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Chamber and committees

Meeting of the Parliament

Meeting date: Tuesday, May 30, 2023


Hospital at Home Programme

The Deputy Presiding Officer (Liam McArthur)

The next item of business is a debate on motion S6M-09191, in the name of Michael Matheson, on the hospital at home programme in Scotland. I invite members who wish to participate in the debate to press their request-to-speak buttons now or as soon as possible.


The Cabinet Secretary for NHS Recovery, Health and Social Care (Michael Matheson)

I am pleased to open the debate on the hospital at home programme.

The health of every individual in our society is a priority for the Government. With every shift in the approach to how we provide healthcare to the people of Scotland comes a need for scrutiny and public debate. Projections for future bed demand suggest that, by 2031, Scotland will need to increase hospital bed capacity by around 2,000 to 3,000 beds. That is the equivalent of five large district general hospitals, so it is essential that we consider alternative sustainable solutions for patients and our healthcare system.

Since 2020, the Scottish Government has invested some £7.6 million in the development of the hospital at home programme. I was delighted to announce a few weeks ago a further £3.6 million for this financial year to support the programme’s further expansion across Scotland. That will increase our current capacity by some 50 per cent by the end of 2023-24, which will allow more people to receive at home the care that they would usually receive in hospital.

Hospital at home services are consultant led, with expert teams on hand to provide short-term hospital-level care. Patients have access to interventions such as oxygen and intravenous antibiotics, as well as investigations such as electrocardiograms and scans, at home or in a care home.

The hospital at home programme has been in operation in Scotland for more than a decade. We now have services in nearly every health board area and partnerships across Scotland. I put on record my thanks for the excellent work that is done by the dedicated healthcare professionals who deliver care across the country, around the clock, to make that possible.

We are all aware of the fundamental issues that our health service faces. Increasing demand, increasing complexity and increasing acuity mean that, when there is a surge in demand, our national health service and wider health and social care system are, at times, under significant pressure. We are still dealing with the combined shock of the global pandemic and Brexit, which makes securing the workforce very challenging.

In recent months, services have been working hard to recover, but pressure on acute hospital services has been increasing throughout the United Kingdom for some time. That has culminated in increased hospital occupancy levels that are routinely at around 95 per cent, which is well above historical levels and beyond what is acceptable. In the best interests of patients and the people who work in the national health service and the social care sector, we must use every lever that is available to us to address these combined pressures.

Key to reducing demand on our hospitals is the provision of care closer to home. Hospital at home is one of the levers that we are already using successfully. In 2022-23, more than 63,000 bed days were provided by hospital at home services for older people. In fact, data released by Healthcare Improvement Scotland this month shows that the number of older people who were admitted to hospital at home services in 2022-23 was almost the equivalent of a large city hospital such as Aberdeen royal infirmary. That makes hospital at home the fifth biggest hospital for older people.

Beyond considering the challenges to the health and social care system, we must, first and foremost, consider what the people of Scotland want and need. In Scotland, 10 per cent of people over the age of 65 are living with frailty, which we know can have a considerable impact on a person’s quality of life. We also know that older people in Scotland, in particular, are often those who are most significantly impacted by hospital stays. Evidence tells us that, on average, 10 days in a hospital bed is equivalent to 10 years of muscle wasting for an older person. Admission of a patient with frailty to an acute ward increases the likelihood of their losing muscle strength, agility and, of course, confidence. By taking people who might already be frail out of a hospital setting, we can reduce deconditioning and exposure to other avoidable harms such as hospital-acquired infections, including delirium, and falls.

Alex Rowley (Mid Scotland and Fife) (Lab)

As someone from Fife who has watched hospital at home develop over many years, I am a big supporter. However, does the cabinet secretary accept that we and the Government have to ensure that elderly and frail people have the support that they need in the community, so social care needs to be able to respond?

Michael Matheson

I agree with that point, and I know that Fife has been one of the leaders in the development of hospital at home. We need to make sure that social care provision can meet the demands that come alongside that, which is why we are making considerable investment in social care and in the development of a national care service.

We also know that, by its very nature, a hospital stay removes people from their home environment, taking them away from their surroundings and loved ones, which can lead to distress and anxiety. There are practical considerations for a patient’s carers and families. Transport, for example, can make a hospital stay a disruptive and sometimes expensive time for the family. We must therefore ask the question: is hospital always the best place for every patient to receive the treatment that they need? Sometimes, the answer to that question will be yes, but that is not always the case.

A recent evidence review identified several key findings on the benefits of hospital at home. First, hospital at home can be delivered safely, without increased rates of death or readmission to acute care. Secondly, hospital at home might reduce the likelihood of patients living in residential care following an acute episode. Thirdly, patients expressed high levels of satisfaction with the services. Finally, the costs of hospital at home are generally lower than the costs of in-patient care. Crucially, patients value being in the comfort and familiarity of their own home, and they appreciate the reduced disruption to their daily routines.

I think that Finlay Carson has been trying to make an intervention.

Finlay Carson (Galloway and West Dumfries) (Con)

I appreciate the cabinet secretary giving way.

Although many of us appreciate the importance of care at home, areas such as Dumfries and Galloway have a severe lack of nurses and help to deliver that care. There is still a role for cottage hospitals, and their value to communities was recognised by the First Minister in his previous role as the Cabinet Secretary for Health and Social Care. Do you agree that step-down facilities such as cottage hospitals play a big role?

I want to voice my big disappointment that you are not coming to collect a petition—

Through the chair.

—that has been signed by 4,000 people who want to see Newton Stewart and Kirkcudbright cottage hospitals reopened.

Michael Matheson

The design of local healthcare services is best directed by the local health board, the local health and social care partnership and the local integration joint board, which know the best way in which to meet the needs of the local community. That is the most appropriate approach, and hospital at home can play an important part in that. In Dumfries and Galloway, work is being taken forward to develop and expand the service.

We must be honest about the challenges that we face in expanding hospital at home. Although NHS Scotland staffing levels are at an historic high, due to 10 consecutive years of growth, the recruitment and redeployment of staff are clearly limiting factors, particularly in more remote and rural areas. It is unquestionable that the loss of European Union freedom of movement has put in place unnecessary barriers for the recruitment of staff from Europe, and the UK’s post-Brexit immigration system is certainly not helping.

The Scottish Government recognises the challenges that boards and front-line staff face, which is why we announced £800 million of funding to support boards to recruit an extra 750 nurses, midwives and allied health professionals from overseas by 31 March 2023. Boards have made good progress in taking that work forward.

NHS Scotland has been expanding capacity across a series of clinical pathways to manage the on-going pressures of acute care and to support recovery towards a sustainable future. The new models of care have been developed at pace. We have almost doubled the number of virtual beds from 441 at the beginning of 2022 to 806 by the end of March 2023, which is equivalent to adding an extra district general hospital in just 15 months. That is 806 patients, every day, receiving care at home who might otherwise have been in hospital.

Sandesh Gulhane (Glasgow) (Con) rose—

Michael Matheson

I have very little time left, I am afraid.

Since 2020, we have invested significantly in the development of hospital at home, recognising its value as we seek to recover from the pandemic. Our ambition is to continue the expansion of hospital at home across a range of specialties, to expand our capacity in preparation for winter and to create responsive and resilient services for the future.

The recovery of the NHS is dependent on implementing innovative models of care that put the individual’s best interests at their heart. Hospital at home is a prime example of that. It is a delivery model that not only benefits patients, their families and their carers but goes a significant way to reducing pressure on acute hospitals and NHS staff in an effective and compassionate way.

The challenges of the pandemic have compelled our public services to innovate and adapt, and we must build on momentum to transform the way in which we deliver care. The continued expansion of hospital at home supports our ambition to ensure that people receive the right care for them in the right place and at the right time.

I move,

That the Parliament recognises the value of the Hospital at Home programme in ensuring that people receive the right care in the right place at the right time; highlights that it offers a safe, patient-centred alternative to an acute hospital admission across a range of specialty areas, providing a better outcome for many people, without some of the challenges associated with an acute admission; welcomes that Hospital at Home has eased pressure on acute hospitals, with over 63,000 bed days provided last year by Hospital at Home for older adults; notes research showing that Hospital at Home is a cost effective alternative to acute care and provides very good clinical outcomes, and acknowledges the excellent work done to date by Healthcare Improvement Scotland, National Education Scotland and dedicated clinical networks to support the development of Hospital at Home.


