Long queues in emergency departments is something that never seems to go away, regardless of healthcare management strategies to fast-track certain patients and free up hospital beds for those who need further monitoring and treatment.
But, what if patients – even those with complex medical needs – could be seen by hospital consultants in their own homes instead?
Dr Daniel Lasserson, professor of acute ambulatory care at the University of Warwick and geriatrician at John Radcliffe Hospital in Oxford, is an expert in the “hospital at home” model of care. And he presented strong evidence on the benefits of this innovative approach to treating sick people at a talk in Maynooth University (MU) recently. “We provide a multidisciplinary assessment and diagnosis. We deliver treatment at home and supportive care and monitoring at the same level as that provided in hospital,” said Dr Lasserson.
The use of hand-held digital devices to carry out ultrasound tests and receive instant results from blood tests – with the data returned via cloud-computing to the electronic patient records at the hospital – can mean faster diagnosis and decisions around treatment than in a busy hospital. Portable heart monitors can also be used and the medics treating a patient at home can speak with cardiologists and other specialists at the hospital to get a second opinion while in the person’s home.
“We take a whole range of common drugs with us and we do e-prescribing as if the patient was in a hospital bed. It’s the equivalent of hospital care, but more personalised. When you are in people’s home, you see a lot about how they live their lives,” he says. The service also delivers intravenous fluids, medicines and oxygen to patients in their own homes.
He suggests that older people are particularly vulnerable to hospital-based care. “The bed is too high. There is a concrete floor rather than a carpet. They don’t know where the toilet is and they can’t walk around like they can at home.”
[ ‘I wouldn’t wish it on anyone’: What to know and do about shingles ]
Dr Lasserson cites a Scottish study of hospital-at-home care which found that there was no difference in patient mortality if patients were managed at home. “There were fewer cases of delirium and fewer patients went into care homes afterwards. And, [even considering the costs of delivering care in people’s homes] it was cost-effective,” he explains.
When asked whether there is resistance among doctors to treating patients in their own homes, Dr Lasserson says that GPs don’t have a problem with it. “They just ask us to let them know when we are handing back the patient care to them.
“But hospital consultants take two different views – some are glad that someone is doing it, but not them. And some geriatricians are resistant because they fought hard for older people to get the care they need in hospitals.” Some professional specialist societies are also resistant to developing policy frameworks for such an alternative model of care, he adds.
For hospital-at-home care to scale up – there are currently more than 70 examples of it working to varying degrees in the UK – Dr Lasserson says that more healthcare professionals, particularly advanced nurse practitioners, need to have the autonomy to diagnose and treat patients at home too.
And, he contends that healthcare professionals delivering acute medical care in people’s homes need to be willing to take risks. “You have to have the confidence to manage things in people’s homes. You can often end up giving a drug for the first time at home so it’s case-by-case learning. For some patients, I have brought the hospital pharmacist with me when making these decisions.”
As people are living longer with multiple conditions and treatments, healthcare is undoubtedly becoming more complex. Dr Lasserson argues that to cope with these changing healthcare needs, hospital care should become more targeted. “Understanding what’s wrong with you before you go into hospital is the key. This should be the reason why to go from home to hospital. If you land in hospital with a plan already in place, you can get out quicker.”
We need culture change. There are no training pathways at the moment – you are either a GP or a hospital doctor
— Dr Daniel Lasserson
As a geriatrician, he often treats people in the last year of their life who don’t want to go into hospital. “We actually see people who are sicker on average than those who go into hospital. But we also see people who want to stay at home rather having multiple admissions and then die in hospital.”
Dr Lasserson was visiting Ireland because he is interested in international collaborations to advance the hospital-at-home movement. “We need culture change. There are no training pathways at the moment – you are either a GP or a hospital doctor. We need doctors in the future who have a blend of hospital training and community understanding. And we need to democratise diagnostic and treatment skills so that are spread throughout the medical team.”
