At present, the NHS is facing unprecedented demands on its services, with 11.8 million people over 65 years and 4 million people with long-term illnesses living in the UK (Age UK, 2018). Alongside this, emergency department (ED) staff are witnessing the highest ever bed occupancy rates, which underlie their aim to discharge patients back into the community for further management (Royal College of Surgeons, 2018). A King's Fund report highlighted the need for better alignment of primary, community and acute care to reduce avoidable hospital admissions and length of hospital stay (Imison et al, 2012), and this has been re-enforced in the recently published NHS Long Term Plan (NHS England, 2019a). The ‘hospital-in-the-home’ (HitH) model is one solution that allows patients to return home and receive short-term treatment in a familiar environment. Since its inception in 2014 (Lee and Titchener, 2017), many countries have created their own version of HitH services and reported very positive results in terms of various aspects, including efficacy, safety, cost and patient satisfaction (Caplan et al, 1999; Van Donk et al, 2009; Montalto, 2010; Rodriguez-Cerrillo et al, 2012; Varney et al, 2014). Studies have also highlighted the need for strategic planning and coordinated partnerships to ensure the success of HitH services (Brody et al, 2019). One study noted that the use of HitH resulted in a reduction in hospital readmissions from 7% to 3% (Rodriguez-Cerrillo et al, 2012). Another review of HitH services concluded that HitH care was at least equivalent to hospital-based care and offered greater cost savings (Varney et al, 2014). In terms of satisfaction with the HitH service, the literature reports the positive impact of HitH on patient care and notes the overall efficacy of the HitH programme (Caplan et al, 1999; Montalto, 2010; Montalto et al, 2010; Varney et al, 2014). Patient satisfaction is a goal in its own right and, more importantly, it is an important determinant of patient concordance with advice and treatment. Patient views are considered a legitimate, important measure of care quality and an indirect measure of health outcome (Hardy and West, 1994).
The @home service
The @home service is a nurse-led integrated care team (including dedicated GPs and consultant sessions) that aims to provide hospital care to patients in their homes or usual place of residence. It is commissioned by Lambeth and Southwark Clinical Commissioning Groups (CCGs) in London. The service is predicated on the aim of integrated care to improve patient experience, efficiency and value from healthcare delivery while reducing fragmentation in patient services (Shaw et al, 2011).
Southwark and Lambeth are among the most densely populated boroughs in London as well as the UK, with a population of 610 000. The population is culturally and ethnically diverse, with 28% of residents born outside of the European Union; 60% from black, Asian or other minority groups; and over 150 languages spoken. A large number of people registered with GPs within these two boroughs (43 300) are living with multiple long-term conditions, have complex needs and are frail or vulnerable, and some 6700 residents are in need of end-of-life care. There are extreme distributions of income, educational achievement, access to employment and housing quality. An integrated approach to healthcare provision was essential to meet the needs of this diverse population and provided justification for the establishment of the @ home service.
The @home service in Southwark and Lambeth aims to treat up to 300 new patients per month and focuses on reducing avoidable hospital admissions and supporting rapid and safe discharge from the EDs, acute assessment units and acute wards of three London hospitals (Lee et al, 2015; Lee and Titchener 2017; Lee et al, 2017). Referrals from the acute hospitals are facilitated by two in-reach nurses based at St Thomas' and King's College Hospitals in central London. Their roles include participating in post-take ward rounds. In addition, referrals are taken from GPs and specialist community teams and via the London Ambulance Service.
Briefly, the @home service provides intensive care with treatments, interventions and monitoring for a short episode through integrated team work with the aim of supporting the patient to return to their previous or an improved health status following an acute episode of ill health. The service operates 365 days a year from 8 am until 11 pm. Typically, patients receive up to four visits a day during their episode of care, which on average ranges between 4.8 and 6.4 days. The patients are assessed within 2 hours of referral. The main criteria for referrals are that the person is aged 18 years and over, is living and registered with a GP within Lambeth or Southwark and has an acute onset of illness (including acute exacerbations of chronic conditions). The most common conditions or interventions for which patients receive care include:
Details on the service have previously been published in detail (Lee and Titchener, 2017). Given that @home is a relatively new service in the UK, this article aims to report on an evaluation of the GSTT@home service with respect to patient satisfaction.
