Jon Glasby, Rachel Thwaites, Nick Le Mesurier, and Rosemary Littlechild

The NHS faces unprecedented challenges, and the capacity and funding concerns faced by acute care in particular are constantly in the news.  At the front-line, the pressures are intense.  Faced with growing need and demand on the one hand, and sustained funding problems on the other, the longstanding issue of how best to make use of scarce, expensive resources like acute hospital beds remains as crucial as ever.

In response, the NHS Confederation commissioned a recently published report into older people’s urgent care: ‘Growing Old Together’.  It highlights some important suggestions for improvements to older people’s care and explores what good care should look like (Growing Old Together, p.6).  Several of these suggestions for what excellent care should look like revolve around prevention of unnecessary use of emergency care, instead encouraging earlier intervention to avert crisis and ensuring patients are educated about their condition and available services so they only use acute care when really necessary.

These recommendations speak very much to our current research project at HSMC and the Department of Social Policy and Social Work, funded by the National Institute for Health Research (NIHR): ‘Who Knows Best?’.  This study of older people’s experiences of emergency admissions in three case study sites has so far interviewed over 100 older people or their families and 40 professionals to understand the problem in more detail by exploring the actual experience of older people and front-line staff. 

There are key gaps in our current knowledge and our attempt to understand the issue of ‘inappropriate’ emergency admissions by combining a formal rate of inappropriate admissions and talking to older people is – incredibly - believed to be the first of its kind in the UK and quite possibly in the English-speaking world.

Throughout, our contention has been that too much of the current debate is dominated by media depictions of ‘bed-blockers’ or ‘inappropriate use’ and by overly-simplistic prescriptions for what might reduce emergency admissions.  We argue that it is only older people themselves who have a longitudinal sense of how their health has changed over time, how they came into contact with services, what happened next and what could have been done differently to avoid admission (if appropriate).  Understanding both patient and professional perspectives in the round is crucial if our subsequent policy responses are going to be sufficiently rigorous, nuanced, and multi-faceted to tackle such a complex issue.

Our research will report later in 2016 and will be accompanied by a national good practice guide, drawing directly on older people’s experiences, sent to every hospital Trust in England.  At present, our emerging results appear to suggest that many older people are admitted to hospital entirely appropriately – and it is even possible that current debates could prompt some people to delay seeking help in an emergency for fear of being a burden or using services inappropriately.  Some of the older people in our study were already in contact with a range of community services (suggesting a potential scope for a more proactive preventative approach in some situations), and others were unsure what to do for best when significant problems occurred out-of-hours.  Family, friends and the ambulance service also seem crucial in influencing the decisions older people make in a crisis. 

Front-line health and social care staff do not always agree on the extent to which inappropriate admission is a problem and knowledge of existing community alternatives is inconsistent, particularly when working across local authority social service departments.  Thus, early indications are that many of our admissions were seen as ‘appropriate’ but that a small number might still have been prevented by a different course of action at an earlier stage (albeit many were still needed at the point an emergency occurred in the older person’s health). 

Against this background, the NHS Confederation’s analysis of what constitutes good care seems exactly right – but putting it into practice will be tricky and contested.

Notes for Editors
This blog presents findings from ‘Who knows best?  Older people’s contribution to understanding and preventing avoidable hospital admissions’, a research project funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0712-28045). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.

The National Institute for Health Research (NIHR) is funded by the Department of Health to improve the health and wealth of the nation through research. Since its establishment in April 2006, the NIHR has transformed research in the NHS. It has increased the volume of applied health research for the benefit of patients and the public, driven faster translation of basic science discoveries into tangible benefits for patients and the economy, and developed and supported the people who conduct and contribute to applied health research. The NIHR plays a key role in the Government’s strategy for economic growth, attracting investment by the life-sciences industries through its world-class infrastructure for health research. Together, the NIHR people, programmes, centres of excellence and systems represent the most integrated health research system in the world. For further information, visit the NIHR website.