By Andrew Holt
A report published today by The King’s Fund shows that 7000 fewer emergency hospital beds would be needed by the NHS if all areas of England achieved the rate of admission and average length of stay for over 65s as those with the lowest use.
This equates to a potential opportunity to reduce the number of overnight stays by 2.3 million per year and to reinvest £462 million a year in community and primary care services.
Older people and emergency bed use: exploring variation looks at four groups of primary care trusts (PCTs), including those with the highest and lowest bed use, to understand what might drive the wide variation in the use of hospital beds.
The rate of emergency bed use by the over 65s among PCTs with the highest use is four times greater than PCTs with the lowest bed use.
Every year there are 2 million unplanned admissions among the over 65s.
This accounts for over two-thirds of all hospital emergency bed days.
An emergency admission to hospital is a disruptive and unsettling experience for an older person whose independence will often suffer as a result.
This analysis demonstrates a significant opportunity to reduce these admissions and lengths of stay in hospital.
Many older people could be being supported at home or in the community.
The report also shows that areas with lower emergency bed use for older people also delivered a good patient experience and had lower readmission rates.
The researchers found that the drivers affecting the variation in bed use are complex, for example the links between bed use and access to community services such as GPs, community nursing and social care is not clear cut, but there are some key drivers that emerge. For example:
1. Geography – there is much lower emergency bed use in rural areas than urban ones – all of the PCTs with the lowest bed use are in rural settings and 7 out of 10 PCTs with the highest emergency bed use are in London.
2. Average age of local population – areas with a higher proportion of older people have lower rates of emergency bed use than areas with lower proportions, suggesting that these areas have prioritised the needs of older people and have better strategies in place to minimise admissions.
3. Integration of services – PCTs with the highest bed use tended to have excessive lengths of stay for patients in transition between home and supported care suggesting community, primary and acute provider services are poorly integrated. The average stay in these PCTs is 36 days whereas the PCTs with lowest emergency bed use achieve stays of at least 9 days shorter.
Across England the PCTs with the lowest rates of emergency bed use have been leaders in integrating health and social care yet the report’s researchers found that there wasn’t a single shared denominator.
However, key factors that could help reduce admissions include:
1. Hospitals can play an important part in reducing admissions and lengths of stay for older people. For example, the presence of a senior physician at the admission stage can reduce general admissions by 12% and to acute medical units by 21%. Length of stay is similarly reduced by factors such as frequent medical review, specialist input and training – geriatrics, stroke, dementia, and access to therapist assessment but the key challenge is co-ordinating these to work together.
2. Local strategies need to look across the system to align and co-ordinate services between primary, community and acute care.
3. Commissioners, in particular the new clinical commissioning groups (CCGs), need to pay careful attention to their relationship with providers as a closer working relationship allows more integrated models of care and reduced admissions.
Candace Imison, deputy director of Policy at The King’s Fund, and the report’s lead author, said: "An emergency admission to hospital can be distressing and unsettling for older people and increase their dependency.
"Currently two-thirds of emergency bed admissions are for elderly people and our research suggests that we can significantly reduce these numbers. With better design and co-ordination of services focused on the needs of older people, we estimate that the NHS could reduce overnight hospital stays by 2.3 million annually.
"Not only would this minimise exposure to psychological and clinical risk but would provide a model of care that is far more clinically and financially sustainable."
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