Acute Home Visiting Service

The Acute Home Visiting Service (AHVS) is for patients who need to be seen in their own home/care home. When patients contact their GP requesting a same day home visit, the GPs can choose to refer on to the AHVS, and a dedicated team of Advanced Nurse Practitioners (ANP’s) and Emergency Care Practitioners (ECPs) will visit patients in their own home or care home.

This Service is provided by Primary Integrated Community Services (PICS) and has been delivered across 39 practices in Mid-Nottinghamshire, covering Mansfield, Ashfield, Newark and Sherwood for four years.

The aim of the Service is to reduce unnecessary hospital admissions and enable patients to be cared for at home, when it is clinically safe to do so. The Service supports GPs to manage urgent care needs, enabling them to focus on other priorities in Primary Care.

NHS Nottingham and Nottinghamshire Clinical Commissioning Group (CCG) sought to hear from people who had accessed the AHVS, their carers and primary care professionals across the Integrated Care System (ICS), including Bassetlaw, to inform future reviews of the Service.

In total, three service users and one carer got involved via the online survey, with another carer participating in a telephone interview. Additionally, 97 primary care professionals across the ICS participated in an online survey to share their views. Two further emails were received from primary care professionals outlining their experiences.

Overall, it was found that:

• Service users and carers felt that the support and service received from the AHVS was good.
• Service users and carers felt reassured and listened to.
• Patients and carers would have contacted their GP again, called 111 or attended their local Emergency Department if they were not offered a home visit.
• Patients and carers would like to see this Service continue in the future and have thanked the Service for its support.
• Most professionals in Mid-Nottinghamshire  value the Service highly, and all want to see it continue in future.
• Suggested improvements for the Service include simplifying the referral process, relaxing referral criteria, increasing capacity for home visits and the AHVS tackling urgent tasks, rather than bouncing back to GPs.
• Professionals who do not have access to the AHVS, feel that they would benefit from having it in place for reasons including, increasing demand for home visits and the lack of capacity to accommodate home visits alongside routine appointments.

The current Acute Home Visiting Service (AHVS) is provided by Primary Integrated Community Services (PICS) in Mid-Nottinghamshire. It involves a highly skilled team of Advanced Nurse Practitioners (ANP’s) and Emergency Care Practitioners (ECPs) providing acute visits to patients in their own homes or care homes. When patients contact their GP requesting a same day home visit for an acute need, if clinically appropriate, the GPs can choose to refer on to the AHVS.

The aim of the service is to:

•         Avoid inappropriate hospital attendances and admissions.

•         Enable patients to be cared for at home through early treatment and intervention.

•         Support GPs to better manage urgent on the day needs.

•         Enable GP capacity to focus on managing long-term conditions and Multi-

           Disciplinary Team meetings, an essential component of the proactive care model  

           in Primary Care.

The initial patient contact remains within General Practice through a triage and referral system, maintaining continuity for patients. The Service has been designed to provide optimal care for patients to keep them at home wherever possible, to maximise workforce efficiencies, and to demonstrate value for money by reducing non-elective admissions and Emergency Department attendances.

Although this is a Mid-Nottinghamshire only service, it is in line with the Integrated Care System’s (ICS) strategic objectives and the developing urgent care agenda.

Currently Nottingham City and South Nottinghamshire do not have an AHVS model. Patients who require a home visit will be seen by their own GP, as part of the GP core contract requirements to provide home visits. If the GP is unable to provide a home visit due to capacity issues, patients would most likely seek alternative healthcare options.

Commissioners at NHS Nottingham and Nottinghamshire Clinical Commissioning Group (CCG) would now like to understand the experiences and views of those who have accessed the AHVS, either as a service user, carer or a professional, to contribute future reviews of the Service.

Aim and Objectives

Engagement was undertaken with service users, their carers and staff within primary care. The aims were as follows:

• Service users and carers with experience of accessing the AHVS – To understand what their views and experiences are,  having accessed support via the AHVS.

• Primary Care colleagues – To understand the clinical value and how they feel that the Service supports both General Practice and patients.