Methods
The @home Service Evaluation Working Group developed the patient satisfaction and preference questionnaire based on key elements of a literature review and the tools used by Utens et al (2013), Jester and Hicks (2003) and Jester et al (2015), as their validity had been established. In both studies, the questionnaires were validated following the procedure to develop a questionnaire that would provide answers to their respective research questions. The @ home patient satisfaction questionnaire required some adjustments to meet the specific requirements of this evaluation. The questionnaire comprised 20 questions, 19 of which used 5-point Likert response options including a ‘neutral’ or ‘don't know’ option. Question 9 required respondents to choose as many adjectives that applied from a list of 10 (seven positive and three negative). Although the service evaluation working group did not include service users, the views of these individuals were elicited via discussion with the trust's communications and public relations group and a patient and public engagement specialist and patient representative during the designing of the pilot service.
The reliability and validity of the patient satisfaction questionnaire were tested before it was administered to patients using the GSTT@home service. Five sets of questionnaires were given to randomly selected @ home service clinicians for them to complete and provide feedback. The aspects of feedback required to establish the questionnaire's reliability and validity were (1) relevance of the questions to the service delivery; (2) user friendliness in terms of the layout and language; (3) ease of completing the questionnaire; and (4) length of time required to complete it. All five clinicians provided positive reviews and collectively agreed that the overall questionnaire had complete relevance to the day-to-day service provided to patients.
The questionnaires were distributed to patients by GSTT@home service team members during their visits; they were left with the patient and/or their family to return in a pre-stamped envelope. The questionnaires were then reviewed by the @home clinical development matron and an external academic advisor, and data were entered into an MS Excel spreadsheet. Patients were not required to provide their personal details. To minimise the risk of bias in analysis and to optimise neutrality, all questionnaires were reviewed by the external academic advisor.
Data analysis
The questionnaire data were analysed descriptively and reported using frequencies and percentages. Where free text comments were recorded, basic thematic analysis (Vaismoradi et al, 2013) was undertaken to identify common themes in the responses.
Ethics approval
Ethics approval was not required for this study, as this was deemed a service evaluation by the trust.
Findings
A total of 1426 questionnaires were distr ibuted between February 2015 and 2016, of which 206 (14%) were returned (Table 1).
| Question | Extremely likely | Likely | Neither likely nor unlikely | Unlikely | Extremely unlikely |
|---|---|---|---|---|---|
| Q1: How likely are you to recommend @home service? | 156 | 44 | 2 | 2 | 2 |
| Q2: Overall, how satisfied were you with your treatment on the scheme? | Very satisfied 164 | Satisfied 39 | Don't know 0 | Dissatisfied 1 | Very dissatisfied 2 |
| Question | Strongly agree | Agree | Don't know | Disagree | Strongly disagree |
| Q3: The @home team have helped me understand about my illness/condition | 108 | 82 | 11 | 5 | 1 |
| Q4: The @home team have made clear the treatment they are giving me and why | 109 | 76 | 3 | 2 | 1 |
| Q5: The @home team have kept me up-to-date on my progress | 106 | 78 | 11 | 1 | 1 |
| Q6: The @home team gave me time to discuss my treatment | 102 | 81 | 11 | 4 | 1 |
| Q7: The @home team are being clear about what medicines I am taking and why | 104 | 77 | 12 | 4 | 1 |
| Q8: The @home team are available to give me help when needed | 110 | 67 | 27 | 3 | |
| Q9: How do you describe the @home staff attitude towards you? | Friendly 180 | Helpful 170 | Warm 118 | Cold 1 | Polite 124 |
| Q10: How often do the staff ask for your views about condition and treatment? | Seldom 20 | Infrequently 17 | Don't know 16 | Frequently 93 | Very frequently 58 |
| Q11: I felt supported by caring and friendly @home staff during the treatment period | Strongly agree 125 | Agree 67 | Don't know 3 | Disagree 0 | Strongly disagree 1 |
| Q12: Were your concerns or worries addressed by the @home team? | Fully 96 | Very good 68 | Adequate 21 | Not fully 1 | Not applicable 5 |
| Question | Extremely safe | Very safe | Safe | Unsafe | Very unsafe |
| Q13: How safe did you feel during the days in the treatment period? | 106 | 60 | 30 | 1 | |
| Q14: How safe did you feel during the nights in the treatment period? | 74 | 54 | 40 | 5 | 1 |
| Question | Extreme pain | Severe pain | Don't know | Mild pain | No pain |
| Q15: How much pain have you experienced since your discharge? | 3 | 19 | 8 | 70 | 57 |
| Question | Completely satisfied | Very satisfied | Satisfied | Dissatisfied | Most dissatisfied |
| Q16: How satisfied are you with how your medications were managed? | 100 | 42 | 39 | 2 | 1 |
| Q17: How satisfied were you with the management of your symptoms while on the @home service? | 104 | 44 | 39 | 2 |
Responses to closed questions
When asked how likely they were to recommend the GSTT@home service, 200 of the 206 respondents (97%) replied that they were likely or very likely to recommend it (Figure 1). This question mirrors one of the key questions in the NHS national patient survey with the assumption of a positive association between patients recommending a service and their satisfaction with the service (NHS England, 2019a).
