissions. That was nice. And what that also showed that they then worked out how much the services cost in comparison to the classic, you know, it costs X amount to keep somebody in hospital. And mostly driven by significantly shorter length of stays, but also actually cheaper day-to-day care. It was in the Southeast in that year, it made about a ten million pounds cost saving, which is interesting. It's not randomized or anything like that. So it's flawed, but I think in the same sense, it gives a very good indicator. And what I thought was really interesting is that you can't expect a new board Who are just starting out to make a big difference at the beginning. You need to give them time to gain the skills, gain the confidence, understand the risks. And I think one of the things we should talk about in a minute is the risks. And then I think then you can start to reap the benefits. I think that's really interesting.  

AD: One of the things you said about new services versus more established services that had the opportunity to work in quite a new hospital at home and one that had been running for quite a long time and It's quite a journey to, I suppose, both work with the teams that are referring to you or to try to help build up those relationships. And also to build up the skills within your team and the networks within the community to keep people at home and then seeing, I suppose, How a really experienced team is able to work to support people and that it's not just the doctors and nurses that need to be skilled, but it's also, you know, all of the support workers and Logistics around the clinical team that really kind of seemed to bring everything together. You've also, I suppose, alluded both to, I suppose, patients stepping up into hospital and or else avoiding admission or stepping out of hospital and it might be useful, I suppose, to give an example of a hospital at home patient. Who you would perceive to be a patient who would really benefit from hospital at home and also kind of patient where there might be more risk in someone being admitted to hospital at home are the things that we might want to consider. Where it might be the right thing to stay at home but also it sometimes might be the right thing to move up to the bricks and mortar as you were talking about. 

CS: So I've been working in a service for the last fourteen years, I suppose, Aoife, when you were talking about, you know, the new versus the kind of more established services, I absolutely agree with what you said. It takes time to get services set up. And it does take a lot of collaboration with different people, both in primary care, secondary care, social work, you know, the whole, I suppose, There's a group that are required to keep these patients at home, but I work in hospital home twice a week and we do see the mainly admission avoidance. So I'll give you an example. We either take I suppose there's a couple of ways we get patients directly from Scottish Ambulance Service. We take patients that are referred by the GP and also the care home patients and So this is trying to avoid the patients even hitting the front door at A&E because we know that once the patient gets to the front door it's quite hard to then turn them around and get them back home again. Types of patients that we see, you know, for example, yesterday I had a patient with a background of dementia and who had a history of delirium when they were coming into hospital. And they had presented with a chest infection, slightly hypoxic and had a acute kidney injury in their blood test. So a number of things going on there and we felt well Could this patient be managed at home? We know that they come into hospital, they're more at risk of getting delirium and increasing the length of stay and all the kind of hospital acquired things that we know about that can happen. We were able to assess, I mean, it's very much assessing the patient, assessing the, and discussing with their Caregiver, you know, so whether this is something that could be managed at home. And as we've said, safety certainly is priority, but also what are the patients' and families' wishes? So their main priority was to stay at home and we provide oxygen in our service. We provide IV fluids if required. So sometimes in our patients actually just withholding their nephrotoxins and, and actually when they've got carers, you know, this, The husband was there, was able to actually give this patient, you know, plenty of fluids. We know in the hospital it can be quite tricky, you know, when there's twenty-four patients in a ward and limited staff. So we were able to give the patients fluids at home and oxygen and actually just discussing with the family about what we can do. And I think it helps being a consultant also in the acute hospital because we can see that This is what we would be doing in the hospital in the same way as what we would be doing at home. So, and certainly I think it does depend on Who's potentially at home with a patient. This was a patient with dementia and had somebody to support them. I think it can be a bit more tricky if the patient is at home. You know, if they're wayfinding, we're having to give oxygen. Sometimes actually it can be more risky with trip hazards. So I think we've talked about this before, Shelagh and I, about, you know, kind of, we can manage very sick patients at home. But it depends on what the patient's wishes are, family wishes are, and supporting that. So I think there's, yeah, I think we can manage lots of patients, and certainly in this patient's It was very appropriate to manage them at home.  