Service users and carers

As patients and carers would struggle to differentiate between a home visit from their GP and the AHVS, the CCG worked closely with PICS to promote this opportunity for engagement. A total of 200 promotional leaflets were shared with PICS, who then handed them out to carers and service users that they interacted with, between 19^th April and 17^th May 2022.

Service users and carers were offered the opportunity to share their views via an online survey, or by requesting a hard copy of the survey (see appendix). The opportunity to share views over a telephone call was also offered to service users and carers (see appendix for a copy of the telephone interview questions).

A total of three service users and one carer participated via the online survey and one telephone interview took place with a carer.[1] No hard copies of the survey were requested. See appendix 3 for all equality and diversity information collected via the online survey.

Primary care staff

Primary care colleagues across the ICS, including Bassetlaw, were also invited to share their views via an online survey (see appendix) and via a telephone call (see appendix for a copy of the telephone interview questions).

Opportunities to get involved were promoted via:

• Clinical Directors
• Practice Managers
• GP TeamNet
• GP Bulletin
• Nottinghamshire Local Medical Committee

A total of 97 primary care colleagues participated via the online survey. A further two contacted the Engagement Team via email to feedback directly. No telephone interviews were requested.

---

[1] It is important to note that the number of responses received is aligned to that received by the provider of the service, and at the same time acknowledging that patients who are being visited by the Service are acutely unwell which impacts on the number of responses received.

Service user and carer insights

Below are the insights collated based on the four responses from service users and carers via the online survey.

Survey findings

Service users and carers firstly reported on their satisfaction with the appointment times offered by the AHVS (please see graph below). 100% of those who engaged via the online survey were satisfied with the time they were seen for an appointment and the time slot offered, which led them to accept the appointment.

Service users and carers reported on the support that was received by the healthcare professionals. 100% of those who engaged via the online survey reported that the professionals gave them enough time to talk about their health concerns and were good at listening to them during their appointment.

People then reported on how satisfied they were that their/their loved one’s needs were met via the AHVS. All reported that the Service was good at meeting their needs.

People were then asked what they would have done if they were not offered a home visit.  Service users and carers reported that they would mostly get in touch with their General Practice again, with other contacts for support including NHS 111 or attending their local Emergency Department (see graph below).

Called NHS 111	Called 999	Attended local A&E	Called back to my GP practice	Nothing	Not Sure	Other
25%	0%	25%	75%	0%	0%	0%

Following this, service users and carers were asked if they would like to see this offer of home visits continue. As shown in the graph below, all those who participated via the online survey would like to see this offer continued in the future.

Service users and carers were then asked what they like about the Service and what improvements can be made for future. The table below outlines their comments, which highlights that people are mostly in favour of the current way in which the Service operates.

What would you like to see continue in future?	What would you like to see improved for future?
Very convenient for people that can’t get to their GP.	Nothing, exceptional service.
Gives you peace of mind that you are going to be helped and listened to.	Easier to get through on phone for appointment, took 35 mins.
Mum is housebound so it’s easier than trying to get her out to an appointment.

Overall, people were asked to describe their experience of the home visit. 100% of respondents reported their experience of the home visit was good.   

Finally, service users and carers were provided with the opportunity to input any additional comments. The following two comments were received:

“Excellent service. Thank you.”

“Just thank you for looking after my lovely mum.”

Telephone interview findings

A telephone interview was held with a carer of a loved one who accessed a home visit. The carer reported:

• The service was excellent and is great as it is.
• The nurse was very thorough and checked vitals.
• The nurse was able to put the carer’s mind at rest and provide extra reassurance that the support provided at home is good.
• Years ago, you could not get people to see you in the home.
• If a home visit was not offered, the carer would have contacted NHS 111.
• The carer wanted to thank the Service for all their help, and they hope that other GPs across Nottinghamshire adopt it too.

Primary Care  

Survey findings

Below are the views from 97 primary care staff across Nottingham and Nottinghamshire, including Bassetlaw. Of these, 91 professionals outlined their job role within Primary Care which consisted of GPs (66%), Practice Managers (23%), Healthcare Professionals (3%) and Practice Nurse (1%). Those who identified as ‘Other’ (7%), reported being Receptionists, Nurses and a Healthcare Manager.

