Older people and emergency bed use: Exploring variation

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.

When 1:6 hospital admission is due to drug related problem which is created in primary care should community pharmacists not be used to reduce not only avoidable hospital admissions but also for non-life threatening urgent care? There is much talk of integration but very little thinking involving whole of the primary care. The report is an example of blinkered vision.

RCPE response to the King’s Fund paper “Older people and emergency bed use: Exploring variation”

The Royal College of Physicians of Edinburgh (RCPE) endorses the desire to minimise the number of admissions to acute beds that all sectors of society, but especially the elderly, require. The RCPE is keen to state from the outset that no consultant physician wants to admit a patient to hospital unless it is absolutely clinically necessary: pressures on acute beds mean that only patients who are in urgent need of medical care can be admitted.

The latest paper from the King’s Fund suggests that if all primary care trusts could reduce admissions and minimise length of stay to that of the most successful areas then 7000 fewer acute beds would be required in England. They acknowledge that the drivers of variation in performance are complex, including age of patient, level of deprivation and geographical access: areas with well developed integrated service and those with higher levels of an aged population have lower levels of acute hospital bed use. It is suggested that areas with a high number of aged population also have a more developed integrated service.

It is for these very reasons that caution is required in interpreting this report. If acute hospital beds are reduced without a concomitant development of integrated services, patients will be potentially worse off. There is evidence of an inexorable rise in acute hospital admissions especially to acute medical units with increasing weight of expectation of what medical care can provide. We feel in these circumstances that it is vital that the promotion of admissions avoidance, particularly of older people, does not restrict appropriate access to best care at times of medical need.

Boarding of patients is rife within the acute hospital sector and this itself is associated with a range of well-evidenced adverse outcomes for patients, including increased death rates, length of stay, re-admission and the development of medical complications (1) . This problem would be exacerbated with even fewer beds being available and the pressure to achieve the elective workstream would increase with more surgical procedures having to be postponed due to a lack of beds.

The RCPE conducted a survey in May 2012 to obtain a snapshot of senior doctors’ practical ongoing experiences of boarding in Scottish hospitals. Key findings included 80% of respondents reported that boarding is now experienced all year round in Scottish hospitals (with 50% reporting that boarding had taken place during the last week in May); 71% of respondents believe boarding levels in Scotland are high and increasing, at a time when the Scottish Government has been reducing the number of acute beds in Scotland; 99% believe boarding has a very negative or negative effect on the quality of patient care, 95% a very negative or negative effect on the length of patient stay, 68% a very negative or negative effect on death rates and 68% a very negative or negative effect on rates of patient re-admission to hospital (2).

It is vital that the significant investment necessary to provide integrated services must be accurately calculated so that if the King’s Fund report is to be implemented, adequate resource is made available to enable this development prior to closure of acute hospital beds. This would allow proper consideration of the most appropriate use of the resource available to the health sector to deliver the services that are required in disparate localities.

We support shifting care closer to home; however the ambition to reduce reliance on the acute sector must not be pursued to the detriment of quality of patient care (3)

(1) Spivrulis, P.C., Da Silva, J.A., Jacobs, I.G. et al. (2006). The association between hospital overcrowding and mortality amongst patients admitted via Western Australian emergency departments. Med J Aust, 184(5); 208-212.

(2) rcpe.ac.uk/press-releases/2012/doctors-warning-scottish-hospital-patients-receiving-inappropriate-care.php

(3) rcpe.ac.uk/policy/parliamentary-briefings/doctors-warning.php

Dr Crawford you are absolutely right that looking at the places that have improved most would give a greater insight into what can be achieved but I didn't want people to think that Torbay's success was just down to the wealth and health of their patients (by the way I don't work for Torbay I am just impressed with what they have achieved).

It would seem logical that if more effort was made to care for older people in the community ( by meeting their nutritional needs, general well being and support) then the level of emergency hospital admissions would be reduced. However most local authority commissioners are focussed on meeting substantial and critical needs only and that only after undertaking a financial assesment, leaving considerable number of people without care & support.
Community care workers these days can, and are able to, with training, take on skilled tasks that used to be previously performed by nursing staff.

King's Fund reports are always incisive and thought provoking and this one is no exception. But to pick up on H Patel's point about preventable drug related admissions (and readmissions see: Qual. Saf. Health Care 2008;17;71-75) it is interesting to note that increased drug use in older patients is not cited as part of the patient factors (demand side) driving the rate of use of hospital emergency beds for people over 65.
As we keep adding in drugs (and never subtracting ) we are always going to multiply the chance of drug related problems, and thus it seems preventable hopsital admissions,
Silo working and over specialisation in Medicine is just making this situation worse. The NHS must develop a strategy (Physicians, GPs, Pharmacists) for proper medication reviews in older frail patients and have the confidence to stop drugs (and/or respect a patient's own wishes to do so) before they cause the problems.

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