SO: Yeah. But it's like a really good example where I suppose a patient was able to stay at home and be supported in their own environment where the risks of delirium would seem to be so much higher having a journey in through Perhaps the emergency department and then AMU and moving around the hospital where they could have perhaps avoided ever having to leave their own bed. And that's a really good example of, I suppose, where a patient was really well set up to benefit. I suppose sometimes Patients might be referred to hospital at home where it might seem like there is more risk to them staying at home. Are there perhaps particular conditions that might make you more wary of caring for someone at home or where it might be appropriate for them to attend hospital in the first instance and then perhaps step down or? Don't get me wrong. I can't do a hip fracture on the kitchen table. So, you know, some things are, you know, if you're going to have a surgery, then you've got to go. I mean, even though in the context, it really does depend on what their escalation plans are. And you know, I don't know whether lots of people are listening work in a hospital, but there's an idea of if you document somebody's treatment escalation plan, it's ward-based care or escalation to ITU and having treatments such as surgery, et cetera. Or NIV and things, but actually if you document that care plan, some form of advanced care plan when somebody's at home, there are lots of alternatives. And we've used the four peace levels. He's level one is comfort care at home with no treatment. The next one is treatment at home, but no escalation to hospital. Three would be escalation hospital but right eye to you. And then the last one obviously is all bells and whistles. And so actually having that conversation in advance, or if it hasn't happened in advance, but having it at that stage, what would you want? It's so different to being in hospitality. You never go to hospital with having fallen over and banged your head on an anticoagulant and suddenly go, well, you know, at this stage you could have a CT scan or you could not have a CT scan and you could go home. What would you want? But when the person's at home, you can do that. You can say, you know, if you go to hospital, they probably will do a CT scan. That CT scan may show a bleed depending on All sorts of different things that might or might not result in, you know, you being referred to a neurosurgeon or, you know, for an operation. And that, you know, in your case, it would almost certainly not be. So I always talk about sharing the risk. If you give the facts to the patient or if they can't understand for whatever reason their carers or next of tin or power of attorney, And they weigh up those risks, then that's their right, isn't it? Going to hospital isn't the only option. So I think we do have generally very, very sick patients, but they would be more people who the escalation plan isn't particularly for You know, escalation. It's worth saying that that's not necessarily the same around the world. It's a peculiarly UK thing. I mean, having stepping out from home, we went to the world Hospital at Home Congress, Claire and I recently, there was a big contingent. In fact, the biggest contingent of the whole conference came from the UK. And it was really interesting. There was a session on, you know, do you think you should ever step up, you know, without going to hospital and then going back home? And, but in, it's very common. Uh, if they're in, in England, it's about fifty to 60% of all people on a hospital at home or virtual ward have stepped up rather than going to hospital and coming back out, stepping down. But in both cases, it's about sharing the risk with our patients who love it. They really, you know, The idea of having a choice is quite unusual. It's very, very different. The other thing I don't think we've really brought out, but I think Claire did a bit, is what is better about it. And the lady with dementia who could drink because her husband could give her a drink. You know, but at the same time, that drink is coming out of the cup it's always come out of. It's put in the place where it always is. The toilet is in the place where it always has been, and they know exactly how to get there by putting their hands in such and such a place. And therefore, it's really weird, but I genuinely thought That the decondition that people get in hospital was related to their acute illness when I worked there. But I've seen just as acutely sick people and they just don't decondition. They carry on walking and that we hardly ever need to increase a package of care. On discharge from a hospital at home, whereas obviously in hospital, if you work in hospital and you managing people living with frailty, or even to be honest, people who don't, that increase in package of care is very, very common, isn't it?  

