Older people and emergency bed use: Exploring variation

Posted:09 August 2012
Comments 16 comments

Authors

Candace Imison
James Thompson
Emmi Poteliakhoff

Publication details

ISBN: 978 1 85717 641 4
Pages: 24

This paper explores factors that might be driving the significant variation in use of hospital beds by patients over 65 admitted as an emergency.

It considers the contribution made by patient-based (demand-side) factors, hospital (supply-side) factors, the availability of community services and resources, and broader system relationships (how care systems and staff work together and relate to each other) in driving the observed variation in length of stay and rate of admission. Its conclusions are based on new analysis by The King’s Fund of Hospital Episode Statistics (HES) and local population-based data.

Key findings

The potential reductions in 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 those with the lowest use, 5,700 fewer beds would be needed across England.
The links between bed use and access to community services such as GPs, community nursing and social care are not clear cut. But PCTs with the highest bed use tended to have excessive lengths of stay for patients for whom hospital was a transition between home and supported living.
Areas that have well-developed, integrated services for older people have lower rates of bed use. And areas with low bed use also deliver a good patient experience and have lower readmission rates.
Areas with higher proportions of older people have lower rates of bed use. These areas may be more likely to have prioritised the needs of older people and to have developed integrated service models.

Policy implications

PCTs with the highest acute bed use should develop strategies across the care system and align ways of working to identify ways to reduce usage. All clinical commissioning groups would benefit from benchmarking the relative use of acute beds in their area, and the related rates of admission and length of stay.

It is clear that organisational integration alone does not deliver improved performance. The key to reducing use of emergency beds lies in changing ways of working across the care system rather than implementing piecemeal initiatives. Organisations need to prioritise whole systems approaches if they are to deliver a real shift from hospital to community-based care.

Download the appendices for this paper

We have produced information on the length of stay, emergency bed days and emergency admissions for each PCT in England. This information will show PCTs where their organisation ranked with others in our analysis. The emergency bed days per PCT also show where the additional bed savings we have identified exist.

Comments

I am concerned about the unbalanced implications of a relentless focus on hospital avoidance without reengineering community integration to enable community diagnostics. I work in both hospital and community sectors. Community services are driven by an inbalanced preoccupation with function modelling whilst hospital care obsesses about medical "fitness" and shows insufficient investment (and understanding of patterns of functional management in critical care). this is in many ways a side-effect of the Emergency Care Tariff system which is function "blind".
The only headline measure that matters to me is outcome. Protracted lengths of stay in hospital lead to poor outcomes but so do community based diagnosis-avoidance models of care which lead to repeated critical events managed poorly by an overheated emergency care system.
The solution as far as I am concerned is to rebalance and reconnect medical and functional modelling across the older persons health economy

Better communication and integration between Primary and Secodary care is key to reducing emergency hospital admissions.
During a seven months pilot, patients at risk of hospital emergency admission or re-admission were admitted in their homes termed as virtual ward. Admission was based on SPARRA-65 data and personal GP practice/consultant physician’s intelligence.
The virtual ward team comprised of a hospital based consultant physician, two GPs, district nurse and GP practice manager. District nurses paid regular visits to patients. A weekly teleconference was held among virtual ward team to discuss patients. GP practice was enabled to upload virtual ward documentation directly into SCI STORE EPR.
There were twenty one admissions. There were no unscheduled admissions of virtual ward patients into the hospital. There was 25% reduction in emergency admissions, 12% in re-admissions and 12-13% in LOS when compared to the same period in the previous year. Patients felt that they benefited from increased nursing input but not all understood the concept of virtual ward. It was a zero finance pilot. Activity was easily accomodated in current working schedule.
Virtual ward provides a new interface between primary and secondary care for improved patient care due to timely and appropriate intervention, more effective communication, & easier clinical decision making. A reduction in hospital emergency admissions, readmissions and LOS was shown.
Now we are rolling out Lochaber Virtual ward care model to more GP practices in the Fort William area with participation of more hospital based consultants.

I doubt anyone would disagree with the sentiments of the report - arguably this is not news. The difficulties lie in ensuring that all PCTs/CCG are "bought in" and committed. The unfortunate loss of "lead PCT" status has left service provision fragmented in many areas. A national initiative is needed that will be materially supported by the DH and ensure actions are mandatory for commissioners and providers

I am concerned about the issues of health inequalities for older people. We have already seen the impact of people with a learning disability when they are not seen as a group of people who can access main stream health services and now this new group could create the same challenges. I think the idea is great, I have seen some really exciting models and I am hopeful to take the integrated team in this borough forward to new heights! But I remain wary of the pitfalls and I think we all should be mindful of the losses as well as the gains.

I practise outside the NHS, in Nigeria to be precise, but I have been following your regular reports/briefings on issues for years since I attended a course at King's Funds in September 2008. I would say development on issues in respect of NHS has been very dynamic and incisive but the in-put from various sectors, as well as individuals, is of the highest level you can ever get in our world today. I wish we can learn from your experience to transform our NHIS in Nigeria.

I fear groupthink is developing here.
Any question to which Cornwall, Norfolk and North East Lincolnshire is the answer cannot be the right one.
The corollary of supply induced demand is to question the use of demand repression in rural, under-resourced areas.
I agree with the doctor who says that we should only cut emergency beds after system reforms have improved out of hospital care sufficient for us to see that demand for emergency care is reducing. At present it is still increasing.

Why is Torbay, a place where rich people go to retire, used as the exemplar and not one of the moat improved PCTs?

One of the main problems is that GPs are not trained to widen their remit in the care of vulnerable old people which involves giving the patient and carer more time in ad hoc clinics. Unless they know all the medical, functional and socio-economic problems involved and give the patient extra time how can they possibly keep them active and out of hospital for as long as possible?

I may be making a fool out of myself but haven't you overlooked the community hospital stay. If you have then by ignoring the additional stay those areas with community hospitals are likely to have shorter length of stays within the acute setting, a more balanced view would be given by using the 'superspell' stay. As such the impact of rurality or distance from emergency care may not be the cause but rather that generally more rural areas have more community hospitals. What is not in doubt however is that Torbay have a very good model, and to Dr Crawford I would say that the full integration has more of an impact than wealth as there are areas within the South West that are wealthier and yet don't come close to Torbay's length of stay.

To respond to Richard Blackwell, Torbay is indeed a good model but it is starting from a position of extreme advantage. It would be much more instructive to have presented an in-depth study of one or more of the "improved" group of PCTs.