Sandesh Gulhane (Glasgow) (Con)

I wish to declare an interest as a practising NHS general practitioner.

The hospital at home programme’s aims are laudable. It is right, where safe to do so, to provide elderly patients and other people who need it with medical treatment and care in the comfort and familiarity of their own home. Treatment might include having an IV or oxygen supply. There is scope to provide access to hospital tests. As a doctor, I can see how good hospital at home can be; I have seen it with my own patients. The more we can deliver safe care at home, the more we can free up capacity in our hospitals.

We are crying out for solutions because of the undisputed fact that successive Scottish National Party health secretaries have failed to tackle delayed discharges from our hospitals. In February 2015, when she was health secretary, today’s Deputy First Minister declared in yet another tiresome SNP announcement that she would end delayed discharges in Scotland by the end of that year. The reality is that, in the past eight years, more than 3,000 patients who were medically fit to go home have died on hospital wards. In March 2023, more than 54,000 days were spent in hospital by patients whose discharge was delayed.

Hospital at home can make a difference, but we must be realistic about resourcing the programme and deploying teams of mobile specialists. Tapping into the seemingly endless number of beds available in patients’ own homes does not solve the problem of the shortage of clinicians within the NHS.

Since the programme first launched in 2011, it has been rolled out to every health board except NHS Dumfries and Galloway and NHS Shetland. During the key years of the Covid pandemic, between 2020 and 2022, the programme received £8.1 million in funding.

Emma Harper (South Scotland) (SNP)

It is interesting to hear what Dr Gulhane says about NHS Dumfries and Galloway. It is my understanding that NHS Dumfries and Galloway has taken a home teams approach and that that is how that health board is delivering the equivalent of hospital at home.

Sandesh Gulhane

As I said at the start of my speech, I welcome anything that reduces delayed discharge.

By May 2022, the Scottish Government said that an estimated 275 virtual beds had been created through the hospital at home scheme. For comparison, there are 333 staffed beds at University hospital Ayr. It was then announced that that number of 275 virtual beds would double by the end of last year. That did not happen. Now we have another announcement of £3.6 million for the hospital at home programme in this financial year to create 156 additional virtual beds.

Scottish Conservatives support any measures to alleviate the pressures on our NHS, including the SNP’s delayed discharge crisis. Members may recall that our winter recovery plan contained a raft of proposals, including plans to expand the rehabilitation and assessment in the community and home—ReACH—team, which is the initiative that helps patients to rehabilitate following a hospital stay and to make adaptations to patients’ homes.

The Royal College of Physicians of Edinburgh has said that, although it welcomes increased investment in efforts to get patients out of hospital sooner and those to reduce admissions, such initiatives require extra staffing.

“Hospital at home services must be developed and resourced in addition to existing services, not instead of existing services.”

That is not my view; it is the view of the Royal College of Physicians of Edinburgh. That would require adequate numbers of well-trained staff in multidisciplinary teams, including medical, nursing, rehabilitation, therapy and care staff. Professor Andrew Elder of the Royal College of Physicians of Edinburgh is reported as having said:

“We do not have sufficient numbers of such staff at present, either in hospitals or in the community, and we will need to see more recruited as our population continues to age and their care needs rise.”

If the hospital at home programme is to be expanded, the health secretary should fully assess the impact on informal carers. Hospital at home services should not pile unsustainable pressures on unpaid carers. It is important to get that right: the last thing that we need is another announcement with no credible plan and failed delivery.

We know that elderly people who receive care at home have a lower risk of delirium at the one-month follow-up. We also heard from the health secretary that care at home improves muscle mass. Having patients stay in their own homes for longer without losing their independence results in better wellbeing and satisfaction.

However, we cannot consider health solutions in isolation. Silo thinking will not work. To make care at home work, we must improve performance along the whole elderly care pathway. More cash for hospital at home should go hand in hand with marked improvements in accident and emergency waiting times, because we must remember that our over-75s attend A and E at higher rates than any other age group and at twice the rate of 65 to 74-year-olds. In the week ending 14 May 2023, only 64.1 per cent of patients were seen within four hours; 11 per cent waited for eight hours and 4.4 per cent waited for more than 12 hours.

Bob Doris (Glasgow Maryhill and Springburn) (SNP)

Sandesh Gulhane makes a very important point. Do you agree that the hospital at home initiative is also about anticipatory care? Referrals can come from GPs before a hospital admission or at A and E instead of a hospital admission. That chimes very much with the point that you are making.

Please speak through the chair when making interventions and other comments. I will give you the time back, Dr Gulhane.

Sandesh Gulhane

Yes, I have made a referral to the hospital at home service. However, more people were waiting longer in A and E departments at the end of the First Minister’s tenure as health secretary than when he started the job. A and E waiting times must improve so that our elderly are seen sooner and have better outcomes when they return home.

The SNP-Green Government still seems to be pursuing the establishment of a national care service that will centralise rather than empower local decision making, despite the criticism of the plans from SNP members, Unison, the Convention of Scottish Local Authorities and the Scottish Ambulance Service. Here is a flavour of what has been said. One stakeholder said that the NCS bill does not represent any value for money whatsoever; that it is a “blank cheque” from the public purse; and that it seems like

“a sledgehammer to crack a nut.”—[Official Report, Finance and Public Administration Committee, 25 October 2022; c 24.]

A social work staff member said:

“If this proposal goes through staff are going to feel concerned about their jobs, and their wages and pensions”.

As a result, they will look for jobs elsewhere.

The proposal risks the overall NHS Scotland ambition to shift the balance of care. For the hospital at home programme to work, we need a strong primary care service. However, with closures such as the closure of the general practice in Invergowrie just today, the SNP Government is failing the people of Scotland. After 16 years, the SNP-Green Government seems to be out of ideas when it comes to fixing our NHS. Although the principle of hospital at home is good, the Government is tinkering. It is devoid of strategy, we cannot see joined-up strategy and there is no vision.

Scotland needs a fresh approach that incorporates a modern, efficient and local solution into healthcare. The Scottish Conservatives would increase the primary care funding envelope to 11 per cent.

I move amendment S6M-09191.2, to insert at end:

“; emphasises that maintaining existing programmes is vital to keeping people out of hospital; highlights that some Hospital at Home initiatives are threatened by staffing shortages; asserts that these programmes are needed more than ever, as hospitals across Scotland are currently struggling with capacity, with patients being treated in corridors at peak times; notes that tackling delayed discharge is a key component of increasing capacity, and acknowledges that many delayed discharges are of older people who could be cared for within social care settings.”


Paul Sweeney (Glasgow) (Lab)

Labour supports the hospital at home initiative. We have already heard about the benefits of delivering healthcare external to hospitals and acute care settings, all of which are entirely valid and commendable. For a long time, we have been advocating an approach to healthcare that is based on prevention rather than reaction, and we have been arguing that reducing the pressure on hospitals and acute care settings is essential and will deliver better outcomes.

Everyone in the chamber is well aware of the benefits of early intervention. Equally, we are all aware of the consequences for hospitals and acute care settings when services that facilitate early intervention and prevention fail. Therefore, we support the principle of the hospital at home programme, and we will work with the Government to ensure that patients who are in a position to benefit from the programme are able to do so.

Throughout my time in this role, I have always done my best to be constructive, and I would like to continue that approach today. A cross-party approach to tackling the crisis in our national health service will be crucial. In the interests of co-operation, we will support the Government’s motion and the Conservatives’ amendment. In the interest of trying to make a success of the hospital at home programme, it is important that the Government acknowledges that turning it into a sticking plaster just will not suffice. If we are to make a success of the programme, we need to recognise that, in many ways, our NHS is in dire straits and that we must address the root causes of the problems that we face today.

Those problems are found across our national health service. One in seven people in Scotland is on an NHS waiting list. The social care policy programme is in tatters. More than 160,000 bed days have been lost as a result of delayed discharge in 2023 alone, and more than a million bed days have been lost as a result of delayed discharge since the current First Minister was appointed as health secretary. One in 10 general practices in Scotland no longer accepts new patients. The vacancy rate for registered nurses in district nursing is more than 11 per cent, and it is 12.5 per cent for registered nurses in community settings.

I take absolutely no pleasure in rhyming off that list of problems. I want nothing more than for each and every one of them to be resolved immediately for the benefit of patients who desperately rely on such services, because we all have skin in the game.

However, the reality is that those problems exist today, and the harsh truth is that, for as long as they do, the hospital at home programme will fail to live up to its full potential.