Professionals were then asked to identify the area in which their practice is based. As seen in the graph below, most professionals were based in Mid-Nottinghamshire, followed by Nottingham City, South Nottinghamshire, and Bassetlaw.

Bassetlaw	Mid-Notts	Nottingham City	South Nottinghamshire
4%	66%	18%	12%

The survey then split into two parts to firstly understand the views and experiences of colleagues in Mid-Nottinghamshire who already have access to the AHVS, and to then understand the views of colleagues in Bassetlaw, Nottingham City and South Nottinghamshire who do not have access to the AHVS.

Views from colleagues within Mid-Nottinghamshire

In total, 61 primary care staff identified as being located within Mid-Nottinghamshire. These professionals were asked a series of questions relating to their experience of using the AHVS. Before this, professionals identified their Primary Care Network area within Mid-Nottinghamshire. As seen in the graph below, professionals across all six Primary Care Networks in Mid-Nottinghamshire participated in the online survey.

Ashfield North	Ashfield South	Mansfield North	Rosewood	Newark	Sherwood
15%	8%	18%	7%	37%	15%

These professionals were then asked if their practice has referred to the AHVS. 100% of professionals in Mid-Nottinghamshire, who completed the survey, reported that they have referred into the AHVS.  

Primary care staff then reported on their overall experience of referring a patient into the AHVS. As seen in the graph below, most reported this to be either good or very good.

Very Good	Good	Neither good nor Poor	Poor	Very Poor	Unsure
85%	8%	3%	0%	0%	3%

Professionals also reported on whether they received feedback from patients. Of those who had received feedback, most noted that this feedback was either positive or very positive (see graphs below).

Yes	No	Unsure
63%	22%	15%

Very Good	Good	Neither good nor Poor	Poor	Very Poor	Unsure
73%	22%	3%	3%	0%	0%

Following this, professionals were asked to rate the outcomes for people who were referred into the Service. As per the graphs below, most felt the outcomes for patients were either good or very good.

Very Good	Good	Neither good nor Poor	Poor	Very Poor	Unsure
76%	19%	2%	0%	0%	3%

Professionals were asked what can be done to improve or deliver the Service differently. The following key themes were reported:

Theme 1. Service delivery

Professionals are wanting to see greater capacity within the Service i.e. more staff, more appointment times for home visits and more appointments offered earlier and later in the day. It was suggested by one professional that cases could be prioritised, based according to their population size and their population demographic, with those located in more deprived  communities having priority.

“Often reaches capacity with no pm availability. Needs more staff. It’s an essential service”

“Increase capacity later in day (take new referrals until 630pm)”

“…The AHVS do not start accepting visits until 10am on most days – this needs be made earlier…” 

“Allow more time ie after 10 am to allocate visit”

“Practices with larger list sizes should be prioritised on a pro-rata capitation basis. Practices with higher deprivation indices should also be prioritised on a weighted basis as we know socio-economic deprivation impacts on health outcomes and therefore the rates of house-bound visit requests.”

In addition, it was requested that those conducting home visits take action on urgent tasks (e.g. taking bloods), rather than bouncing it back to GPs who may not always be available to respond. It was also noted that the current variation in the knowledge of staff leads to differing outcomes for patients.  

“The notes do not need to be so detailed or verbose. The practitioner should take blood tests and not task this back to the surgery. Especially if the bloods are urgent or the patient is at risk of renal failure. The practitioner should try to promote this service because patients still expect their own GP. However, this is impossible and the practitioners are knowledgeable. So it’s a shame patients don’t understand or appreciate the AHVS. It is a scramble to get visits accepted by 9.30am. This is a shame.”

“Some variation of the ability/medical knowledge of staff so some visits have better outcomes than others.”

“…AHVS staff should not send tasks re: urgent matters to GPs as tasks may not be checked due to annual leave/sickness.”

Theme 2. Positive comments

A significant number of positive feedbacks were also received about the AHVS, with primary care professionals describing it as an excellent service that is beneficial and valuable, with great staff. Professionals also felt that consultations were good and helped to ease pressures within primary care. It was hoped that AHVS would be rolled out more widely.

