Cliff Kilgore currently works for Dorset Healthcare NHS trust, where he has been a community consultant practitioner for 10 years. He started his nursing career in 1999 and has specialised in the care of older people for most of this time.
The growth of Hospital at Home (H@H) has changed my role considerably. Previously my role as a consultant practitioner for older people focused on complex long-term conditions and most referrals came from primary care colleagues. H@H has returned me to a much more acute-focused role for older people experiencing a health crisis who require considerable clinical care.
Formally known as virtual wards, working in H@H takes up almost half of my job plan. My time with H@H involves a daily virtual ward round, where all patients currently under H@H are discussed, results and diagnosis are reviewed, and a plan is made for the next 24 hours. The ward round is made up of registered nurses, AHPs, pharmacy and a consultant (me) with brilliant support from a health and social care coordinator who ensures the patients are on the list, documents all decisions and records the summary of the plan. I am reminded every day of the importance of my colleagues and the vital importance of a multidisciplinary team in acute care, particularly when it involves people living with frailty.
It is always incredible to realise the variation of age of people living with frailty and we see anyone with a frailty history who would otherwise be in hospital. This can mean someone aged 103 or someone in their 50s! We have also recognised that there are a growing number of people who refuse hospital admission, and this can result in managing a high level of risk for some. We have discussed this as a team and while we recognise that care is not poor in hospitals, it clearly does not always meet some people’s needs, and these people will risk death rather than be admitted. An area of research, I am sure, when I find the time to start the literature search!
One of the key things for me is communication. We cannot do this enough. This includes speaking with other healthcare professionals in the wider system, arranging diagnostics but also crucially ensuring we are speaking with patients and families. Being surrounded by brilliant colleagues is very helpful for this and most communication with families is done by the wider team but when levels of complexity are high, I do this myself.
When I think about the successes of what I do, I consider the stopped medications, of which there are many, and the grateful patients and relatives who thank the team for amazing care and for the ability to stay at home. A recent piece of work with HealthWatch indicated a high level of satisfaction from carers, which I was surprised about as I do worry about the burden that we can add to carers by keeping people at home. However, the reality from the interviews with carers was very different to my perceptions and it just reminds me that we need to ask questions of the people that use healthcare services. I also have a sense of pride in what we all do. The people we see in acute health crisis, overall improve and return to their normal lives. Anecdotally, people need less rehabilitation by staying in their own home, and evidence suggests that Hospital at Home can be a cost-effective alternative to inpatient care with an NIHR randomised control trial finding a mean difference of -£2547 for Hospital at Home patients, compared to those receiving inpatient care.1
The remainder of my job plan allows for two clinical sessions which I still use for face-to-face home visits. This enables me to still have some focus on prevention of deterioration and giving advice to primary care for advance care planning. As a consultant practitioner, I am also required to demonstrate consultancy in education, research and national strategy and these other elements make up my full working week.
There is a huge satisfaction in what I do and although I am frustrated by the system at times, I can honestly say that I enjoy my role. Some of that is due to great colleagues but there is also a sense of achievement in feeling we make a difference to people’s lives. In the end, that should be the aim of all healthcare professionals and when that stops, maybe it will be time to move on…
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BGS. Hospital at Home for frailty: Current situation and future potential: https://www.bgs.org.uk/HospitalAtHomeFrailty
