Admission impossible? Understanding and reducing the emergency admissions of older people

The National Institute for Health Research (NIHR) has published a piece by Professor Jon Glasby, Professor of Health and Social Care and Head of School of Social Policy which explores older people's contribution to understanding and preventing avoidable hospital admissions – the original article can be found here.

Whenever there are significant pressures on acute care and on A&E, the tendency is to assume that there is a potentially large group of often older patients in hospital beds that could be cared for more appropriately elsewhere:

“Half a million elderly people a year are being unnecessarily admitted to hospital as emergency patients because of stark failings in community care” (The Independent).

“Elderly people would need to spend less time in hospital if care in England were better organised” (BBC).

“Every year millions of patients seek emergency help in hospital when they could have been cared for much closer to home” (The Telegraph).

However, it is often hard to find the data to back up such claims, and existing research is often better at identifying problems than it is at proposing solutions. Above all, previous studies have tended to review medical notes retrospectively in order to judge whether admissions were ‘appropriate’ or ‘inappropriate’, failing to take into account the reality of local services, the complexity for individual clinicians having to make such decisions on the ground and, above all, the experience and expertise of older people themselves. Despite all the policy emphasis on ‘nothing about me without me’, it is possible that our recent NIHR study ‘Who Knows Best?’ is one of the first to calculate a rate of appropriate and inappropriate admissions, while also seeking to engage meaningfully with older people and front-line staff.

In our two-year national research project funded by the Research for Patient Benefit (RfPB) Programme, we interviewed 104 older people or their families. This took place in three case study sites within four-six weeks of their emergency admission and we sent surveys to their GPs and a hospital-based doctor – receiving 45 responses. We also reviewed the previous literature in the UK and beyond, interviewed 40 health and social care professionals and explored the stories of some of the older people who took part in focus groups with 22 local front-line practitioners.

Contrary to popular opinion, we found that the older people in our sample typically needed to be in hospital, with no real scope for alternatives (both in their own view and in the view of their GP or a hospital-based doctor). Indeed, several of our participants even delayed seeking help, perhaps through fear of being perceived as a burden on scarce NHS resources, and seemed to be doing all they could to stay away from hospital until they had no other choice.

During the research, older people, their families and frontline staff contributed lessons from their personal experiences around how we could identify more preventative health and social care services in the longer run. We summarised these in a national good practice guide sent to every hospital, CCG and director of adult social services. However, we did not find large numbers of older people in hospital beds when they did not need the services provided there.

Even where improvements or preventative approaches were suggested, there were few easy answers and little that would suggest a simple service, a new approach or a clear cut innovation that could easily reduce current numbers of emergency admissions.

Ultimately, our conclusion is that debates about emergency admissions are inherently complex and multi-faceted – and that any discussion of potential solutions needs to be equally multi-faceted. As part of this, we miss a major trick if we don’t draw on some of the most important expertise available to us: the lived experience of older people and the practice wisdom of front-line staff.

Our project was overseen by a national sounding board comprising: Age UKAgewellthe Association of Directors of Adult Social Services (ADASS)the NHS Confederation and the Social Care Institute for Excellence.

More information is available in the full research report, our good practice guide.
Or watch our Social Care TV training video.

*The NIHR has issued a highlight notice to launch its 2017 themed call focusing on complex health and care needs in older people.
For more information and to apply for research funding to improve outcomes in this important area visit our themed call pages.

The views and opinions expressed in this blog are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.