“It is already being provided and delivered in an excellent way.”

“The service is excellent and really helps the burden on primary care. There is certainly the demand for it, and if the service was able to expand its capacity then there would certainly be the need for it.”

“None. It is excellent. Excellent staff who liaise very well with our practice and perform comprehensive assessment of patients.”

“it’s a very important service for practices, it benefits patients who get more responsive visits (and more time with them), it frees up GP time to enable us to develop better care for others”

“…Home visiting service are good in communicating to GP practices via task if needs further follow up or additional need after their assessment”

Theme 3. Referrals

In addition to the earlier mentioned improvements around service delivery, professionals also felt that the referral processes could be improved. It was suggested that the AHVS use an online system, to enable GPs to see availability and understand capacity of the Service on any given day. It was also suggested that it has access to shared systems like SystemOne.

“…I am not sure if admin when accepts visits use system1. For every visit we have to provide nhs number, address,name and date of birth. It would be quicker process if they did use S1 so that it cuts telephone time for both parties…”

“I think the referral process could be better e.g. waiting for certain times to make our referrals can be hard in the middle of a busy morning. Also, we have to call to check for capacity – I am not sure if it is possible to have some where we can all access to see what capacity is like at any time of the day?”

It was also felt that other professionals within primary care, besides GPs, would benefit from knowing if they can make referrals to the AHVS, and how to do this. A further comment was also made for the Service to allow referrals to be booked a day in advance, to support patients who may have been triaged by their GP towards the end of the working day.

“…To be able to refer a day in advance of visits which are still acute but can wait further 24 hours. Especially will be the case when visits come late (past 1630) but after appropriate triaging able to refer to visit for the next working day.”

It was also felt that the referral criteria for the Service could be relaxed and further extended, to include more patients with urgent needs e.g. mental health concerns, long-term conditions and those on the End Of Life pathway.

“The service refused to see a patient with history of alcoholism re a physical problem unrelated to his alcohol use. Perhaps the service guidelines re this are too rigid?”

“…It would be good if AVS could extend their service for EOL patients who still need urgent care – like anticipatories, managing end of life symptoms”

“The service is excellent, it would be nice if there was some afternoon capacity for late visit requests but I appreciate how busy everyone is.  It would also be nice if the type of visits deemed appropriate for AHVS could be expanded.”

“…Support with housebound patients with long term conditions”

Following this, professionals reported on how satisfied they felt that the AHVS has supported their practice to:

• Avoid inappropriate hospital attendances and admissions.
• Enable patients to be cared for at home through early treatment and intervention.
• Manage urgent on the day needs.
• Focus on managing long term conditions.

The graph below highlights that most professionals were very satisfied that the Service had positively contributed to addressing these four priority areas.

	Very Satisfied	Satisfied	Neither satisfied or dissatisfied	Dissatisfied	Very dissatisfied	Unsure
Avoid inappropriate hospital attendances and admissions	82%	16%	2%	0%	0%	0%
Enable patients to be cared for at home through early treatment and intervention	86%	14%	0%	0%	0%	0%
Manage urgent on-the-day needs	82%	16%	0%	0%	0%	0%
Focus on managing long term conditions	44%	25%	23%	7%	0%	2%

Overall, all professionals in Mid-Nottinghamshire who completed this survey reported that they would like to see this Service continue to be offered to their practice, with over half noting that they would consider providing resource to it (see graphs below).

Yes	No	Unsure
100%	0%	0%

Yes	No	Unsure
57%	9%	34%

Views from colleagues in Bassetlaw, Nottingham City and South Nottinghamshire

In total, 32 professionals reported being located outside of Mid-Nottinghamshire. Of these, four professionals were from Bassetlaw, 17 from Nottingham City and 11 from South Nottinghamshire. As seen in the graph below, most professionals reported that they do not have a service similar to the AHVS in their area. The one professional who reported having a similar service noted that they have access to a Paramedic Home Visiting Service in Bassetlaw.

Yes	No	Unsure
3%	97%	0%

As seen in the graph below, most healthcare professionals felt that they do not have capacity to support those who require a home visit due to their acute healthcare needs.