Prof Martin Curley, professor of Innovation at MU and former digital health lead with the HSE, invited Dr Lasserson to speak on campus. “Shifting more care from hospital to home is one of the key shifts needed to drive change in our healthcare system,” says Prof Curley. As a strong advocate of digital healthcare, he argues that the use of hand-held diagnostic devices and digital technologies that measure patients’ vital signs are key to such a transformation. “It is positive to see the HSE looking to introduce virtual ward solutions but we need to go faster to help solve Ireland’s acute hospital bed occupancy problems and more importantly to bring better care and a better patient experience to all.”
Ireland currently has the highest levels of acute hospital occupancy in Europe. Implementing such a transformative change to treat more patients in their own homes rather than in hospitals would also require parallel levels of support for carers – either family members or professional carers – to meet the needs of patients in between visits from their hospital-at-home medical teams.
Hospital consultants have warned that it may take up to a decade to clear existing hospital waiting lists after the latest figures showed an increase.
Data for March, published by the National Treatment Purchase Fund (NTPF) on Friday, shows there were just over 463,000 people waiting outside 10- and 12-week Sláintecare targets. About half that number were within target waiting times.
The Department of Health said progress was being made in addressing long wait times, with a 3 per cent drop in numbers waiting outside its targets compared to the previous month.
Overall, since the pandemic peaks, it said there has been a 26 per cent reduction in the number of people waiting longer than the Sláintecare targets, which equates to approximately 164,000 people.
“Despite the significant challenges from the aftermath of the Covid-19 pandemic, emergency department pressures and other operational factors, including recruitment, our hospitals have delivered improvements which are making a real difference to patients,” the department said in a statement.
“Many individual hospitals have delivered impressive reductions in both their waiting lists and waiting times. The HSE is currently working to replicate this positive performance across the entire hospital system.”
However, the Irish Hospital Consultants’ Association (IHCA) pointed to an increase of more than 24,000, or 4 per cent, in the three main waiting lists for hospital appointments and treatments in the first three months of 2024 alone.
The department’s €437 million action plan for this year has set a target to reduce waiting lists for outpatient appointments and inpatient and day case treatment and procedures by 39,300, or 6 per cent, by the end of December compared with the number waiting at the start of the year.
This is an increase on the 3 per cent reduction achieved last year, and the Government says there is a targeted 10 per cent reduction in the number of patients breaching the Sláintecare time targets.
The IHCA said similar action plans in 2022 and last year had set ambitious reduction targets of 18 per cent and 10 per cent, but only cut waiting lists by 4 per cent and 3 per cent respectively.
Prof Gabrielle Colleran, the association’s vice-president, said a new waiting list action plan, published by the department two weeks ago, has “already fallen at the first hurdle”.
“While we welcome any funding which aims to cut these unacceptably long waiting lists and allow patients access to the care they require, perhaps it is time the Government takes a different approach, if it is doing the same thing over and over again and still expecting to get different results,” she said.
“The NTPF figures released today confirm Consultants’ grave concerns that these waiting lists may take a decade or more to get under control unless the opening of long-promised additional hospital capacity is fast-tracked by the Government, and simultaneously the one in five Consultant posts vacant or filled on a temporary basis are permanently filled.”
Sinn Féin’s health spokesman David Cullinane TD also expressed concern that waiting lists were going in the wrong direction.
“The Minister for Health’s waiting list plans have failed to make a dent in hospital waiting lists. The truth is the Minister can publish as many plans as he wants, but without adequate funding to increase capacity they are just meaningless words on paper,” he said.
Mr Cullinane said a recruitment embargo was biting hard, and lack of funding for new measures is holding the health service back.
“To properly and sustainably tackle waiting lists, the recruitment embargo should be lifted and the Government should fund the 1,500 rapid build beds that are needed. These are crucial to reducing waiting lists at pace and with ambition,” he said.