CS: Yeah. And I think that's why a lot of our patients don't get out of the hospital because certainly in Scotland, uh, and if you working in Scotland as well, we know that there's a lot of delays at the moment in getting patients’ home. So, in actual fact, when we see them at home, we do occasionally in our hospital and service add in packages of care, you know, Trying to get those quickly can be difficult and the natural fact sometimes our patients end up coming into hospital because they just don't have the support networks at home. It's not usually from their illness, it's More so that we actually can't safely look after them at home because they're on their own, they've got a delirium, they're wayfinding. But I think it's important to say that, you know, we've We've certainly been asked in the past about exclusion and inclusion criteria for your hospital at home service. And, you know, I think it might be different in different specialties, but seriously in frailty, I think if you have too many exclusion criteria, you're denying your patient the option of having hospital at home. You know, as Shelagh said, things like fractures, absolutely, we can't manage fractures at home. Things like NMI, you know, that's something that We can't do either. And then we looked at certainly in our service about stroke being, uh, you know, exclusion criteria. Now we know the evidence basis for inpatient stroke units, but if we've got a very, very frail elderly care home patient that actually We feel it's not going to change management bringing them in, then we're not going to deny them input from the hospital home service. I think it is important that we don't have very focused criteria. Certainly in the frailty patient, this is what we're talking about because it is important that we get what patient's wishes are. We know a lot of patients are scared of going into hospital because we know that they say, well, I might not get back out or I might end up having to go to a care home. And so I think it is important that we do discuss with patients and their caregivers what their wishes are. I think that's so true and I suppose when you're having those discussions it can be a fluid process in that what's right today might not be right in three days time and that even if someone does require to go into hospital For potentially a particular treatment that it might actually be possible to come back again if it were needed to step back down if there was ongoing treatment still required. We're not denying patients' hospital admission. I think that's the important thing, you know, that, you know, if a patient does need to go in for whatever reason, then yes, you know, they need to go in. But I think When you're setting up hospital homes as well, that you've got good links with your radiology departments, your cardiology departments, so that if patients do require investigations, whether it be a CT scan or a chest x-ray ultrasound, That they get them as quickly as if they were an inpatient. So we have to make sure there's no inequality there. So that's certainly been very useful. And I think, you know, if you are setting up also having the good links with the different departments to get patients quick access. It's essential. It reminds me of a patient I saw on Friday. We based one of our team in the ambulance headquarters each day because that we can get referrals. It's called the stack in the ambulance world, but we can take patients from the stack. And there was a man who had Quite nasty pneumonia, but not something that we couldn't manage and probably was going to need intravenous Antibiotics, et cetera. And the ambulance person was there and we had all this information and I did a sort of video consultation and I was saying, you know, we can offer you this treatment at home. And he said, oh, it's okay. The ambulance is here and I think I'll go to hospital. And I sort I've tried a bit, you know, to say, you know, it's a bit grim in hospital at the moment. I happen to know that there's quite a bit of a queuing going on. You know, we could get somebody out to you within the next hour to start your treatment. And he was like, no, I think I'll still go to hospital. And so, you know what? You went to hospital because it's not about denying people. What's right for some people isn't right for others. And I just love the idea that it's a choice. It's genuinely a choice that patients have and the same with, you know, you're sick enough, you know, you've got your heart failure, you know, you could go home and have your You know, the next couple of weeks or week of, you know, high-dose IV, Fruzamide, for instance, at home with remote monitoring and point of care testing and all this sort of stuff, or you can stay in hospital. And some people would say, oh, that sounds hideous. Much rather to stay here. And, you know, I suppose within reason, because obviously hospitals are very full and we need to find a way of changing the narrative, but it's about patients feeling safe. And I like that.  

AD: Yeah, I think that's so true as well but seeing people in their own home for some people that feels like the safest place they could possibly be where they have their own carers coming in and out or they have their family around. And that for some other people at times, they might want to know that there's someone that they can press a call bell and that there will be someone who might be able to help them. You're also talking about access to radiology and I think when I've spent time in hospital at home, it's one of the things that's been most impressive to be able to run out through radiology reg and that the patients actually had the scans sometimes faster, it seems, than they might have from the warder. In one hospital, the patient transport had arrived to the house to take the patient for a CT scan. I met them up in A&E having their sandwich after they've had their scan and got the results and then they got home before three o'clock that afternoon and he said it was almost a nice day out rather than what could have been, you know, three days sitting waiting in A&E. And that was, you know, one of the times when it felt like a much nicer journey for the patients and also as a doctor, it was really nice to see people in their own home and getting back home the same day. I suppose you've mentioned a little bit about things like antibiotics and I suppose it's maybe worked well thinking about How hospital at home perhaps differs from something like OPAT services or where it might overlap or where there might be passing between boat services. I don't know if you've any thoughts on that or...  