Of all the problems that exist, the most egregious is the workforce crisis that is engulfing the NHS and social care. As I outlined briefly, vacancies are at a record high. Given the multifaceted and multidisciplinary nature of the hospital at home programme, there is a distinct possibility that it will fail purely because of a workforce shortage. That is why our amendment sets out the need for a long-term funding settlement for the hospital at home programme. We will happily work with the Government on that, should it desire it.

Although the workforce crisis in our NHS may take some time to resolve, given the training lead times and issues around that, there is no excuse for the workforce crisis in social care. The backlog in delayed discharge is down in no small part to the lack of a social care plan. One of my primary concerns about the hospital at home programme is that it will be used to try to mask the crisis in delayed discharge.

We can see that playing out in adjacent services such as hospice care. Just a few weeks ago, I visited the Prince & Princess of Wales Hospice in Glasgow, where people highlighted the fact that one third of its beds are unusable due to the lack of specialist nursing staff.

Labour has therefore set out our plan to increase the pay of social care workers to £15 per hour, at a cost of approximately £150 million a year. We have also identified three areas of an opportunity-cost value of almost £300 million, from which that money could be found, which would ensure that we have a further economic multiplier effect in our wider economy, through the marginal propensity to consume. I call on the Government to back us in that commitment and to increase the social care pay to £15 an hour. That would go a long way to alleviating the pressure on hard-pressed social care staff and to resolving the workforce crisis in social care; and, fundamentally, it would ease the pressure on front-line services by reducing the level of delayed discharge that is clogging up the system.

The Labour party supports and commends the hospital at home programme. However, we are clear that there needs to be a realistic and pragmatic assessment about the extent to which it will be beneficial, given the crises that I have mentioned. Without a long-term funding settlement or a plan to fix the workforce crisis in our NHS, and without a long-term prospectus for the future of our social care sector, hospital at home risks becoming a mere sticking plaster—another initiative that is doomed to failure before it has gotten off the ground. That would be a real shame, because the need for such a programme to succeed is greater than ever—and, if done right, it has the potential to enable significant progress for public health in Scotland.

I move amendment S6M-09191.1, to insert at end:

“; notes that one in seven people in Scotland are on NHS waiting lists, delayed discharge remains too high, and thousands of NHS vacancies are unfilled; recognises that Hospital at Home requires sustained investment to bring hospital-standard care into the home using technology, in addition to retaining and recruiting the multi-disciplinary teams that are required; considers that Hospital at Home is being hindered by the Scottish Government’s failure to tackle the social care crisis, which is essential in helping people to live independently, and calls on the Scottish Ministers to deliver a long-term funding settlement for this programme, to take urgent action to deliver well-funded and locally available social care services by immediately uplifting social care pay to £12 per hour, with a plan to raise it to £15 per hour, and, as recommended in the Feeley Review, to remove non-residential care charges.”


Alex Cole-Hamilton (Edinburgh Western) (LD)

I am pleased to speak for the Liberal Democrats and I thank Michael Matheson for securing time for the debate. Liberal Democrats are committed to improving the quality of care for patients across Scotland and believe that the hospital at home programme is a valuable way of so doing.

As we have heard, the hospital at home model of care provides treatment and support for patients in their own homes rather than in a hospital setting. It can relieve the interruption of flow that, as we know all too well, causes delays in accident and emergency departments and results in cancelled operations for people who are stuck in our main hospitals. It is a patient-centred alternative to acute hospital admission. It reduces the number of patients who are stuck in hospital wards and removes many of the challenges that are associated with admission.

It also leads to better outcomes for many people, because home is a better place to be. There are clear and obvious health benefits in allowing patients to maintain their independence and spend more time with their family and loved ones. Such programmes also reduce the risk of infection. In addition, hospital at home could save the NHS millions of pounds every year.

That is why hospital at home was in my party’s manifesto at the last Scottish election and why we have consistently called for more money to be invested in rolling out the programme more extensively. I am gratified that the Scottish Government has followed our lead with the £3.6 million investment that it announced this month. That is a welcome step, but the Government needs to go much further, because there are a number of issues with the service. There have been reports of a lack of co-ordination at some points between the hospital at home team and other healthcare providers such as the doctors and nurses who work at a hospital. That is not to denigrate their work in any way but to recognise the immense pressures that they are under. The resulting confusion makes it difficult to ensure that the patients receive the best possible care.

In addition, the service also remains unavailable in a number of areas across the country, thus adding to the list of valuable services for which a postcode lottery takes place. My party wants an expansion of the service to cover more areas of Scotland and an increase in the number of staff that attend to it.

We also want more training for the staff who currently work in the service and an investment in new technology. For example, the use of more remote patient monitoring, which can help to identify problems early can assuage the need for those patients to be admitted to hospital in the first place.

Emma Harper

Would Alex Cole-Hamilton welcome the remote monitoring that has been implemented by NHS Dumfries and Galloway for the monitoring of their chronic obstructive pulmonary disease and respiratory patients? That is working really well to keep folk out of hospital.

I can give you the time back, Alex Cole-Hamilton.

Alex Cole-Hamilton

I congratulate that health board on rolling that out successfully. Any remote monitoring, particularly for long-term, chronic conditions, including those with attendant co-morbidities, is to be welcomed, so I welcome Emma Harper’s intervention.

It is vital that hospital at home services are

“developed and resourced in addition to existing services, not instead of”

them. Those are not my words, but the words of Andrew Elder, the president of the Royal College of Physicians of Edinburgh. He also raised concerns about current staff shortages in our hospitals and communities.

Our NHS is indeed being stretched beyond its capacity. We hear that day in, day out, in debates such as this in this chamber. It is no different when it comes to hospital at home, while the Government’s total failure to tackle delayed discharge is continuing to have a significant impact.

If the scheme is going to work, it needs to be valued by the Government. That is why I am calling on it to make sure that the £3.6 million investment, as welcome as it is, is just the floor—just the beginning—and that we build on it significantly and swiftly hereafter. If the Government is struggling for ideas for how to pay for that, I suggest that it scraps the multibillion-pound takeover of social care.

We move to the open debate.


Clare Haughey (Rutherglen) (SNP)

I refer members to my entry in the register of interests.

We all want to be in a position where as much healthcare as possible can be provided to people closer to their homes. Over the past few years, there have been sustained and co-ordinated efforts in providing community alternatives to hospital, all while maintaining and improving patient experience.

It is vital to make it easier than ever for patients to know where to go to get the right care in the right place, as was evidenced during the pandemic, when it saved patients time and freed up space in our GP practices and hospitals. Whether it was through NHS pharmacy first Scotland or the hospital at home service, those initiatives played a key role in relieving pressure on our health and social care services.

During times of ill health, most of us would want to be with or close to our loved ones and in familiar surroundings. The hospital at home service enables people to receive treatments that would otherwise require them to be admitted to hospital, such as an intravenous drip for the administering of antibiotics, or oxygen therapy. It also provides access to hospital tests under the care of a consultant in an individual’s own home.

Hospital at home as an alternative allows patients to receive high-quality person-centred care and treatment in the right place, while at the same time reducing acute admissions and supporting timely discharge. Additionally, the provision of the service has the benefit that it can help avoid some of the risks of healthcare-acquired infection.

The effects on older people of remaining in hospital too long are well documented: deconditioning, pressure sores, and a loss of independence, which can make it harder for the individual to return home. We know that frail patients tend to occupy hospital beds for a longer period of time, and alternatives to that can produce far better health outcomes. That is why admission to hospital should happen only when the patient’s clinical need requires it. If that level of care and treatment can be provided at home, we should endeavour to provide it there.

Hospital at home has been in existence in a number of countries across the world for around 25 years. The first service in Scotland was introduced in 2011 by NHS Lanarkshire, the health board that serves my Rutherglen constituency. That multidisciplinary acute care service delivers specialist, co-ordinated and comprehensive assessment and care to frailer older adults in their own homes.

Although hospital at home is not a new approach, efforts to expand it are currently being ramped up. Only this month, the health secretary announced a further £3.6 million for the service.

The investment for 2023-24, which will take the total funding in the programme to more than £10.7 million since 2020, will increase by 50 per cent the number of patients who are managed through hospital at home, which is the equivalent of an additional 156 beds. From the success of the scheme so far, we can see that there is a real benefit to treating people at home where possible.