Patients were asked about their overall satisfaction with their treatment, and 99% of respondents (n=203) reported being either very satisfied or satisfied (Figure 2).
Similarly, the responses to the other 18 questions demonstrated a high degree of patient satisfaction. The length of the visit is important in ensuring that optimal care is delivered, and overall, most respondents (89%) believed the time allocated for the visit was appropriate. This has to be balanced with staff workload and the need to be efficient with time. Overall, the respondents felt that the duration of the initial assessment and the frequency of follow-up visits were both suitable.
The survey also highlighted a few areas requiring ongoing investigation and improvement. Specifically, for Q10: ‘How often do the staff ask for your views about your condition and treatment?’, 37 respondents (18%) stated ‘seldom’ or ‘infrequently’ and a further 16 (8%) responded that they did not know. Additionally, with regard to pain, 22 respondents (11%) reported either extreme or severe pain, and a further 70 (34%) reported mild pain. Patients who were referred to the service and were identified to have long-term pain issues were referred back to the pain specialist services for further pain management, which needs regular follow-up and review of pain medications.
Analysis of free text comments
A total of 48 of the 206 respondents provided qualitative free text comments, with the majority completed by patients and a few by family members. The comments were very positive and supportive of the service, with only a few comments that could be considered negative or indicative of a need for improvement. These are included in the thematic analysis of the comments presented below. Thematic analysis of the free text yielded in five themes and one sub-theme, which are presented below with a selection of representative verbatim quotes to illustrate each theme. Broadly, the themes were (i) preferred being treated in their own home, (ii) a service to be proud of, (iii) staff attributes, (iv) family involvement and support and (v) feeling safe.
Theme 1: preferred being treated in their own home
This theme related to respondents feeling they had recuperated better in their own home environment and had appreciated the choice of either not having to be admitted to hospital or being facilitated to leave hospital as soon as possible.
‘The @home team definitely helped my road to recovery at home instead of a hospital environment. I feel the @home service was extremely important to me. I was more comfortable at home, as conversations with nurses were not rushed and seeing me at home, they learnt a lot more about my home life and circumstances’.
Theme 2: a service to be proud of
This theme related to satisfaction with the quality, organisation and delivery of the service. Overall, the patients and carers stated that they were very satisfied with the service. One patient simply wrote ‘a service to be proud of’ and another respondent said: ‘I cannot praise this service highly enough, as without this service, my 89-year-old mother would be taking up a hospital bed and not getting anything like the service she received from this team’.
Theme 3: staff attributes
There were several positive comments regarding the GSTT@home team and how patients and families had felt cared about; specifically, the words ‘kind’, ‘friendly’ and ‘caring’ came up repeatedly within respondents' comments. One of the positive comments was: ‘I thought the nurses provided a high standard of care, and I had quite a good rapport with them. They were friendly, and supportive and very caring’. There were only two negative comments regarding staff members, and these are provided to ensure equity of reporting. A negative comments stated: ‘One male nurse was rude to me, I don't want to see him again, but all the others were brilliant’. The individual nurse was named by the patient in the feedback and was subsequently spoken to by the clinical lead of the service, who addressed the nurse's behaviour with the opportunity to reflect, learn and action to uphold the trust's values and behaviours at all times.
Related to the theme of ‘a service to be proud of’ was the sub-theme of co-ordination of care and communication, which reflected, in the most part, patients and families wanting to know when the team would be visiting so that they could plan other activities such as meals, going out and having visitors. However, one patient did comment: ‘Visits were at agreed times to suit me’.
Theme 4: family involvement and support of informal or family carers
This theme related to patient and families commenting positively about the GSTT@home service facilitating greater involvement of family in patient care and treatment and informal carers feeling supported by the team.
‘This service is important to the patient in that it allows the patient to be treated at home in friendly surroundings, with the added care of family members with professional backup to allow family members to be part of the care and treatment’.
A message from one of the carers was that: ‘They gave me the support and knowledge to enable me as his carer to look after him to the best of my ability’.
Theme 5: feeling safe
This theme concerned patients and/or their family feeling safe and supported while on the scheme. There was a general feeling from the patients and their next of kin that they were safe and well supported by members of the @home service team.
‘I feel very safe knowing I have the support of the @home service team’.
Another commented: ‘Both of us have felt in very safe hands and very supported by your wonderful team’.