CS: We just define what O-PAT is because I think not everybody will know. Our patient's parental antibiotic therapy. For some of our patients, In Scotland, sometimes it can be oral antibiotics as well. They're doing what they call COPAT, which is complex. Oral antibiotic therapy as well. I think we've been seeing more as well where patients are perhaps coming up to outpatients or occasionally getting antibiotics in their own homes. But not necessarily under the care of the hospital at home teams. It's a bit different in Scotland and England, isn't it? I mean, I suppose if we've obviously done this podcast, there'll be people listening from different areas across the world. And certainly, you know, the likes of Australia, their OPAT service is Part of hospital at home. Whereas in the UK and certainly in Scotland, OPAT has been established for many years, you know, run by the ID physicians. So, you know, they have been running a lot longer than hospital home services have been. And I suppose in Scotland certainly the OPAT service is now coming under the umbrella of kind of this virtual capacity. So not necessarily specifically hospital home, but as one of the kind of strands of the virtual capacity to try and reduce patients being admitted into hospital and reducing their length of stay as well. And we've had conversations with our colleagues about where OPAT and where Hospital at Home lies and I think it's tricky and we're certainly looking at seeing how we can work together The OPAT tends to be very much the specific condition, you know, whether it be their osteomyelitis or their endocarditis. But what happens when that patient then develops an acute kidney injury or another condition exacerbation of COPD? And I think that's where the OPATS team can keep it. Look after the patients and they would otherwise require to be admitted to hospital. So I think this is where could that patient be, I suppose, cared for Alongside the hospital of home service. And I think this is where there's lots of conversations about what happens with these patients. And, you know, we've said, you know, in our hospital home service, well, we could manage that. They don't need to come in. We could, so they could still be getting their IVs in. I know Pat, with our frail patients, they're now looking at, you know, not necessarily coming up to a day unit, actually, the community nurses going out and doing their IVs at home, sort I think it is complex and I don't think we're there yet with how best because we're still sitting a bit in silos. And it's just how we work that in different areas because every health board will have a slightly different way of working. But I think we need to be working more collaboratively. Shelagh, I don't know if there's anything down in England.  

SO: So we explicitly excluded said that OPAT in its long-standing definition that it does not fit the criteria as a hospital at home or virtual ward mostly because it's People go, so-and-so is medically fit for discharge, don't they? They're medically fit for discharge, but they still need IV treatment. So they're not sick. They're well. The sick part of it has happened when they're in hospital. Then they're well and they need more treatments. So that classic thing, it doesn't fit the criteria, but it's a great thing. It's a really brilliant thing, much better than staying in hospital for it. But actually where people are being innovative is you've actually got a whole load of people who have great skills in providing treatments in people's homes. Why not use those people as part of your hospital at home models? So people who are being innovative are not trying to train a load of other people up to do, you know, intravenous treatments using elastomeric pumps and all these sorts of things. They're using those people. Who are all working together. And in that sense, I think that that it's all about using the best resources. We do not live in a place in which there was a lot of money to, you know, magically set up lots and lots of new things. So, and One of the amazing things about hospital at home is how it really, really breaks down the borders between hospital at home and at primary care. It's really sits in that middle space that not many things do. It's providing hospital type treatments, but in people's homes is very, very unusual. And still, you know, some people just don't believe we can do it. They just don't believe it could possibly be what we're doing, but it's true. We are. And I suppose you've touched there on technology. I think so much of hospital at home is about people, but you have mentioned just with things like Elastomeric prompts for antibiotics, I think, earlier on we mentioned point of care testing. It was what technologies or adaptations of what we do in the hospital can make things more deliverable at home. Or is it best to just stick to what we're used to doing? I think it's important to say that if you are setting up a new hospital and service, it's not essential to have all the extra technology. I think, you know, we set up our service many years ago without all the technology, so it can work. However, I think technology supports services, helps with decision making, makes us more efficient.  