Yes	No	Unsure
21%	64%	15%

When asked to provide any anonymous feedback or case studies to evidence the lack of capacity, the following themes were identified:

Theme 1. Capacity

With regards to capacity, it was reported that professionals struggle to fit home visits into their day, alongside routine appointments. As a result, GPs are either working longer hours or delaying home visits. Where home visits are taking place, it creates significant delays to routine work.  

“We do not have enough capacity to meet needs of pts who need home visits as well as meet urgent same day clinical of pts who either visit the practice, call or send online consultation. It can usually take about 1 hr to complete a home visit and then to return to the Surgery to complete notes.”

“General feeling is that home visit requests are a struggle to fit into the working day, often deferred to after hours when the 9-5 services and pathways are not available but pressure at present is huge and visits sometimes have to be delayed…”

“Specific evidence is about the waiting time for routine work. We have to, of course, prioritise urgent work, and therefore accessibility for routine work becomes the indicator that matters. At the moment, there is pressure on us to shorten routine wait times. That’s fair enough, but it will mean the capacity to perform acute home visits, as well as other acute work, will fall. We are already working way beyond our contracted expected hours, so any new service will mean pressure on other currently-delivered aspects of the service.”

Theme 2. Demand

Staff within Primary Care have identified that there is a growing demand for home visits, due to the ageing population, and have reported that home visits are straining an already stretched system.

“For practices to remain sustainable and attractive for recruitment we need this service in the City. The current ask for practices to manage daily home visiting is putting a strain on an already stretched system.”

“We have a high elderly population which means we have above average requests for home visits.”

“…With an ageing population the demand for home visits also seems to be increasing and I can only see this posing more of a challenge in the future.”

Professionals were then asked how satisfied they feel that such services may support a practice to:

• Avoid inappropriate hospital attendances and admissions.
• Enable patients to be cared for at home through early treatment and intervention.
• Manage urgent on-the-day needs.
• Focus on managing long term conditions.

The graph below outlines the views of professionals. Most professionals believed that the service would help to address these four priority areas.

Professionals were then asked if the Service would be desirable for their practice and if they would consider providing resource to it. As seen in the graph below, most professionals believed that the AHVS would be desirable for their practice. Half of the professionals would also consider providing resource to this Service from their PCN additional roles, whilst others are unsure or would not consider this as an option.

All professionals in Mid-Nottinghamshire, Bassetlaw, Nottingham City and South Nottinghamshire were finally asked to state whether they would like to see the provision of something different. The following themes were identified:

Theme 1. Resources

Some professionals noted that they would like to see staffing improved, such as employing Advanced Clinical Practitioners (ACPs) and GPs as part of this Service.

“We would like a service similar to that provided in Derby where ACP’s can visit with GP support if needed.”

“It needs to employ a GP so that calls are not as often queried back due to inability to deal with a problem”

“The service could be delivered by employing ACPs. Practices could be charged differential rates according to usage.”

In addition to this, professionals would also like to see an increase in working hours as part of the AHVS, by providing appointments earlier and later in the day, and to support with providing more holistic needs for people.

“Later time extension. We pay 2% of our budget for this service so we need to ensure that it meets the needs of practices.”

“In addition to acute on-the-day work. It would be good to see the practitioners addressing holistic needs – such as repeated visit requests, chronic condition management and scheduled visit requests for long term ill patients.”

Resource was also referred to in terms of funding with funding approaches needing to be further considered. Some suggested a collaborative approach to using Primary Care Network (PCN) funding at a Place level.  Another suggested that if resource, such as paramedics, are going to be deployed from the PCN roles, then the funding differential for the Enhanced Service Delivery Scheme (ESDS) would need to be corrected. Others felt that they would want this Service, but they do not have resource to contribute towards it.

“A collaborative approach using PCN funding for City practices would be desirable.  Thanks.”

“If paramedics are going to be deployed from the PCN roles, then we would expect the funding differential for the ESDS to be corrected.”

“We would like to see the service provided however as we already work at capacity we would struggle if our PCN staff were removed to staff such a service.”

“We would like to see the service provided however as we already work at capacity we would struggle if our PCN staff were removed to staff such a service.”

