Put clinical homecare centre stage

There are many ways that homecare can benefit patients and the health system, through reducing infection rates and waiting times, improving adherence, enabling real-world data capture and lowering costs. So why isn't it mentioned explicitly in NHS England's Five-Year Forward View, asks James Featherstone.

Putting patients at the centre of healthcare delivery has become the norm, and rightly so – the wellbeing of patients and their families is paramount, so factoring their needs in to healthcare decisions is critical. One way of meeting patients' needs and wishes is to acknowledge where they would like to receive treatment, which, for many, is at home. Delivering clinical care in the home also presents an opportunity to release capacity in the healthcare system, allowing more patients to flow through and receive high quality care and innovative treatments.

With a move to more personalised care, and in a tight fiscal environment, it's become an expectation that medicines, particularly high-cost ones, come with a wraparound added-value service. Clinical homecare is an efficient way of delivering this while also providing an opportunity for valuable data capture in a real-world setting. More importantly, evidence indicates that outcomes are improved through greater adherence and persistence.

The clinical homecare market is growing at a rate of more than 20 per cent per year, a trend which, if it continues, could deliver even greater value.

Five-Year Forward View

The NHS England Five-Year Forward View (5YFV) has been at the centre of many new initiatives since its launch just over a year ago. With seven new care models and much talk about care closer to home, it is somewhat surprising that there is no explicit mention of clinical homecare. One reason for this may be that the clinical homecare industry has failed to define exactly what clinical homecare is and articulate its benefits.

Defining clinical homecare and communicating its value

The term homecare is applied to a broad range of services, from domiciliary care through to complex chemotherapy in the home, so before its value can be communicated, consensus is needed on a clear definition. This is why the first market inquiry into clinical homecare was instigated in June 2015 and was a key focus for the expert panel, made up of 13 organisations from across the public and private sectors, including the NHS, ABPI and pharma companies.

Christine Outram, chair of the Christie Hospital, was put in place as the independent chair of the inquiry, bringing invaluable experience of working with local, national and private health organisations.

Building the case for clinical homecare

A plethora of evidence demonstrates the value that clinical homecare brings to patients and the health system, from reducing infection rates and waiting times to improving quality of life. For example, a study by the Christie NHS Foundation Trust showed that when cancer patients received treatment and nursing care at home, there were significantly fewer side effects and unplanned admissions compared to Christie best care alone.

With the expert panel and the wider industry, we have worked to define clinical homecare and compile a compelling evidence base, with the panel findings published in a White Paper, Building the case for clinical care in the home at scale. This document assesses the benefits of five service areas: cancer, long-term conditions, end-of-life care, virtual wards and timely discharge services, and suggests metrics to measure outputs and outcomes.

'Clinical care in the home is:
Integrated care, treatment and support that takes place in a person's home or place of residence. This can directly reduce the need for, or prevent, an overnight or inpatient stay in hospital or a day case or outpatient visit. This can include patients with more severe conditions and those with long-term conditions. Normally, the hospital or NHS provider retains responsibility for patient care.'

Defining the units of value

Defining clinical homecare was an important part of the panel's focus but, more importantly, this was the precursor to defining the units of value that different models of clinical homecare can deliver. It is important to recognise and quantify the value that it can offer to a range of key audiences; the pharmaceutical industry, the NHS and, most importantly, patients. These units of value might fall into four broad categories:

• Treatment adherence

• Reablement and quality of life

• Patient activation

• Healthcare system financial savings

Treatment adherence

According to the World Health Organisation, around 50 per cent of people with long-term conditions do not take their medicines as prescribed. This can be costly to the health system but, most importantly, it can result in poor outcomes for patients, particularly in the treatment of long-term conditions with patients cycling through different therapies. Specialist clinical homecare nursing support programmes can identify and address barriers to treatment adherence, whether intentional or unintentional, leading to fewer relapses and hospital re-admissions. They also provide a platform to gather valuable data that can prove a product's worth to payers and HCPs alike. Data also show that patients on enhanced nursing programmes remain on treatment for longer than unsupported patients, which is a clear benefit to the pharma industry.

'The National Clinical Homecare Association reports that mean persistence on homecare is 500 days compared to mean persistence in community of 315 days. An enhanced homecare service, featuring bespoke nursing support, had a mean persistence of 708 days compared with 437 days in the aggregated standard service cohort.'

Reabling patients and improving quality of life

With care now involving a more holistic view of patients' health and social needs, reablement has become a higher priority. Reablement means helping people regain the ability to look after themselves following illness or injury. Social Care Institute for Excellence research shows that reablement improves wellbeing and independence, prolongs people's ability to live at home and removes or reduces the need for commissioned care hours. Working-age ill health costs the economy £100 billion a year, an issue that clinical homecare could help to address.

Patient activation

Patients with long-term conditions who are highly activated in the management of their condition are more likely to engage in positive health behaviours, leading to fewer hospital admissions and A&E visits. According to a 2014 study by the King's Fund, highly activated patients are more likely to adopt healthy behaviour, to have better clinical outcomes and lower rates of hospitalisation, and to report higher levels of satisfaction with services. Clinical homecare increases patients' ability to self-administer treatment at a place and time to suit them, which can lead to greater patient activation.

Healthcare system financial savings

With an ever-stretched NHS pushed to achieve more with less, we need to find new ways to achieve efficiencies that do not compromise care quality. Clinical care in the home can yield financial savings and, while more investigation is needed, initial findings from the services analysed in the White Paper indicate that savings could comfortably meet the 3 per cent efficiency savings specified in 5YFV. In addition to the four broad units of value identified in the report, clinical homecare can also reduce pressure on acute hospitals by:

• Reducing unplanned admissions

• Bringing down waiting times

• Reducing the number of cancelled operations

• Expediting integration with social care

• Preventing re-admissions

• Freeing capacity and ward space for more appropriate allocations

• Reducing hospital-acquired infection rates

Delivering care excellence

The NHS remains under immense pressure to create and implement innovative care models that enable it to meet the objectives laid out in 5YFV. There is limited awareness of the value of clinical homecare services in the UK yet, if adopted at scale, they could help the NHS meet some of its most pressing needs. The White Paper is just the first step towards raising the profile of clinical homecare. While the four units of value outlined are currently hypotheses, they do bring to light key evidence and are a starting point to kick-start future work and metrics to deliver the evidence required.

The expert panel has committed to continue this important work by gathering comprehensive outcome data that will confirm the value of clinical homecare. Meanwhile, NHS and private sector leaders should read the White Paper to fully understand the benefits this care model can offer and join the conversation.

About the author:

Dr James Featherstone is the chief operating officer of Healthcare at Home and instigated the launch of the market inquiry. Prior to joining Healthcare at Home in 2015, he spent seven years at Quintiles, most recently as senior vice president of Integrated Healthcare Solutions. In this role, he was responsible for global commercial strategy and data-driven projects, working with the pharmaceutical industry and the NHS to help patients realise better health outcomes.