Admission impossible? Understanding and reducing the emergency hospital admissions of older people

Featured article - 08 September 2016
By Jon Glasby and Rosemary Littlechild - University of Birmingham

Head-shot of the author, Jon Glasby and Rosemary Littlechild - University of Birmingham

Every so often, the national media and policy-makers focus on the pressures on acute hospitals. Many accounts imply that at least part of the problem is to do with potentially large numbers of older people being admitted when they do not need to be in hospital. Over time, the reasons given can vary: delays accessing social care, difficulties seeing a GP, problems with out-of-hours services; and possibly even hospitals themselves having perverse incentives to admit some patients rather than diverting them elsewhere where this is appropriate. Sometimes there may even be a figure identified, with a certain number of older people alleged to be in hospital beds when they could be cared for elsewhere. However, such estimates rarely state the basis on which such figures are calculated and, crucially, don’t seem to have talked to older people themselves (or to front-line staff) about their perceptions of the issues at stake.

SCIE: Integrated health and social care

Against this background, a new study - conducted by the University of Birmingham’s Health Services Management Centre and the Department of Social Policy and Social Work - has explored these issues with older people and local health and social care professionals, in three case study sites around the country. Working with 104 older people and some 40 local professionals, the research looked in detail at how the older people were admitted to hospital, whether they felt this was the best place for them and what alternatives might have been explored. Similar questions were also asked of a GP and / or hospital doctor representing as many of these older people as possible. As far as we can tell, this may be the first study in the UK (and possibly internationally) to produce a rate of so-called ‘inappropriate admissions’ whilst also engaging meaningfully with older people themselves. If this really is the case then it seems truly shocking, especially at a time when other aspects of health policy are seeking greater patient and public involvement in order to improve services.

In our research, only 9% of older people felt that they could have been cared for outside hospital (and even these people seemed very sick and unwell to us). All GPs and hospital doctors who took part felt that all of the admissions concerned were necessary (making a rate of ‘inappropriate admissions’ of 0% from a medical perspective). Indeed, some older people seemed to have delayed seeking help for as long as possible, perhaps through a fear of being seen as taking up scarce NHS resources unnecessarily. By talking in detail to older people with direct experience of the issues at stake, we also identified further things, such as an apparent lack of social care prior to a hospital admission, poor experiences for people with dementia and that some older people hadn’t felt sufficiently listened to in previous encounters with health services (so that initial problems recurred later on). Our study is called ‘Who Knows Best’, and we firmly believe that a problem as complex as the appropriateness of emergency hospital admissions cannot be understood and resolved without drawing on the lived experience of older people themselves. To help improve policy and practice, a guide based on the experiences of older people will be sent to every hospital, clinical commissioning group and director of adult social services in England – and a video resource is available for front-line practitioners from SCIE.

About the study

This blog is based on a two-year national research project funded by the National Institute for Health Research (Research for Patient Benefit programme). In total, we interviewed 104 older people or their families within 4-6 weeks of their emergency admission and sent surveys to these people’s GPs and a hospital-based doctor (with a total of 45 responses). We also reviewed the previous literature in the UK and beyond, interviewed 40 health and social care professionals and explored the stories of some of the older people who took part in focus groups with 22 local front-line practitioners. The project was overseen by a national ‘Sounding Board’ comprising: Age UK; Agewell; the Association of Directors of Adult Social Services; the NHS Confederation; and the Social Care Institute for Excellence.