Looking at the feedback from patients and relatives, it is clear how valued the hospital at home programme has been and how beneficial it is for patients’ care. From the hospital visits that the service has saved to how supported individuals have felt in their recovery, it is clear that the service is overwhelmingly viewed as positive.

However, as was highlighted by Healthcare Improvement Scotland in 2020, the hospital at home service is not a silver bullet for reducing pressures on acute hospital care provision. As a result of the pandemic backlogs, Brexit-driven staff shortages and UK inflation costs, the Scottish Government is required to look across the wider health and social care system and implement innovative approaches to meet those on-going challenges. Hospital at home, taken together with work in tackling delayed discharge, improving A and E waits and increasing NHS and social care staffing levels, will improve patient experience and ensure better outcomes.

Thank you, Ms Haughey. I call Oliver Mundell, to be followed by Christine Grahame. You have around four minutes, please, Mr Mundell.


Oliver Mundell (Dumfriesshire) (Con)

Through my own, albeit limited, life experience and my work as a constituency MSP, I am well aware that, for many people, hospital is not the best place to be. Of course, no one really wants to be in hospital at all if they can avoid it, but, for some people, the disruption and change that is involved when admitted to an acute setting can teeter on the brink of outweighing the benefits of medical treatment. For those individuals, this initiative is and has the potential to be transformative.

However, if the initiative is to work, it must be promoted on that basis. It should be for the patient’s benefit, not merely to serve the system. Indeed, as Professor Andrew Elder has stressed, as mentioned by Alex Cole-Hamilton, access to acute hospital care for older people has been a hard-won right and it should not just be given away because an alternative is there. That alternative must meet the needs of every patient who is pushed towards it.

Looking now beyond the individual, I have to say that I am always fearful when I hear this SNP Government promoting the expansion of relatively new initiatives. Those concerns stem from the staffing and cash crisis in our NHS, and from my experience of a persistent lack of rural proofing when it comes to policy implementation.

The chief of NHS Dumfries and Galloway, which covers my constituency, has told this Parliament that the level of financial challenge is such that

“technically, I cannot afford one in 10 of my workforce”.—[Official Report, Health, Social Care and Sport Committee, 2 May 2023; c 13.]

Therefore, when I hear my colleague Finlay Carson asking about the future of cottage hospitals, it is hard to trust the decision that the health board is making because it is operating in financial circumstances in which it is making the best of the resource that it has got rather than doing what is best for its patients.

We already see patients unable to access core day-to-day services such as GP and dentistry services. We see challenges around recruiting and retaining specialist medical professionals. Who are the consultants who will be helping with patient care? Social care and care home beds are being rationed, with care deserts emerging in some parts of the region.

I set that out not because I do not support the concept of hospital at home but because many constituents, patients and hard-working staff will be questioning the capacity to pull that off at any significant scale in the current climate.

I am also concerned that, when it comes to stabilising our local health service, this SNP Government is not willing to confront the realities on the ground. All the strategies and policies that have been laid out today speak to that, as they simply do not match with the scale of the challenge that lies ahead. In place of a laser-like focus on, for example, getting people who are already in hospital home, we come up with new ideas and initiatives rather than trying to resolve the existing serious underlying issues.

I am equally worried about how the policy can be delivered in a constituency such as mine, where people live a considerable distance from the hospital that is overseeing their treatment. They may even be being treated outside the region altogether, never mind having to travel for pushing an hour from Dumfries and Galloway royal infirmary in Dumfries. Care at home should mean that they have access to good-quality local healthcare in their region. We must take account of the additional costs, pressures and time constraints that rurality brings in order to deliver projects such as hospital at home across vast and sparsely populated rural areas. Given the Scottish Government’s record, I am not convinced that it has got that right.


Christine Grahame (Midlothian South, Tweeddale and Lauderdale) (SNP)

I have to admit that, until recently, when I heard a news programme about it, I was unaware that the hospital at home service existed. That was my failure. I note that the Scottish Government’s motion states that it is

“a cost effective alternative to acute care”,

but, more importantly, that it

“provides very good clinical outcomes”,

which is what we all want. It also frees up hospital beds and, of course, the staff to service them.

Hospital at home is a short-term, targeted intervention that provides acute-level hospital care in an individual’s own home or in a homely setting. So far, it has led to a 53 per cent increase in the number of patients who are being managed by such services. It has prevented more than 11,000 people from spending time in hospital during 2022-23, thereby relieving pressure on A and E and, importantly, the Scottish Ambulance Service.

What is also important is that those patients were in the comfort of their own home, surrounded by the familiar, all of which, in my view, aids better physical and mental health. I will quote one patient, who said:

“I was delighted, it was unbelievable ... It was totally different to being in hospital. One thing I haven’t mentioned is the fact that it’s the personal ... between the two of us, I wasn’t just a number. It makes a difference.”

Midlothian’s hospital at home team has the acronym MERRIT, which stands for Midlothian enhanced rapid response and intervention team. It is an acute care team, based in Midlothian community hospital, which offers an assessment of a patient’s medical needs in their own home, or in a care home, by using a holistic, multidisciplinary approach during the acute phase of their illness. The service offers an opportunity to identify a potentially unwell patient, better persuade a patient to accept hospital admission as a safer place of care or direct them to a more appropriate service.

However, it should be recognised that there might be specific circumstances in which remote triage might also be appropriate, such as when the patient has been seen within the past 24 hours by a GP or another clinician; when there is a clear indication of a known recurrent or stable condition; or when examination findings are unlikely to change the appropriate place of care. In other words, as other members have said, it is about giving the right treatment in the right place, which might be either in hospital or at home.

I will give some examples of the criteria for referral to the hospital at home service. For Midlothian’s service, the patient must be resident there. In addition, their personal care requirements must be able to be met in the community: that is to say that they will be safe at home, either caring for themselves, having an existing package of care or receiving the support of their family.

There is also strict guidance on not referring patients with, for example, chest pain, acute stroke, asthma, suspected deep vein thrombosis, a suspected fracture or another suspected acute surgical emergency or, indeed, where the patient or their family is unwilling for them to stay at home. A discussion should be had with the person in their own home about what is most suitable for them.

NHS Borders’ hospital at home service started admitting patients only in April 2023 and so is the newest such service in Scotland. Rurality is an issue, but such areas can still be covered. Borders general hospital is far away for many people.

I welcome the progress that has been made on hospital at home, which seems to me to be a plus all round—and, in particular, to patients if it is practicable for them to be assessed and treated in familiar surroundings, which must be good for them.

I call Carol Mochan, to be followed by Emma Harper. In accordance with an agreement reached with the Labour group, Ms Mochan will have six minutes for her contribution.


Carol Mochan (South Scotland) (Lab)

I am happy to be speaking in this evening’s debate. I reiterate my party’s support for hospital at home services, which we know to be vital for delivering the healthcare of the future by bringing hospital-standard care into the home using technology.

Although we agree with the benefits of the hospital at home programme, recognise its usefulness thus far and want its success to continue, it is disingenuous to suggest that investment here is anywhere near enough—we need widespread resource for our NHS, which is struggling on many fronts. We need the Government to explain its long-term investment plan for the hospital at home service.

It was right for my Labour colleague Paul Sweeney to set out the reality in our health service, which is the backdrop to today’s debate. One in seven Scots are on waiting lists, delayed discharge is alarmingly high and NHS staff, despite their great efforts, are being let down by a Government that—no matter how often it tries to argue to the contrary—has undervalued and underresourced that critical workforce. Our patients are being failed by the lack of support for the staff. Initiatives and programmes such as hospital at home are welcome, but the wider picture cannot be ignored.

It is also correct that we ask the Scottish Government to set out its plan for delivering hospital at home services for the longer term as an alternative to acute hospital care, so that that is understood, rather than such services being seen as a quick fix or a tokenistic gesture, which just allows pressure to be put back on acute services when funding falls short.

At this juncture, I wish to recognise the multidisciplinary nature of the service and the importance of various workforces within our NHS and social care services in its delivery. It is right that we commend Healthcare Improvement Scotland and NHS Education for Scotland for their work in this regard so far. I pay tribute to our allied health professionals, who make up the third-largest workforce in our NHS, who go above and beyond to deliver specialised care services for our most vulnerable people in the most challenging of times. We are all aware that, without doctors, nurses, carers and unpaid carers, and allied health professionals working together to meet the individual needs of every patient, hospital at home does not work, so it is right that we do all that we can to support them.