Theme 2. Positive comments

There were many positive comments about the Service, with professionals describing it as a helpful and excellent, leading to improved patient care and reducing the use of other acute services.

Professionals felt that the Service is good value for money and needs to continue.

“It is vital that this service is continued and would be a very retrograde step if decommissioned”

“This is the best service ever provided by the CCG for better patient care in this practice.”

“This service is crucial to the survival of general practice – please continue it”

“Really helpful service. Definitely reduces admissions and work going to out of hours. Would be badly missed and lead to increased admissions”

Theme 3. Communication

Some professionals asked for frequent communications from the Service, but also general communications about other services that are currently available for all patients, and for these services to continue beyond their initial pilot phases.

“It is good already that I get a phone call, but I think more exchanges would be even better”

“I would like an information leaflet of all services within the area and their role. I would like to be able to be more informed about each of them and also for them to continue and not just be a pilot scheme as so many of them are”

Theme 4. Other

Other comments included professionals expressing the need for AHVS as demand for home visits is increasing. It was also suggested that other options are considered, such as minor illness clinics.

“Consider minor illness clinic.”

“I feel this service would be received really well in Nottingham West. The demand for visits is significant and I can only see this increasing in the future.”

Emails from primary care

Two emails were also received from primary care colleagues who shared their experiences of working with the AHVS. The themes from these emails include:

Theme 1. Prevention

Professionals believed that the AHVS has enabled patients to receive timely support, thereby decreasing the need for patients to call the ambulance and being taken to the Emergency Department and being admitted to hospital.   

“…We have found that it decreases admissions because highly trained staff are getting to patients quicker which stops them calling an ambulance and being taken to ED…”

“…The Acute Home Visiting Service has provided practices with excellent support – being able to carry out visits in a timely manner which on occasions has I am sure prevented patients from being admitted needlessly to secondary care…”

Theme 2. Resources

The Service has been described by professionals as being important to the running of their primary care services, as it has enabled primary care to spend more time on telephone and face to face appointments.

“It also allows GPs more time to see patients face to face and clear the covid backlog.”

“…In the case of our practice, we have been able to re-invest the time saved in undertaking home visits to offer an increased availability of telephone and face to face appointments…”

A comment was made that the funding that practices contribute towards this home visiting service would need to be returned, if it is stopped.

“It is our understanding that there is £2 per head top sliced off our ESDS to fund this in mid notts. If it was stopped we would expect that money back.”

Theme 3. Valuable

Overall, professionals described this Service as invaluable and an excellent support to their work. The AHVS has also been very well received by patients and carers.

“After discussion at our practice meeting today, the partners want to get across how important the running of AVS is to our services… We think it is an invaluable service that has transformed the way we work.”

“The service has also been very well received by patients and carers.”

Overall, service users, carers and professionals have reported several positive experiences of the AHVS. Service users and carers reported feeling listened to, reassured, and supported by the AHVS. Had they not been offered a home visit, service users and carers would have contacted their GP again, called NHS 111 or attended their local Emergency Department. They would like to see this offer of home visits continue in future.

Similarly, professionals in Mid-Nottinghamshire who have access to the AHVS also reported on many positive experiences for staff and patients, with improvements to be made including, simplifying the referral process, relaxing referral criteria, increasing capacity for home visits and the AHVS tackling urgent tasks rather than bouncing back to GPs. All those in Mid-Nottinghamshire would like to see the Service continue in future and professionals in Bassetlaw, Nottingham City, and South Nottinghamshire would like to see AHVS offered to them for reasons including, increasing demands for home visits and lack of capacity to fit these in, alongside routine work.

The findings from this report will be considered to help inform future reviews and plans for the AHVS going forward. A copy of this engagement report will be shared with those who helped promote and participated in the engagement activity.

We would like to thank all the colleagues who supported in promoting the engagement opportunities with professionals, service users and carers. We would also like to thank all those who participated in the engagement activity for taking the time to feedback their views and experiences.

To access the Service user and carers survey, Service user and carer telephone interview, Equality and Diversity of patients and carers, Professional’s survey, or Professional’s telephone interview, contact nnicb-nn.engagement@nhs.net