Use of emergency hospital beds: why is there so much variation?

How many times have you heard people talk with resignation about the number of older people in hospital beds who ‘don’t need to be there’? The often quoted figures are that between 30-50 per cent of older patients could be managed safely outside hospital. There is evidence to support this, but what we hear less about is the variation between different areas’ use of hospital beds.

Research that we have just completed at The King’s Fund shows a four-fold variation in the use of emergency hospital beds by patients over the age of 65. Average lengths of stay for those over 65 varied from 6-13 days. For patients over the age of 85, who had been admitted from home but needed to be discharged to supported accommodation, there was nearly a five-fold variation in average length of stay, from 11 days to 51 days.

If the 10 primary care trusts (PCTs) with the highest bed use achieved the rates of the ten PCTs with lowest use, around 1,350 beds would not be needed. More than 7,000 hospital beds across England could be released if all PCTs achieved the rate of admission and average length of stay of the lowest 25th percentile. Our research also identified ten PCTs that had managed to reduce average length of stay by 25 per cent in three years, and their use of emergency beds by around 20 per cent.

So relatively rapid change is possible, but how can it be achieved? Firstly, commissioners and providers need to understand their current position. Do they know how the length of stay in their hospital, or the hospital they commission from, compares to others? What about the rate of admission? Having established the opportunity for improvement, what action is needed? Our case study from Torbay suggests that having a clear vision, bringing together frontline teams and general practices and considering simple and inexpensive innovations, such as the appointment of health and social care co-ordinators, can have a major impact in delivering improvement.

However, there is no silver bullet. In particular, there is no clear correlation between investment in community beds, social care or GPs and use of hospital beds. One cannot quantify how many community beds would be needed to support the closure of acute hospital beds. Some areas cope with very few, others use many more. There is just as much variation in community beds, general practice and social care as there is in acute care. The answer seems to lie in how the whole system operates together to ensure that services deliver more than the sum of the individual parts. Our analysis revealed that the areas that have shown a long-term commitment to integration – for example through joint teams, shared records and joint budgets – demonstrate better results and much lower use of emergency hospital beds.

An emergency admission to hospital is a disruptive and unsettling experience, particularly for an older person, so surely we owe it to our patients to reduce the current variation and the avoidable distress?

Read the paper: Explaining variation in use of emergency hospital beds by patients over 65

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Comments

#1312 Andrew Vallance-Owen
Self employed

I certainly agree with your evidence-based conclusion that better integration will be crucial to obtaining better results and better value, but I was surprised at how little was said about 'step up' care. You say: 'But while access to intermediate care beds brings benefits in terms of care quality and outcomes, there is little published evidence to suggest that their use generates overall savings (O’Reilly et al 2008)'. Surely if outcomes are better (e.g. fewer hospital induced infections etc) then savings will accrue. Is more research needed on this?

#1313 Dr Michael Crawford

"The potential reductions in emergency bed use by patients over 65
are considerable; if all primary care trusts (PCTs) achieved the rate of
admission and average length of stay of the lowest 25th percentile,
7,000 fewer hospital beds would be needed across England."

Oh how simple!

Question, if you were a GP looking to settle down and bring up your family in a pleasant environment, where would you prefer to be. Torbay or Trafford? See figure 14.

Question, the denominator of these stats is bed use per person over 65. Which areas have the largest proportion of their elderly population in self-funded care homes or with self-funded assistance? Is it perhaps the areas where affluent people go to retire as distinct from the areas where poorer people stay because they cannot afford to move anywhere else?This is another way of interpreting Figure 17.

One cannot doubt that there are opportunities to look after people out of hospital in such a way that the crises that inevitably occur do not result in admission to hospital. Step 1, develop the out-of-hospital service. Step 2, demonstrate reduced bed usage in hospitals. Step 3, close the hospital services thereby made redundant.

Unfortunately, Department of Health thinking is all about closing facilities first and sorting out community support on a make-do-and-mend basis. The highest bed use metropolitan areas of London and Manchester have specifically been mentioned as having "too many beds." To close beds that are still needed is inhumane and unintelligent.

#1314 Ed Macalister-Smith
CEO
NHS Wiltshire and Bath

The repeated lesson of history in the NHS is that if you create new system capacity in the hope that old capacity will become redundant and you can then close it, that won't happen. Creating new capacity without a very clear, short and determined plan to exit the old capacity just results in the new capacity silting up.

Without whole-system sign-up to potentially uncomfortable (and indeed apparently un-commercial) impacts on the separate parties will result in a plan not delivering. This mutual agreement is tough to achieve, but not impossible. So acute FTs need to accept that their A&E revenue will fall. And GPs need to change their standard working practices so that urgent home visits that might result in a GP-initiated admission take place early in the morning, not after morning surgery. And community services need to move to routine 7-day working. And adult social care need to significantly accelerate their assessment regime.

Mutual agreement is helped if key parts of the system are integrated. So an integrated care commissioning set-up between CCG and ASC, an integrated community provider between NHS and LA, an integrated OOH Single Point of Access call centre.

And ultimately, pooled budgets - firstly as a measure of the trust built up between parties, and secondly to avoid the fights about who pays for a particular care package.

Torbay, often quoted, is not the only place to have made some of this work better. Time to expand your exemplars of better ways of working please, Kings Fund...

#1315 Francesco Pama
Bristol & South Gloucestershire LINks

The progress made in Torbay with the intergration of health and social care will serve them well. Older persons in the area account for 22-23% population the most of which have disposable income thus FACS critera would apply, couple this with being a pilot area for personal health bugdets/direct payments has enabled them to be innovative. Compare this with a similar population without access to dispsal income/without intergration of health and social care and being a pilot area for PHB then the outcomes/LOS in secondary care would be in the future would be unsustainable. Piloting direct payments for residential care is a step in the right direction for the future. The model in Torbay works, highly unlikely to work even if service redesign to the NHS/LA was applied due to the higher successful funding applications of FACS. Torbay is indeed forunate to its population and forward thinking parnterships.