Therefore, it would be appropriate for the Scottish Government to listen to the concerns of, for example, the Royal College of Physicians of Edinburgh. In its comments ahead of today’s debate, the college highlights concerns about a potential overreliance on unpaid carers, who are already under serious and significant pressure to look after those in their care, to provide support during periods of increased patient need. Indeed, the RCPE argues that the provision of hospital at home must be in addition to existing services, rather than a replacement for them, in order to ensure that the hard-won rights of older people to receive care in acute hospital settings—should that be most appropriate to their needs—are not lost. It would be useful for the minister to outline the long-term future of hospital at home and to address some of those important points in her concluding remarks.

Christine Grahame, who spoke before me, mentioned that she was unaware of the hospital at home service. If MSPs are unaware of the service, that gives us a sense of the extent to which people out in the communities understand the service. I see that the minister and the cabinet secretary are looking surprised—I know that they feel that the service is very embedded, but it does not feel that way to many people, and it would be useful to address that.

We need to consider the staffing challenges that we face: one in 10 GPs have formally closed new patient lists, the Royal College of Nursing Scotland confirms that community nursing teams are under extreme pressure, and AHP vacancies are causing stress, too.

That is all underpinned by a failure thus far to fully implement the safe staffing legislation that the Parliament passed years ago to protect an overworked workforce. We know that such services need to be met with strong protections for NHS staff. We should look back at that legislation to ensure that it is implemented appropriately in our wards and in services such as hospital at home.

We have touched on social care. All community services are undermined by the crisis in social care. The Government cannot avoid that. Carers are not being paid the fair wage that they deserve, and there are serious concerns across Scotland about the provision of well-funded and locally available social care.

It is clear, as Scottish Labour’s amendment sets out, that we will be able to deliver the standard of social care that is required and a strong hospital at home programme only by immediately uplifting social care pay. I mention the recommendation in the Feeley review to remove non-residential care charges. Those important issues have not been addressed by the Government.

I reiterate my party’s support for the intentions and aims of hospital at home and recognise that it is an important step in encouraging the use of alternative care options. A close friend of mine who has many years of community nursing experience tells me that patients seem less anxious, which must be a good thing for care. However, it is clear that there are issues in relation to support and resources for the NHS and social care workforce, and I hope that the minister addresses that in closing the debate.


Emma Harper (South Scotland) (SNP)

I am pleased to speak in favour of the Government’s motion. I remind members that I am a registered nurse and former employee of NHS Dumfries and Galloway.

As members and the cabinet secretary have indicated, the purpose of hospital at home is to reduce hospital admissions by providing treatments in the comfort and familiarity of a person’s home. Clare Haughey described the types of treatment that are received, which include intravenous infusions and oxygen therapy.

Evidence shows that those people who benefit from the service are more likely to avoid hospital or care home stays after a period of acute illness. For older patients, that means remaining at home longer without losing their independence, which has contributed to overall improvements in patient satisfaction.

I am a member of the Health, Social Care and Sport Committee, which is currently undertaking scrutiny of NHS boards, including the rural boards in my South Scotland region. The chief executive of NHS Borders, Ralph Roberts, told us about the reablement work that is being implemented in his board. Reablement refers to the care that a person receives after experiencing an illness or injury. The main aim of reablement is to allow people to gain or regain the confidence, ability and skills that are necessary to live as independently as possible, especially after an illness, injury or deterioration in health. Reablement is a person-centred approach, and support is usually delivered in the person’s home or in a care home. That work has led to an increase in people receiving hospital at home care, which is of course welcome.

Delayed discharge is one the biggest issues that health boards in Scotland face. I welcome the fact that, as the motion indicates, the Scottish Government is providing on-going support to boards in a range of areas, including discharge planning.

Will the member take an intervention?

Emma Harper

Gie me a wee sec.

Home teams is a new health and social care model of working that is being delivered in Dumfries and Galloway to help people to live happier and healthier lives in their own home and to tackle delayed discharge.

Finlay Carson

Does the member recognise that there are huge gaps in the provision of home care in Dumfries and Galloway, which has much to do with rurality and the lack of staff? Does she agree that step-down facilities, such as our cottage hospitals or similar facilities, are needed in our rural towns to ensure that people can be looked after close to home and that they do not add to the record-breaking figures for delayed discharge in Dumfries and Galloway royal infirmary?

I will give you the time back, Ms Harper.

Emma Harper

Rurality is a hugely important issue for us in Dumfries and Galloway and the Scottish Borders, and I acknowledge that the health and social care partnership is consulting right now on community bed provision. I look forward to the results of that, but I agree that we need to look at whatever care can be provided as close to home as possible. I support whatever mechanism we can use to take that forward.

Similarly to hospital at home, the home teams model, as I was describing, pulls together the multidisciplinary team and other resources in the community under one team. That ensures that there are fewer referrals to acute care, that people tell their story once without having to repeat it, that reduced waiting response times are delivered and that a holistic person-centred approach is taken.

The home teams initiative has led NHS Dumfries and Galloway to redeploy 52 community staff to support 102 packages of care, which equates to 120 individuals receiving the hospital at home model, and 18 beds have been created in Mountainhall treatment centre as an intermediate care facility and a step-down from acute care. That is similar to what Mr Carson talked about earlier.

Oliver Mundell rose

I do not think that I have time to take another intervention.

No. I am afraid that you should wind up.

Emma Harper

It would take a six-minute speech to go into the detail of the provision that is required across the whole rural area. I apologise to Mr Mundell that I cannae do that.

I am looking forward to the community bed provision consultation responses. We all know that people want their care to be closer to home.

I thank NHS Dumfries and Galloway for the innovative work that it is taking forward to make a difference to patient outcomes. As well as hospital at home, the out-patient parenteral antimicrobial treatment scheme and respiratory community response teams now offer more than 600 virtual beds to treat patients for conditions that would traditionally need hospitalisation.

Could you bring your remarks to a close, please, Ms Harper?

I welcome that support, and I look forward to decision time, when I will be supporting the Government’s motion.


Gillian Mackay (Central Scotland) (Green)

As we have heard, the hospital at home programme allows patients to receive acute care in their own home or in a homely setting. The success of the service has clearly shown that it alleviates pressure on unscheduled acute care in hospitals by reducing admissions. Between April 2022 and March 2023, 11,686 patients were supported by hospital at home services. That is a 53 per cent increase on the previous year. Healthcare Improvement Scotland has said that the equivalent emergency admissions to in-patient hospitals might have equated to significantly more occupied-bed days due to the likelihood of delayed discharges.

Furthermore, hospital at home is now growing and is the fifth-biggest hospital for older emergency in-patients, with the number of people benefiting from the service being similar to the latest published numbers of people aged 65 or over who were admitted as emergency in-patients to Aberdeen royal infirmary or Victoria hospital in Kirkcaldy.

As I have said, hospital at home services are clearly reducing pressure on accident and emergency departments and the Scottish Ambulance Service, but they can also vastly improve the patient experience. That is what I would like to focus on in the rest of my contribution.

Hospital at home has high rates of satisfaction and patient preference across a range of measures. We can see that from the increased demand that I referred to earlier. It allows people to be cared for in their own home, where they are comfortable, where family and friends can easily visit them, and where their things are—their home comforts, pets and the other things that we all take for granted, until they are not there. That impact cannot have a price tag put on it. We often lose humanity for individuals when we talk about large-scale programmes.

In hospital at home services, care is co-ordinated in the community by GPs and district nurses, so they ensure continuity of care and the building of positive relationships between patients and healthcare staff.

Gillian Mackay is absolutely right that GPs in primary care need to be there. Therefore the closure of GP practices, such as in Invergowrie, would make that really challenging.

Gillian Mackay

I can say that such closures absolutely would do that.

The programme can also positively impact on social care delivery. Patients losing their care packages due to hospital admission can lead to delayed discharges, and patients can be stuck in hospital when they do not need to be. We know that longer stays in hospital can lead to increased frailty in older patients. By preventing hospital admissions, the hospital at home service enables patients to keep existing agreements with carers who visit their home to help with essential needs. That, too, maintains continuity of care and allows people to build relationships with their carers, which can be of great comfort to vulnerable patients.

I want to read one testimony from within my region, which was posted on the Care Opinion website. It demonstrates the positive impact that hospital at home can have on patients. The testimony said:

“I would like to thank the H@H team in Coatbridge for the level of care from the team which exceeded mine and my mums expectations. The care and attention can only be described as excellent.

