Delivering healthcare at home can benefit thousands of patients with long term conditions as well as commissioners, say Chris Wallis and Jo Phillips

Thousands of NHS patients are currently benefiting from being treated at home and many more could reap the benefits offered by this model, which incurs less cost to the healthcare system than hospital based care.

Driving transformation that improves quality and reduces cost is an economic necessity that must take place at a speed and scale never seen before

NHS commissioners are facing a huge challenge in managing the demands of an ageing population and the rising tide of chronic disease. For those wanting to commission and/or deliver more out-of-hospital care, there are several services and patient groups where home based treatment models are working to optimise bed use, including enhanced supported discharge, home chemotherapy, end of life care and chronic disease management.

It is vitally important to recognise that moving care out of hospitals and into homes is more than just a change of location. Secondary and primary care clinicians need to be confident that home based treatment services are based on well organised operational arrangements to ensure that patients are treated in a safe manner and are clinically and psychologically well supported in the home environment.

Successfully delivering high quality patient focused care and treatment requires detailed planning between provider clinical teams and commissioners. A broad range of issues must be addressed, including patient need and future demand, 24 hour cover, clinical responsibilities, clinical data recording and reporting, and staffing, skills and training requirements. Simply transferring an existing service model to a different location will not deliver the change and savings needed.

Driving transformation that improves quality and reduces cost is an economic necessity that must take place at a speed and scale never seen before.

Out-of-hospital care offers an attainable model that can help realise and contribute to significant cost savings, while protecting high quality care and patient choice.

Economic modelling provides a good starting point to identify the areas that offer the best potential financial benefit. The focus should be on calculating and comparing the current costs of in-hospital care and home based healthcare to identify net potential savings.

While this does require specified methods, assumptions and detailed analysis, it does not need to be overly complicated.

To make significant savings organisations will need to be bold and take a managed risk in introducing new look services. Experience to date suggests that timid incremental steps simply allow inefficiencies to return.

A new provider model adopted by NHS Birmingham East and North in partnership with Healthcare at Home illustrates the real scope for achieving savings from delivering services at home rather than in hospital.

A recent report based on analysis conducted by Dr Foster Intelligence provides examples of potential savings in four service areas: care for people with long term and ambulatory care sensitive conditions; enhanced supported discharge; end of life care; and home chemotherapy.

Examples of approximate savings extrapolated for each of these areas can be seen in the table below.

It is not only the maths that work ­- there is a moral imperative to homecare that cannot be ignored. Allowing people to die in the comfort of their own home, or telling a recently diagnosed cancer sufferer that they can have chemotherapy at home rather than having to further disrupt their lives with regular travel to and from hospital is hugely important.

It is within our power to offer this choice to patients and we should make it happen.

Top tips for significant savings

Providing care at home can deliver significant savings if the following key points are taken into consideration:

  • Think big. The larger the service, the easier it becomes to realise the cost savings.
  • Make realising savings possible - in order to make “real” savings, you need to restructure. The elimination of existing costs within the business is key.
  • Look at areas where the biggest savings can be made. For example, an end of life homecare service can save between one and three patient admissions in the last six months of life, which is a saving of between £1,300 and £6,000 per patient.
  • Look for problem areas within the organisation - eg where are excess bed days unusually high? Where are emergency readmission rates higher than average?
  • Look beyond the problem areas and consider where you can optimise your bed days: the reduction in length of stay should ultimately result in a renegotiated reduction in tariff.
  • Remember: reductions in admissions are likely to lead to reductions in readmissions.
  • Look at the ambulance and A&E costs that can be saved by having homecare and 24/7 access as the first point of contact.
  • Savings will also be generated through fewer outpatient episodes and a reduction in the use of follow-up services.

Success factors

  • Tailor the service around the needs of the patient
  • Invest time and effort in planning and working with local clinical teams - involve them right from the start
  • Develop robust clinical protocols and procedures that prioritise safety, deliver timely treatment and ensure patients are well supported in the home setting
  • Develop and maintain service accountability and review arrangements
  • Collect robust patient experience and satisfaction data to monitor the homecare service
  • Measure outcomes for service evaluation
  • Capitalise on the experience and expertise of the independent sector to bridge gaps in service or where nurse resources are under pressure

 

Service

NHS BEN

old model cost (£)

Home-based care

cost (£)

Potential 

savings (£)

End of life care1.4m0.7m0.7m
Enhanced supported discharge 6.6m4.7m1.9m
Home chemotherapy2.8m2.4m0.4m
Long term conditions8.8m7.1m1.7m
Total19.6m14.9m4.7m