CS: You know, I don't want to say that you must have the technology to set up a hospital and service. That's not a barrier because we have been doing it, but it can support us. And in recent years with point of care blood testing. It allows us to make a decision quicker. So for people who maybe don't understand about point of care blood testing, we take the machines into the homes with the cartridges, take the blood and within two minutes, you've really got an answer. Depending on what cartridges you have and what blood tests you specifically get from the cartridges. But, you know, knowing their renal function, their CRP, their haemoglobin and calcium being the main ones I think most people would be using. That would give us an answer, you know, within a couple of minutes about how we want to manage that patient. Now, that may be that actually, oh, the renal function is absolutely awful. Do they actually need to go into hospital? Do they need IV fluids there and then? And even things like blister packs, which so that people know in the podcast are devices for medications and trying to take nephrotoxins out. If you're not knowing the blood results right there and then and have to go back two hours later and try to take them out is really an inefficient use of staff time. Point of care certainly helps with efficiencies, help with decision making, quicker decision making, and I suppose optimum management of a patient, so Because we find that when, before we use point of care blood tests, if you've got a patient that's ten fifteen miles away from the hospital, it's taking a lot of time for the staff to Get the bloods, take them back to the hospital and then if you're then finding out a few hours later, you know, their biochemistry is completely abnormal, having to then send staff back out and get whatever treatment option that it is now. We know clinically there'll be certain things that we can do right there and then, you know, without the blood's back, but it certainly helps. And having used point of care over the last one to two years, I certainly would advocate it for our new patients. There are costs relating to point of care blood tests. We know that. We know it's, you know, significantly more expensive than if you got your bloods done in a lab. But you do have to look at the cost of petrol back and forward. You could take an extra patient on that would otherwise have to be admitted to hospital because you don't have the capacity. So the difficulty, I suppose, with using point of care is actually getting staff to change their ways And using it, I found it interesting. I kind of thought it would be, oh, we'll just start using it and we're all happy and it's great. But actually changing people to do new ways of working. Using technology takes a bit of time so if you are starting something new it does need the training and Just getting people understanding why you're doing it. So actually there's been lots of people have looked at point of care and certainly in our program, in our service, one of our nurses did look at How often we were using points of care, which wasn't great, but it certainly helped. And then when they looked to see actually did it change management and the numbers were, you know, it was actually staggering how much it did change management. So hopefully that will now change. The way staff think about how we can use it. So certainly beneficial, but you can set up a service without it. Yeah.

AD: Any thoughts on that, Shelagh?  

SO: I love all the kit. I think it's brilliant, the kit that we can have. So we use point of care testing, very similar to Claire, but we did it right from the beginning. So literally nobody even questions our use of it. In fact, sometimes I'm like, Do you think you could just send that one to the lab? Cause you know, cause it's going to be much cheaper and there's a transport for going and it's not urgent blood. So we're a little bit the opposite, but there are other things that we haven't really mentioned. Other kit that is, you know, really, really useful. So for instance, there's tiny little things these days that can give you a single lead in the six lead ECG. In seconds without any, you know, untangling all those wires and trying to find the tracing, et cetera. So that, you know, just Bluetooth thing to your phone. So that's really good. We use something called Cardia for our team, but there are lots of Others available. Point of care ultrasound is increasingly used to really make sure you've got the right diagnosis. Really good for some of the things like So really probably better than a chest x-ray for knowing what your diagnosis is. So there are people who are really advocating for that and training up to use that in the hospital at home space. And then we haven't really talked about remote monitoring, but if you think of you replacing hospital level care, one of the things that happens in hospital is a nursing team will come around and do your observations once a day, twice a day, whatever, all times a day, you know, or more. And all of that can very easily be replaced by a remote monitoring. There are various types. So there's intermittent where they put the blood pressure cuff on and it usually Bluetooth to a Some form of a device, which then, so there's usually people at the other end looking at that and making sure that there's not any problems. There's an easy way to contact people through the devices. So patients often really, really like it. That's a place where I have found my team because we only added it a little while ago. I found my team to be a little bit less enthusiastic than I am. But when you provide hospital level care at home, there's a hell of a lot of stuff to carry. And there's a lot of big bags now. A patient once said that I, I'm like Mary Poppins. I opened up my bag and pulled out of hospital. But you know, it's lots to carry. And by the time you, then you have to remember to carry the remote monitoring and you might not use it. And so it's work in progress. And a lot of the step-down models are based very much on using the remote monitoring. And there are places, Northwest London, for instance, they have, you know, hundreds of patients on remote monitoring, many of whom would otherwise be in hospital, not all, but You know, so the remote monitoring side of things is a really big addition as well. And you can actually get continuous passive monitoring. So you like wearing a watch or putting a sticker on and all these things will get better and better. As we move forward, I think the kit is such an enabler. And as Claire said, you don't need the kit, but it's a massive enabler to make this really effective for our patients.  