Not only did this prevent my mum having to go into hospital on two occasions but the communication, advice and support from the team not only helped my mum but gave me the confidence that I was treating her to the best of my ability.”

That testimony clearly shows how hospital at home and the incredible teams that work in the service can improve patients’ experiences and provide comfort and stability when people are unwell.

More broadly, the Health and Social Care Alliance Scotland has said that the hospital at home service reflects a positive change in the culture of how health and social care is delivered, by focusing on shared decision making and delivering the personalised outcomes that matter to individuals and their families. It enables more person-centred care, which empowers patients to make choices about their care in an environment that is safe and familiar to them.

Although hospital at home services alone will not eliminate pressure on acute services, they will form a vital part of a wider system transformation that aims to reduce hospital admissions and ensure that more people can be treated at home or in a homely setting.


David Torrance (Kirkcaldy) (SNP)

I welcome the opportunity to speak in this important Scottish Government debate on the hospital at home programme. The extraordinary initiative has reshaped the landscape of healthcare delivery and quality in our nation. It has touched on and transformed lives in my Kirkcaldy constituency and across Scotland.

There is widespread agreement that our health and social care system has faced a number of challenges and obstacles. We have all spoken in the chamber about complex, prolonged and relentless change. Brexit, the cost of living crisis and Scotland’s changing demographics, in combination with the challenges of a post-pandemic world, have emphasised the urgent need for innovative patient-centred healthcare solutions.

In that context, the hospital at home programme is thriving and ensuring that our constituents receive the right care in the right place at the right time. I therefore very much welcome the additional £3.6 million that has been allocated to support more than 150 extra virtual beds under hospital at home.

Thousands of patients in Fife have benefited from the hospital at home service. In 2021-22, more than 1,000 patients were supported. The additional funding will help the programme to reach more of our constituents and continue to provide comfort and reduce anxiety for people across Scotland.

Hospital at home is a safe and dignified alternative to acute hospital admission. It bypasses the anxiety, disruption and disorientation that are often associated with hospital stays, while delivering the same—or better—quality of care. Whether the specialty be cardiology, geriatrics or any of the plethora of others, the programme transcends conventional barriers and opens the door to healthcare that is truly personalised and patient centred.

Last year, hospital at home offered more than 63,000 bed days for adults—more than 60,000 days when older adults could heal in the comfort and familiarity of their homes, while surrounded by loved ones, and more than 60,000 days when the dread of an acute hospital admission was replaced by compassionate care that respected people’s routines, homes and dignity.

By reducing the pressure on our hospitals, the service creates a virtuous circle of care. Fewer acute admissions means more time for hospitals to focus on complex cases, less strain on our devoted healthcare professionals and more efficient utilisation of resources. The hospital at home programme is not just beneficial for patients; it is a holistic solution that aids the entire healthcare ecosystem.

None of those achievements would have been possible without the relentless dedication and concerted effort of Healthcare Improvement Scotland, NHS Education for Scotland and the clinical networks, whose tireless work has supported the development and implementation of hospital at home. I recognise the invaluable service of our dedicated doctors, nurses, therapists and other healthcare professionals who make hospital at home a reality, who navigate the complexities of individual patient needs, often at unsocial hours, and who continue to learn and evolve in order to serve their patients better.

Hospital at home is not a replacement for hospital admissions; it is only an alternative. I have full confidence that the Scottish Government and our health ministers will continue to manage the pressures that remain on services across our health and social care system.

It is vital that we build a health service that best meets the needs of the people whom it will serve, which is why the Scottish Government is committed to doing what it can to ensure that those with experience of social-care support and community healthcare have a sufficient chance to share their views. That includes patients who have experienced the hospital at home service. Anyone who uses the service, who has a loved one who relies on care or who has worked in the sector will be able to have their say on our future healthcare landscape.

Hospital at home represents a leap in the evolution of healthcare delivery in Scotland. It embodies an ethos that recognises holistically patients’ needs, upholds their dignity and optimises the country’s health resources. As we continue to tackle the many challenges that Scotland faces, I welcome the continuation of hospital at home so that everyone can receive the right care at the right time in the right place.

I call Bob Doris, who will be the last speaker before the closing speakers contribute.


Bob Doris (Glasgow Maryhill and Springburn) (SNP)

I am pleased to speak in this debate to acknowledge the contribution of the Scottish Government’s hospital at home strategy. In Glasgow, a test-of-change pilot for hospital at home was introduced by the Glasgow city integration joint board in January 2022. By March this year, it was reported that up to 1,200 at-home bed days had already allowed many Glasgow residents who are over 65 to leave hospital earlier, or to avoid admission to hospital and instead receive enhanced care at home. That is better for patients and it takes strain off our NHS in acute settings.

Receiving the care that they need at home from nurses, advanced nurse practitioners, GPs, pharmacists, occupational therapists and consultant geriatricians with a wraparound service has allowed more than 300 Glaswegians to be at home rather than in hospital. That is a success story, but I am keen to hear about any qualitative data that has been collected regarding the views of people who have benefited from hospital at home and any changes that they have suggested could be adopted.

I am also keen to hear about whether, as part of hospital at home, patients who are required to run essential medical machines and other equipment, such as air mattresses or electric hoists, in their homes have been offered support with their utility bills. More generally, people who live at home with medical conditions long term incur more expense, which can be due to their need to wash and dry clothes and bedding more frequently, or to keep their homes at the right temperature to support their care. I would welcome any information that the Scottish Government can provide, in summing up the debate, on how it offers assistance with that.

I acknowledge, however, that hospital at home is a success and should be expanded. I also welcome the £10.7 million investment in hospital at home since 2020. Given that the initiative is funded by channelling money via integration joint boards, and given their financial challenges, I am interested in learning more about how the Scottish Government monitors the wider budget pressures on IJBs. I have written to the cabinet secretary about concerns regarding changes to provision in my area that might impact on frail elderly people. We do not want any unintended consequences. I look forward to a detailed response on that matter from the cabinet secretary, in due course.

This week, I am sponsoring Chest Heart & Stroke Scotland’s exhibit in the Scottish Parliament promoting the hospital to home service that it offers. Hospital to home is not just for the over-65s; it is for everyone, and it offers significant support. Chest Heart & Stroke Scotland states:

“Every day people in Scotland are leaving hospital feeling scared and alone. But our amazing nurses, support workers and volunteers are here to make sure you don’t have to recover alone.”

The service offers free practical help, support and advice, which is often face to face and one to one, through community support teams and home visits. Many people who have suffered cardiac arrest or stroke might previously have been active. Others might previously have lost the confidence to be active, or have lost the networks that enable them to be connected and active and to avoid social isolation. The work of Chest Heart & Stroke Scotland can make a real difference in that context. Its hospital to home service can lower rates of readmission to hospital and avoid unscheduled care and presentations at accident and emergency departments.

Hospital to home clearly has an important part to play and surely complements hospital at home. I look forward to further expansion of hospital at home in an iterative way that is informed by patient experience and is part of a broader range of services.

I will support the Government motion.

We move to closing speeches. I advise members that we have some time in hand.


Paul Sweeney

It is a pleasure to close this debate on behalf of the Labour Party. There is broad consensus across the chamber on the benefits in principle of hospital at home. Certainly from personal experience, I know, as I am sure that many others do, that being in hospital is a rubbish experience. It is frustrating and deeply tedious, certainly for a younger person but, for an older person, it can also be potentially life threatening. We have heard of the potential impacts relating to frailty and acquiring an infection, which can potentially lead to a fatal spiral. Therefore, any measure that can move the emphasis of care away from acute settings and into home settings is to be commended. That is why we all broadly support the scheme.

However, the member for Glasgow Maryhill and Springburn made an important point about that when he asked how we ensure the resilience of the home setting. There is an emphasis on hospital, but how do we emphasise the resilience of the home setting?

There is much more work to be done in that space. Mr Doris mentioned, for example, how we need to ensure that adaptations are made to homes to make a sufficient facility available for people. We need to do much more to ensure that housing associations and registered social landlords are supported.

Edward Mountain (Highlands and Islands) (Con)

It is about not only adaptations to the home but making sure that the correct equipment follows the patient to the home. That has been a problem across the Highlands. Has that been a problem in Mr Sweeney’s area and does he think that more work should be undertaken on that?

Paul Sweeney

I absolutely recognise that. It is a major issue and one that is not well understood. The call for extra data and understanding of that qualitative experience is essential in order for us to ensure that the system works as best it can.

