Hospital at Home: The Alternative to General Hospital Admission PDF
Preview Hospital at Home: The Alternative to General Hospital Admission
Hospital at Home Dedicated to the many hospital patients I have known whose dearest wish was to have been looked after at home, in the hope that those among us who may one day be in a similar position will have that option. Hospital at Home The Alternative to General Hospital Admission Freda Clarke M MACMILLAN © Freda Clarke I 984 All rights reserved. No part oft his publication may be reproduced or transmitted, in any form or by any means, without permission. First published I984 by Higher and Further Education Division MACMILLAN PUBLISHERS LTD London and Basingstoke Companies and representatives throughout the world British Library Cataloguing in Publication Data Clarke, Freda Hospital at home. Home care services I. I. Title 362.I'4 RA645.3 ISBN 978-0-333-37526-6 ISBN 978-1-349-17693-9 (eBook) DOI 10.1007/978-1-349-17693-9 Contents Abbreviations v1 Acknowledgements vn Introduction 1 1 Pre-twentieth-century health provision in Britain: an introductory sketch 7 2 Foundations of modern health care in Britain: a divided medical service and consequences for the sick 21 3 The National Health Service: high-dependency patients at home-the case for a secondary domi- ciliary care service 35 4 Overseas experiments in the home care of the sick 52 a 5 Hospitalisation domicile, France: a first-hand account 70 6 Home care experiments in Britain 95 7 Peterborough District Hospital at Home three-year pilot scheme 11 8 8 'Hospital at home' and the medical profession 135 9 Nurses and home care of the sick 144 1o The other carers 155 11 How to get your local 'hospital at home' service 168 12 Summary, conclusions and prospects for the future 183 Appendix A: Some cost findings on the home care of the sick-a reference list 195 Appendix B: Selected book list 197 Appendix C: Official publications 199 Index 200 v Abbreviations AHA area health authority BMA British Medical Association ccs (MacMillan) continuing care service CHC community health council DHA district health authority DHSS Department of Health and Social Security FNEHAD Federation Nationale des Etablissements a d'Hospitalisation Domicile (France) FPC family practitioner committee GP general practitioner a HAD hospitalisation domicile (France) HAH hospital at home HSA hospital savings association LASSD local authority social services department MOH Ministry of Health; Medical Officer of Health NHS National Health Service NHI national health insurance NSCR National Society for Cancer Relief UK United Kingdom vi Acknowledgements To acknowledge everyone who has helped me either directly or indirectly to formulate the ideas contained in this book would be impossible. Their influence extends to a time long before I first set pen to paper. Some, however, must be singled out for special mention: Friends, colleagues and patients of Barnet General Hospital, alongside whom I worked for many years through a series of health reorganisations. The British Council, whose fellowship award in 1972 enabled a the first of my numerous visits to study hospitalisation domicile (HAD) in France; the Nuffield Foundation which, in 1977, enabled a joint study visit to various HAD schemes together with Stephen Cang of the Health Services Organisation Research Unit, Brunei University; the Sainsbury Family Charitable Trusts, whose generous grant made possible the first 'hospital at home' experiment under the NHS. The pioneers and personnel of the Paris, Bayonne, Bordeaux and Grenoble HAD schemes in France, who were unstinting in the time and trouble they took to describe their aims and organisations; nurses and social workers of these schemes, with whom I visited many patients; pioneers and personnel of hospital-based home care schemes in Adelaide and Melbourne (Australia) and Auckland (New Zealand) who kindly wrote to me describing their experiences. The many people throughout the UK who wrote to me, following publication in the early 1970s of articles on the French HAD experience, urging practical action towards the setting up of similar services under the NHS, including health administrators, doctors and nurses, university staff, members of community health councils and other organisations of patient concern. vii Acknowledgements Vlll Members and staff of the Cambridgeshire Area Health Authority (Teaching), in particular of the Peterborough District, with whom I shared some both stressful and im mensely rewarding times; members of the Peterborough Hospital at Home scheme's steering group; the first patients of the Peterborough Hospital at Home scheme, whose testimony of the benefits ofHAH left no doubt in the mind as to the need throughout the NHS for realistic alternatives to general hospital admission. Finally, on a personal note, I should like to thank Joyce Meadows and Shirley Johnston for their painstaking help in typing successive drafts of this book, Ruth Richardson for her help and guidance in its literary expression, and Arthur and Richard Clarke for their suggestions, criticisms and morale boosting support through many difficult times. No person other than myself bears any responsibility for the validity of the historical material contained in this book, nor for its interpretation. Barnet, Herts, 1g84 FC Introduction a Hospital at Home is a title borrowed from 'hospitalisation domicile', the name of hospital-based schemes designed to provide options of home care for certain traditionally hospitalised patients in France. These schemes guarantee to the latter predetermined levels and varieties of care, including specialist care, in parallel with those provided in general hospitals. Their 'beds' are included in the official bed complements of the regional hospital authorities responsible for them. The British system of medicine, whereby general practitioners (GPs) must refer cases to hospitals before patients can receive specialist care, has been with us for so long that it is now difficult to envisage any other. It entails organisational separation between hospital and community sectors ofthe National Health Service (NHS). Measures taken by the NHS to bring these sectors together operationally have not by and large reached the medical profession because G Ps and specialists are deeply resistant to integrated ways of working, other than on an informal basis. Reasons for divisions in British medicine can be traced far back in history. Many generations of specialists have fought against incursion into hospital medicine by their GP colleagues, while the latter have retaliated by defending their work amongst the sick outside hospitals from incursion by specialists. This has led to a two-tier system in medicine, whereby 'primary' care takes place in the community and 'secondary' provision is confined to hospitals. Of course, many patients suffering major illnesses are looked after in their own homes. But it is assumed that any specialist treatment they might need can be adequately met through their hospital out-patient attendances; while their basic support is the responsibility of their families, possibly helped by local authority social services departments. As doctors, nurses and health administrators are well aware, this concept does not fit well with reality. Many patients at home suffer unnecessarily and are denied recovery prospects because 1
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