#1316 Dr Michael Crawford

Ed Macalister-Smith says "The repeated lesson of history in the NHS is that if you create new system capacity in the hope that old capacity will become redundant and you can then close it, that won't happen." This implies that it has ben tried somewhere and at some point and I would be interested to know when & where. What I have seen over the past 4 decades is that when new capacity is introduced it meets unmet need rather than creating more need; the NHS is a small, cheap healthcare system which creates the illusion of size and expense by being perceived as one organisation. Of course, we are capable of creating new need (or do I mean demand?) by introducing new services; think of screening but we are extremely good at hiding need that existing capacity cannot meet. That is the underlying reason for our poor cancer outcomes.

In fact EM-S contradicts himself when he says "...acute FTs need to accept that their A&E revenue will fall;" from his previous point it woould be expected to stay constant if new community capacity is filled with new patients but there is increasingly a perception that the Emergency Department is the place to go. The columnist Matthew Parris (The Times, 16/6/2012) commenting on BMA industrial action recounted how he was told to go to the hospital by his GP's receptionist rather than having GP appointment and a separate X-ray visit. Parris argued that the days of the GP are numbered!

A sore wrist in a man in his early 60s (Parris) is one thing, an older person at tether's end is another. The task is first to develop community working as EM-S says, then to encourage people to believe in them.

My own commitment to moving work out of hospitals is in the acute oncology service. This involves avoiding admissions by encouraging timely diagnosis of cancer in primary care which requires greater capacity in the diagnostic services. This is new capacity doing work which is not currently being done, testing more patients who might have cancer to find earlier those who do. It also requires specialist input into the acute general hospital's teamwork in caring for the cancer inpatient, to shorten stay by identifying how the can receive effective care as an outpatient.

I agree with the ideas of mutually-agreed mutually-funded systems that EM-S propounds. I am old enough to remember that this is exactly how we were thinking before Kenneth Clarke's "refortms" spoilt it.

And is there an acute hospital Trust that regards the ED as a major income centre?

#1317 Anthony Trigwell
PPG Lay Member

I agree entirely with Dr Michael Crawford... The idea that you can plan closures of any type before the new systems are up and running is the stuff of bean counting not clinicians!!

#1318 Lynne Roper
Paramedic
false

I work in Devon, and I'm often caught in the middle as patients are sent inappropriately to area hospitals via EMU/EDs. In many cases, an elderly, frail and deteriorating patient for whom acute medical treatment is wholly inappropriate is removed from their Nursing Home or a Community Hospital bed, and is transported to the EMU/ED for 'investigation'. Often this happens in the early hours of the morning because the Out of Hours GPs will not take responsibility for a 'deterioration' in condition and there is no clear TEP. although there is usually a DNAR! Not only is this clearly not in the best interests of the patient, it's also tying up acute services. There is a shortage of Community Hospital beds in our area which is remote.
In the past few weeks I have seen several examples of inappropriate use of acute services, most notably a patient in her 90s with diagnosed dementia who is cared for in a specialist Nursing Home, transferred to a main EMU for 'investigation for increased confusion'. This necessitated the EMU employing a bank nurse round the clock to walk up and down with the distressed and ranting patient, who was upset at the unfamiliar surroundings and was obviously disturbing and upsetting the other patients.
A coordinator who actively encourages TEPs in Nursing and Residential Care Homes, and in GP practices, would help enormously, as would shared budgets which might prevent the 'passing the buck' culture that currently causes problems which are then mopped up by acute services which have no option.

#1319 Maia
careworker
n/a

Having worked in an appalling care home, i think it should be remembered that rushing to discharge someone to a place
1 their relatives cannot visit them - often poor people have little access to public transport or can't afford it and don't drive
2 where they are going to be miserable, lonely and neglected to the point of abuse (for some reason the food in old people's homes is particularly appalling - liquidised tinned tomatoes, tepid, as 'soup starter' twice a day? presumably the plan was they would starve themselves to death voluntarily. Or eating dinner in your soiled pads.)
are surely not the most vital things to do. There are more important things to keep in mind.

#1320 Harry Longman
Chief Executive
Patient Access

I've published evidence which links lower emergency admissions with lower attendance at A&E, especially in the elderly, and further links lower A&E with better access to GPs, specifically with a system of rapid telephone call from the GP and same day face to face.
patient-access.org.uk/43/aims-and-papers

It was invented multiple times by GPs, now brought together as Patient Access and is being adopted by more and more practices nationally. It truly is a system level change, happening at the small system (GP practice) level but enough times will change a great deal in primary care and beyond. We should compare notes.

#1350 Vinesh Kumar
Programme Manager, Integration
LB Redbridge

Agree with EM-Smith above.

I think pooled budgets, shared risks and outcomes is the closest answer but the hardest to achieve!

We are very good in complicating things.

#2104 Sam Hill

Yes, I agree in theory, but in practice what is happening is that acute beds are being closed without any replacement investment in community services.
Integrated servcies works if this issue is addressed. If it becomes a choice between an acute bed or social care package, it is doomed to failure.

Community beds are a conundrum. In theory they should play an important role. In practice many community hospitals have lost their way on the use of their beds. Older people just get stuck there. It seems to work better when health commissioners commission beds in nursing homes, as the more direct relationship between activity and cost incentivises them to keep people moving. The poor quality of the commissioning of community health services is a ahor factor in their failure. The fact that many were part of their PCT is largely to blame for this.

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