There is not only the issue about facilities and the costs of running equipment—which can be quite energy intensive—particularly in a cost of living crisis; there is also the issue of the complex needs of individuals in the home setting. A very striking exhibition by a series of hospice care providers in Glasgow called “The Cost of Dying” was held at the University of Glasgow. It was quite harrowing to see some of the experiences of people who wanted to die at home—to have a good death—but were prevented from doing so because of the failure of their registered social landlords to make the necessary adaptations to their home, so they ended up languishing in hospital in their final days. That is not acceptable and we need to do much more to ensure that the rights of the patient are upheld. The member for Rutherglen also mentioned that the patient focus is essential.

Also, if someone cannot stay in their home, there may be a role for step-down services. The member for Galloway and West Dumfries mentioned cottage hospitals and how that kind of setting offers a potential opportunity for that, as does having more sheltered accommodation where there is a sort of semi-supervised activity. Certainly, some housing associations are exemplars in providing those facilities. Let us look at how we can build on that capability across Scotland to ensure that the hospital at home concept is better embedded—a need that was recognised by members across the chamber.

Hospital at home might not be as well known as ministers perhaps think it is. Some members certainly alluded to the fact that they were not aware of it prior to today, or have only recently become aware of it. While it is a relatively recent innovation, and one to be welcomed, we need to do more to disseminate the information about how it can function well. That view is often fed back to me, certainly. Particularly when it comes to palliative care, as well, people often do not know their rights and they are so stressed by the situation that they do not realise what they could have achieved for their relative or the person whose care is their responsibility until it was too late and they had already passed away. Therefore, we need to look at that.

We also we need to look at how we build resilience. Mr Doris mentioned the budget of £10.7 million since 2020, but that is set against the fact that, even in Glasgow, as the member will be aware, the integration joint board is facing £20 million of cuts in this financial year alone and has had to dip into its reserves to the tune of £17 million. That is a really shaky peg to be hanging the system on. We need to look at the underlying fragility of the integration joint boards and their ability to step it up, when we are looking at 200 jobs being lost from the IJB service providers in Glasgow alone. That is a major risk to the resilience of the hospital at home system.

We recognise the huge opportunity that presents itself, and that we have one of the most acute hospital-centric healthcare systems among the Organisation for Economic Co-operation and Development countries. We need to move the emphasis out of the hospitals and into the community. We need to look at putting serious resource into that. I would argue that the cabinet secretary has to recognise the need to ramp it up and be serious about it.

That was what my colleague Miss Mochan, a member for South Scotland, meant about the long-term plan. We really need that long-term vision for how the system will develop. We need stable budgeting and the ability for the IJBs to properly plan for the long term, to build those pathways for career development and training, and to increase staff wages, as well, because we are really having a problem with retention and morale. We have heard about the issues of hospices not being able to fully staff their beds. That is just a tip-of-the-iceberg situation; there are huge issues there.

There are also huge issues in the practicalities. Urban settings are one thing, but rural settings are another. A number of members across the chamber have mentioned the practical challenges of managing hospital at home when we are faced with such wide geographical constraints. That needs to be looked at and is something that is essential to be fed back. What will the system look like in a city? What will it look like in a rural setting? It is not a one-size-fits-all thing and it would be good if the minister highlighted some of the challenges faced in those different geographical environments.

There is a major issue about the opportunity to free up capacity. Ms Mackay, a member for Central Scotland, mentioned that the programme is a huge opportunity to free up bed space and reduce costs in the healthcare system but how do we ensure that it does not simply displace staff capacity from other parts of the healthcare system and, thus, accentuate the problems that we have across the entire healthcare ecosystem, as the member for Kirkcaldy mentioned?

Although we all support the programme, we must be cognisant of the major practical constraints that we face. It is essential that Scotland achieves the best possible healthcare system for us all, but we must be aware of the acute problems that we face and work through them in a collegiate and co-operative way.

We are happy to support the Government’s motion.


Edward Mountain (Highlands and Islands) (Con)

I welcome the debate. At a time when our health service is in crisis like never before, patients need smart and resourceful solutions that do not compromise their care. That is exactly why the Scottish Conservatives support the hospital at home programme, provided that care at home will free up capacity in our hospitals. Initiatives such as the programme are vital for reducing hospital admissions for elderly patients, especially those who prefer treatment in the comfort of their own homes.

I will give credit where it is due, because it is important to do that. People who benefit from the programme are far more likely to avoid hospital care and care home stays for up to six months after acute illness. That is good news. It saves our precious hospital beds and creates space for all the other patients—patients who often sit on long waiting lists—to receive the treatment that they need.

However, that is why it is disappointing that the Government failed to deliver on the promise to double the capacity of the hospital at home programme by the end of last year. I question how many patients would have benefited but have not because of that failure. We need to address that question because, although the programme can make a difference, it is only a partial solution to the hospital backlog that has grown under the SNP.

Indeed, hospital at home services are not appropriate for every patient. Much like the roll-out of NHS Near Me, they can act as a complement to, rather than a replacement for, acute patient care. The stark truth, however, is that the programme will not solve the problems of delayed discharge. We know that 1,700 beds are still being blocked every day, that the effects on the patients involved are soul destroying and that the situation leads to increased waits at A and E, as well as lengthy delays for vital procedures.

My colleague Dr Gulhane mentioned in his speech the SNP’s promise to eradicate delayed discharges in 2015. Every health secretary since has failed miserably to do that and—let us be honest—patients are paying the price. Former health secretaries who broke their promises include the First Minister and Deputy First Minister. It is not good enough.

I will make a few points on what I heard from speakers in the debate.

I appreciate the cabinet secretary’s points. I wonder whether he should reflect on the fact that he and the health services should ask not whether we should do hospital at home but whether we can do it. Let us make it possible. Let us urge doctors to ask that question.

We should remember that, although there are risks to sending people home, they might not be as high as keeping them in hospital. When my father was waiting to go home, I was told clearly that there was a risk in sending him home. He was dying. We knew what the risks were. Let us make it possible where we can.

Dr Gulhane also mentioned the importance of delayed discharges. We must work harder at sorting those out and ensure that, when patients go into hospital, there are people there who ensure that their discharges happen and that they go out at the right time. That might require the patients to give them power of attorney over medical decision-making processes.

I was taken by Paul Sweeney’s comments about supporting the principle of the programme and the importance of social care being there to step up when the need comes for the person to go home. It is also important to remember the point that he made that it will not be suitable for everyone. Not everyone can afford the extra cost of going home and of a sensible care package at home that might require extra heating and other use of electricity.

Alex Cole-Hamilton recognised the staff shortages. We all recognise that and understand that, to make this work, we have to recruit additional staff on top of the staff whom we see already in the system.

I agree with Clare Haughey that high-quality person-centred care must be at the centre of all this. That is really important. She also made the point that we need to increase funds. What about the extra kit that is needed, which is a point that I raised with Mr Sweeney? It is really important that we make sure that we have the kit to follow people when they are at home.

Clare Haughey

The heart of all this is about being patient-centred and allowing patients to be where they need to be, whether that be at home to recover or to die surrounded by their loved ones. I mentioned funding but I referred to the funding that the Scottish Government has already committed to this.

Edward Mountain

I thank the member, and I accept her qualification of the point, but the point that I am trying to make is that extra funding will always be required because caring for people at home brings additional costs through extra staff and extra equipment and all that. We need to be responsive to the fact that a cost is involved.

Oliver Mundell and Finlay Carson made a point about the importance of cottage hospitals and the part that they can play in helping patients step down from hospital services and allowing them to go home.

Christine Grahame started off her speech by talking about the extra equipment that would be needed but that then dropped away. I might have misheard her, but I thought she made a point about the importance of having teams that can help people at home.

Will the member take an intervention?

Edward Mountain

I will take an intervention if I have time.

We need teams that are probably a little bit more advanced than those we have in the local community. That is why, in the Highlands, we have the pre-hospital immediate care team that can deploy if it is needed to provide care at home when local doctors are not able to. I give way to Christine Grahame.

Christine Grahame

I thank Edward Mountain but I just wanted to clarify and say that I did not mention extra equipment, although I said that a full assessment has to be made of whether hospital at home is the right thing in the right place at the right time for that person. By implication, that might also involve equipment.

Edward Mountain

That was another qualification but we got to the point that extra equipment might be needed after a full assessment. I take that point.

Emma Harper’s point was interesting. With her experience of nursing, we should be aware of what she was saying about being at home being a tonic to speed recovery and that it helps people to get through their illnesses better. There is general agreement among all other speakers on that.

