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

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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?