AD: And I suppose then with Lynch's the idea then of packing up to go out to see someone, it might be nice just as we start to wrap up to think about what a day might look like if you're working in hospital at Because in some ways it's quite similar and in some ways it's quite different from working on wards in the hospital.  

 CS: There's different models across the country, you know, across all four nations, even within Scotland itself, we have different models of how we work and who goes out. And I don't think one size fits all. And I think that will depend on your workforce that you have in that area, your geography, how rural you are. So I think it's important. I think The service that I'm in were very consultant delivered, which is different from, you know, rural areas up in the north of Scotland where they don't have the same consultant input. But you'll have patients on your virtual ward or your wards that you would be doing a ward round of and that'll depend on, as I say, which service you're in as to how you conduct that. Some do board rounds, some do. Daily ward rounds, I'm twice a week with a consultant, so you'd be having the ward round of the patients that are on your books already, so When we speak to the patients, we say you're treated as though you're an inpatient in a ward. You'll be discussed on a ward round. We'll review all your bloods, your other tests, medications, and decide accordingly. When we need to visit you because we know that not every patient needs a consultant to see a patient every day. Some need a nursing input, some might need the physiotherapy, some might just need bloods and a news score. Some are waiting and imaging, so we do vary each day as to what, what tasks and things are required to be done for that patient. And we'll send out the staff member accordingly. And I think it's something to say is that, you know, we don't want to be sending out a physio, then a support worker, then a nurse, you know, because that's three separate visits. What we're trying to do, and I think that's increasingly in a lot of services, trying to blur the lines of how staff work. So, you know, our physio will be able to take bloods in a new score and some of them are doing advanced practice and the same way our nurses are learning some rehab competencies. So I think that could say that, you know, We want to be as efficient as we can as a service, so sending out the right staff member for those patients already in our books and then deciding a plan of action each day for those patients. The new ones Thinking about, you know, what Shelagh had said about when you're going out to see Newman's with all your kits, we'd have a member of staff going out with point of care kit, hopefully the remote monitoring depending on if we have that better. They remember to take it out because it's a lot of kit that you're having to take out and also your fluids, your IVs and things. So there would be a staff member going out to do that. And doing the initial assessment now in our service, it'll be an advanced nurse practitioner that will do the diagnosis and management, or it will be the consultant depending on who's available. You would then have a kind of diagnosis treatment plan making sure that patient carers are aware of What the hospital home is about and having contact details and an escalation plan and then review things when we get back to base and then it's Same thing again, so, but there's a lot going on and we have, it's vital to have a coordinator for your service so that they know where all the staff are and if patients do become sick who you can send out to what area. So I think that's a kind of rough kind of day in the life, but I think it will vary depending on where you are, what workforce you have. 