Discussion
The survey described here has shown the benefits of the GSTT@home programme as reported by patients and their family/carers. The quantitative and qualitative components of the patient satisfaction questionnaire demonstrated a high degree of internal consistency between them, that is, the free text comments affirmed the responses to the closed questions. This further demonstrates the validity of the questionnaire. The vast majority of respondents were very satisfied with their @home experience, which aligns with the results of previous internal evaluation studies of this service. The approach taken for the evaluation was to provide real-time feedback to the GSTT@home team leaders regarding patient responses. Thus, areas such as pain assessment and pain management on discharge were addressed as soon as the feedback was received. In terms of completing the survey, there were no comments from the respondents around difficulty with this task. The survey findings indicated that safety is important to patients, and vulnerability is a vital consideration, especially when patients are being treated in their own home. However, there is a paucity of research in this area (Scanlon and Lee, 2007), and future studies should shed light on this aspect of the patient's experience.
Previous studies have demonstrated the benefits of the @home service (Caplan et al, 1999; Van Donk et al, 2009; Montalto, 2010; Rodriguez-Cerrillo et al, 2012; Varney et al, 2014), with some proposing that hospitals invest in HitH medical leadership and supervision to expand their HitH services (Montalto, 2010). The growing number of people over the age of 60 presents a challenge in terms of healthcare burden, and it is projected that by 2030, there will be over 20 million people over the age of 60 years (Age UK, 2018). As care shifts from hospital settings to the community, it is expected that programmes such as the GSTT@home service will be a routine provision of healthcare service. Although the results of the present study have shown that patients and carers see the benefits of the @home service, a more detailed evaluation of the GSTT@home service would be useful to understand its contribution to the local health system and inform ongoing service development.
The service must be considered within the constraints of the NHS and the issues of staff vacancies and lack of resources (both fiscal and personnel). This has been outlined by a recent King's Fund response to the worsening crisis in the NHS (King's Fund, 2019). The crisis affects the GSTT@ home service too, and in terms of managing capacity, the senior clinician on duty continuously reviews the capacity and demand of the service throughout the day to ensure accepted referrals are seen within the time frame by the appropriate clinicians and, equally, that patients already on the caseload are reviewed as per the plan of care. The staffing level is one of the challenges that is recognised by the management team to ensure that provision of safe and high-quality care is consistently maintained. Hence, when the service has reached its full capacity, this is escalated to the senior management and communicated to internal and external partners for the service to temporarily close for new referrals until patients are discharged from the caseload and capacity is freed up. Another important challenge is the level of patient acuity, which can change throughout the day. This will then require additional visits and senior clinical reviews, if needed, to establish that it is clinically safe and appropriate for the patient to continue to receive care in their usual place of residence. The service has developed an acuity tool specific to acute care in the community in order to have a consistent approach in reviewing patient acuity. This tool is being piloted, and the results will be published shortly.
According to the free text comments provided by the respondents, the length of visit is an important aspect, and overall, the majority believed the time was appropriate, even though staff were also acutely aware of their workload and ensuring efficiency. The respondents felt that the duration of the initial assessment as well as the frequency of follow-up visits was suitable.
This study does have some limitations that need to be acknowledged. The response rate was low, and there needs to be further discussion about how it can be increased in the future to facilitate ongoing feedback. Further, there were some difficulties with using the RiO electronic patient record system, as it is not set up to allow data analysis to be easily undertaken.
Conclusion
Patient satisfaction is well recognised as an important part of service evaluation. This article reports the results of a survey conducted to examine user satisfaction with the GSTT@home service in the London boroughs of Southwark and Lambeth. Although the response rate was low, patients who used this service and their family/carers reported high satisfaction levels with the service and has shown positive results from the small sample. The approach to the evaluation facilitated real-time feedback, using any issues raised by patients, staff or referrers, which could be discussed and actioned as soon as practically possible.
Through this study, it was recognised that in order to support ongoing evaluation of the @home programme, there need to be dedicated human resources to administer the questionnaires, input the data, analyse the data and report the findings. Additionally, in the future, a screening tool for HitH staff attributes should be part of the recruitment process. In order for staff to have easier access to patient information during home visits, mobile working using tablet computers needs to be implemented. In terms of improving the engagement of referrers, it is recommended to invite key referrers to a meeting to identify how discharge information can be improved, how the referral process can be made easier and more efficient and how communication can be enhanced. Finally, it will be prudent to start evaluating staff satisfaction or experience on a regular basis using a valid measurement tool. Subsequent evaluations of the GSTT@home service have demonstrated consistent positive findings with good feedback, and the management team continue to review the service to ensure that it is meeting local healthcare needs.