I welcome the small but significant amount of progress that has been made in the hospital at home programme. However, patients still need to see some big ideas and big investment from the Government. We need to see sufficient kit to allow patients to go home, and we need to see sufficient care support to allow those people who have gone home to do so in the comfort and knowledge that they will get the best possible care. However, we have not seen the Government tackle the real problems of delayed discharges, long accident and emergency waiting times and the social care crisis. Until we see some fresh thinking on those issues, our hospitals will continue to run out of beds, despite this programme, because the Government has run out of steam on how to resolve those problems and I ask it to resolve them as a matter of extreme urgency.


The Minister for Social Care, Mental Wellbeing and Sport (Maree Todd)

I welcome the opportunity to close the debate, which has provided members with an update on the benefits of hospital at home and the action that we are taking to support the development and expansion of the hospital at home programme. I take the opportunity to recognise the hard work and commitment of our partners who have worked to establish and expand this crucial service.

The services are, by their nature, both personal and person centred. They are delivered by highly skilled and valued health and care staff who are intently focused on delivering for the needs of the individual in their own environment.

I thank Healthcare Improvement Scotland for the support that it has been giving local areas since 2020 to grow an active learning network of health and social care partnerships. That support has enabled the expansion of hospital at home from seven to 21 HSCPs, but I would like us to go further and have an even wider geographical spread.

I also thank NHS Education for Scotland for its work in developing training materials for the hospital at home programme, and I thank our health boards and HSCPs for their on-going support and commitment to delivering more acute care in the home.

I thank members from across the chamber for their input and reflections in today’s debate. There is clear consensus here today that providing person-centred care that takes full account of an individual’s wishes and balances those with safety and clinical need is a priority.

Finlay Carson

The minister touched on the views of the patient. In areas such as Dumfries and Galloway, hospital at home will not always be the ideal situation. Some patients would prefer to be in surroundings similar to a cottage hospital or—where there are services that a cottage hospital would traditionally deliver—to be right at home instead of having to travel potentially 50 or 60 miles to an acute hospital or, as Emma Harper said, 50 or 60 miles to 18 beds that are being delivered in Dumfries. Can you tell us what role step-down facilities such as cottage hospitals should play as part of the package in rural areas?

I remind members that they must speak through the chair.

Maree Todd

As the cabinet secretary said in response to Finlay Carson’s intervention on him, those decisions are best made by local health boards, which are well aware of the needs of local communities.

Let me put to bed the issue around rural areas. A number of members have raised the challenges of delivering hospital at home in rural areas. As a rural representative—I am the member for Caithness, Sutherland and Easter Ross—I am well aware of those challenges, and it could be argued that it is even more important to deliver hospital at home in rural areas because hospital admission is much more disruptive for patients and their families in those areas. NHS Highland is delivering hospital at home in Skye, and it is being delivered in the Western Isles by NHS Western Isles. If it can work in Skye and the Western Isles, it can work anywhere.

I will turn to the specific questions that have been raised during the debate. To respond to Carol Mochan’s point, I note that we have been using hospital at home for more than a decade. It started in December 2011 and we have expanded it recently. It is here to stay, because

“people are at the heart of the Hospital at Home programme; they value the flexibility and security that being in a home setting brings, and particularly for elderly people, familiar faces and spaces reduce the potential for adverse incidents. Ultimately, it’s about creating the options that best suit people and communities, and ensuring access to the right care in the right place.”

That is a direct quote from ALLIANCE director, Irene Oldfather.

The ALLIANCE also spoke to hospital at home patient Stephen Green, who said:

“If you fancy a cup of tea or you fancy a sandwich, it’s there, you know. If you fancy a chat with your wife or with someone on the phone, it’s there. For something like what was ailing me, hospital at home is ideal. This has done me a lot of good, I know, and I would recommend it to anyone it suits.”

We have talked a little bit about the number of people who are benefiting from hospital at home. The latest published data on the number of people aged 65 and over admitted as emergency in-patients are 12,262 people at Aberdeen royal infirmary and 10,999 people at Victoria hospital in Kirkcaldy. Those numbers are pretty similar to the number of people who are benefiting from hospital at home. It makes hospital at home the fifth biggest hospital for older people who are emergency in-patients.

A number of members raised the impact on unpaid carers, and it is essential that our valued unpaid carers are supported and are not overwhelmed, particularly when their loved one is in crisis. Feedback from ALLIANCE Scotland indicates that hospital at home transfers control back to patients and carers and that they value that because it is providing care on their terms and in their environment. As many members have said, that obviously indicates that patients recover faster and feel more involved in decisions along the way.

Some members mentioned the impact on GPs and primary care. There has been some concern that hospital at home places a burden on an already overburdened area of our health and care system. Professor Graham Ellis, our deputy chief medical officer, was asked about that and said:

“I know this was a concern when I met with GPs prior to starting in Lanarkshire, but there is no evidence that hospital at home creates additional work to routine hospital admission and in reality it is about partnership between primary and secondary care in the patient’s interests. It should be recognised that routine hospital admissions can create potential work for GPs and that, arguably, the debate is about what patients need, not about whose workload is affected.”

Oliver Mundell

Does the minister accept that there are now parts of Scotland where primary care has completely broken down and people are unable routinely to see a GP? How can a programme like this one work without that key linchpin?

Maree Todd

I agree that GPs are a linchpin. They are the front door of our NHS and are key, which is why we are investing in general practice and value it so much.

We are addressing the issue of delayed discharge, and we have a hospital occupancy action plan. Addressing delayed discharge is of absolutely critical importance and, although more than 97 per cent of all discharges happen without delay, we have already made available up to £8 million of funding this year to support HSCPs in purchasing around 500 interim care beds to increase interim capacity. Those are in addition to the around 500 interim beds that are already in the system and helping patients.

There is a delayed discharge and hospital occupancy plan that builds on best practice to address the issues that were experienced last year. I can also tell the member that we are already well into planning for next winter and are working at pace to deliver the actions that we know work. A whole-system oversight and planning group is in place to assess progress in the implementation of that action plan and to plan for future peaks. So, a lot of work is going on, right across the board, in a system that we all acknowledge is under pressure.

Christine Grahame made a point about Midlothian. I had the delight of visiting the Midlothian community hospital recently. I met multidisciplinary teams, mainly of allied health professionals such as physiotherapists and occupational therapists, and was inspired. They were working in an incredibly flexible, patient-centred and holistic way to ensure that people got the right care in the right place and at the right time. They were keen to emphasise to me how much better it was to be able to assess people’s abilities in their own homes, where their wider needs were far more visible than they would have been if the assessments had taken place in hospital.

Hospital at home is a tried and tested concept that is deployed across the globe, and Scotland is, in many ways, at the forefront of that growing movement. International evidence of the benefits of the approach has accumulated across a range of clinical specialties, including older people, respiratory care, cardiology, paediatrics and infectious diseases. It offers care that is comparable to that provided in an in-patient bed but with reduced risk of the harms that the cabinet secretary set out in his opening remarks.

Beyond the benefits to the patient of providing care at home and reducing pressures on the NHS, we know that it can reduce the need for all the people to be admitted to care homes. The evidence from a large study that was conducted across the UK found that hospital at home for older people reduced nursing home admissions by as much as 42 per cent. Being able to stay safely in their own home when they are unwell or receiving treatment matters hugely to many people. We also know that hospital at home is able to deliver the best hospital care to people who are in nursing homes, minimising the disruption for some of the most frail in our society.

As the cabinet secretary noted, since 2020 we have pledged a total of £11.2 million to develop and expand the hospital at home service. Given our firm commitment to offering the service to more people across Scotland, we will regularly review our funding for the programme to assess whether it matches our ambition. We are committed to the continuing expansion of the hospital at home service across a range of specialty areas, and I would be very happy to return to the Parliament with an update on that work in due course.

For the reasons that have been set out during the debate, I do not support the Opposition amendments to the motion. Instead, I commend the motion that was lodged by the Cabinet Secretary for NHS Recovery, Health and Social Care.

I look forward to working with our partners to continue the expansion of the hospital at home programme and to ensure that the public is aware of its benefits. We remain committed to patient safety and the highest quality of care. By taking an approach that puts the person and their needs and wishes firmly at the centre, we will provide the type of careful and kind care that we would wish to exemplify in all our services, and we will help more people to receive acute care in a familiar setting in their own communities.