SO: I think that knowledge of geography as well, like you say, that whether you're urban or rural planning people efficiently around your region is a unique skill in itself as well. We did find that AI can help in that space. There was a presentation at the, in Spain, they use AI to work out, so you put in all your current patients and it can work out through with the best staff. Ratio for each different, you know, so that you get, you know, the most efficient travel and then you can add into that. And now I've got a new patient in exit. So I thought that looked great and apparently it wasn't even that expensive. But in the meantime, we go sort of on post codes and the logistics of it is really interesting. And so different. And Claire's day in the life is very similar to mine. We start off with a daily board round, just like you would in hospital. Then we do a combination of visiting and video calling. The current patients, we try to do as much video calling and telephoning as we can so that we save our resources and we try and get people out as early as possible so that we're freed up For the new ones, I mean, ours is a big service, but we have at any one time, two people taking referrals, one person working in the ambulance headquarters and what we call a senior. So that would be the consultant of the day in some form. Doing all the reviewing. So that would be like the post-take order. Yeah. You know, as you go, you know, and the length of stay is fairly short. Our average length of stay is about three days, three or four days. So, you know, there's quite a high turnover. So I think hopefully that's given people a really good understanding from both of you about what it feels like or what it looks like being in hospital at home and What it can offer to patients, I suppose, if you're a GP or in primary care, thinking about who might benefit when you're meeting patients Or if you're working in hospital and thinking about stepping down, I suppose would you have any top tips for anyone thinking about becoming involved in hospital at home, whether that's joining a team or wondering It might be something that would help in their area or hospital. I was a, you know, a registrar in medicine for older adults and hadn't really thought about the kind of community and the hospital at home. And when starting working out, I actually You know, I prefer the hospital home service to actually doing the inpatient work. I feel it's more fulfilling. The patients really enjoy it. I think if you're setting up what I would say, and a slightly different thing is, you know, tips and if you're setting up a hospital owned service, who you want to be involved in your service from day one. And what we found is having a pharmacist in our service official to how things can, can work because there's lots of things that, you know, trying to understand community, And secondary care and medications and what you can take in your bag and travel and how you mix up things. Medications, you know, can it be in the house or does it need to be back in the You know, little but crucial practical things. So certainly if you're wanting to set up a service, a pharmacist being involved, if you're considering working in hospital at home, I would say definitely go for it. It's a really fulfilling area to work in. I'd say the same. Give it a try, Aoife, I'd say. Literally, I did hospital medicine for a very long time and then started providing hospital-level care at home during COVID. People did not hug me like they do in this new job. I cannot believe how fabulous this is. Patients absolutely love it. The feedback is, I mean, we hardly ever manage complaints. And in hospital, it's an industry, isn't it? Managing complaints, responding to complaints, all that, you know, it hardly ever happens. Serious incidents, again, if you've got your patients on side and you've talked to them and you're doing what they want, To do, then it's really great. So I think it's very satisfying. Give it a go. It is the future, you know, the ten year plan. Do you remember from hospital to community, from analog to digital? Those are two of the three Darzy things and it completely fits both of those. So it is absolutely the future. I think it could be massive in the next ten years. Give it a go. Don't write it off.  

AD: Well, thank you both so much for speaking to me. I think My own experiences of hospital at home have been, I think, some of the best weeks I've ever had being a doctor so far. Um, and so I agree that if anyone is interested It's definitely something to go and explore or spend time with the team. The groups of people who work in hospital at home tend to be some of the most enthusiastic and pragmatic and problem solving people that you can, you can find anywhere. I know that both of you have mentioned that you have some useful resources so we'll pop some links to those in the show notes for anyone who might want to access some.  

SO: Useful resources thinking about setting up Hospital at Home and to the UK Hospital at Home Society will include a link there as well for anyone who'd like to find out more information. You'll even join. Do join us.  

AD: Thank you both so much for speaking to us today and I hope other people have the opportunity to interact in some form with their hospital at home services in the future. Thank you.  

CS: Thank you.  

SO: Thank you.  

The T&MC sister podcast, Career Conversations, which supports medical students and trainees with career guidance and progression, as well as professional development. We wish to recommend our Demystifying Paces podcast series on career conversations. As some of you may know, in late 2023, MRCP UK updated the Paces exam format. So, we developed this new series to support PACES candidates. Episodes cover example organization, calibration, every PACES station including key changes, and candidate