In recent years, with a rising proportion
of older people in the population,
many with long-term medical conditions,
older people have accounted for an ever-rising
level of emergency hospital admissions.
The NHS is now experiencing more than
2 million unplanned hospital admissions
each year for people over 65
accounting for 68 per cent of hospital
emergency bed days and the use of more than
51,000 acute beds at any one time.
The issue has made headlines and
more generally become the focus of
media attention.
There's often an assumption in the media
that potentially large numbers of frailer,
older people are turning up at and being admitted
to hospital unnecessarily, when they don't
really need the services provided there.
Supported by the NIHR Research for
Patient Benefit Programme, a team of researchers
at Birmingham University has carried out a study
into the issue across three case study sites.
We wanted to look at what causes the
emergency admission of older people and how
appropriate are those hospital admissions.
And we wanted to understand it from the point of view
of front-line staff who work with those issues
day in and day out - and especially we wanted
to understand it from the point of view of older people,
their experience of hospital admission
what had caused it, what had happened in the run up
to admission, was the hospital admission needed
from their point of view and what might
have been done differently.
We also tried to get some data from people's
hospital doctors and their GPs so that we could
compare and contrast those views.
Alongside that we did a number of interviews in
our three case studies with front-line health and
social care staff to try and understand some of
the services that were available locally and some of
the responses that had been developed
over time to these issues.
And we did some focus groups with those
professionals with vignettes or case studies based
on some of the true stories from our
interviews with older people.
In addition to the report, the research material
is being applied to a Good Practice Guide which
is being sent to every hospital trust in the country.
In the process we are supported by a series of
national and local organisations who are
helping us to disseminate the research.
So as well as being a research study in its own right,
hopefully this is something that can have a policy
and a practice impact because of that national guide
and because of the support that we've got
from national policy partners.
A key finding from the research was that
most of the older people who were the subject
of the study were admitted appropriately.
The bulk of our older people and their professionals
feel that hospital was the right place for them.
Those admissions were primarily appropriate.
Across the study, reasons for admission were
found to be far from trivial.
I've been in hospital thirteen times.
The first time was when I was rushed from the doctor's
to Brighton thinking I had a heart attack.
One of the problems that she had about six years ago
is that she turned over in bed and broke her hip and
there have been several hospital appointments,
hospital admissions because of falls in the last few years.
She'd passed out on the dining table while eating
which is very surprising for us, never had that done before,
she vomited, passed he bodily fluids and her tongue was
to the one side so I immediately thought
that she'd had a stroke.
Only nine out of 104 older people felt that hospital
was not the right place for them - and none of the GPs
or hospital doctors who took part felt that
these admissions were 'inappropriate'.
Sometimes alarmingly, many older people
delayed seeking help.
We also found a number of older people who to us
seemed very unwell or in quite a lot of pain who
delayed seeking help either hoping it would go away
or that they could make it through over night,
for example if something happened out of hours or
or a friend before they sought assistance.
They had clearly read or taken on board
some of the media accounts that you hear and they
described themselves as not wanting to be
a burden on services.
I did feel uncomfortable because they said, well
how many times have you been in now?
I mean not that they didn't treat me, I was being treated
and that, but I just felt uncomfortable about it all.
For the amount of times I keep going into hospital
I was beginning to think they thought I was
a hypochondriac because I kept going in and
that made me feel worse.
In the end I feel as if I don't want to go to hospital.
Even if I was dying I don't think I want
to go to the hospital.
Especially the war time generation who remember
the inception of the NHS.
You donÔøΩt want to keep people in here like me doctor,
you know, I don't want to be taking up a bed, they'll say,
I don't want to be too much trouble.
So they often will feel and obligation and they'll
often say, pulling your leg, but slightly aware of
the realities, I know what you want doctor,
you want my bed don't you.
So I think they do feel that sense of obligation
quite frequently.
Although people were in hospital appropriately,
there might still be some scope for longer-term,
preventative approaches.
When they are at home and often with long-term
medical problems and slipping into some kind
of crisis they could have been supported earlier
there could have been an intervention earlier before
they ended up in the emergency department,
in the acute medical unit.
I think there is an opportunity to look at the time
before hospital and actually going back a few months
before hospital and seeing which of these
deteriorations are predictable.
The research has revealed a strong consensus
that hospital often remains the 'default destination'.
A lot of older people have a number of co-morbidities.
So they are under their GP and they are under
lots of different specialists as well as seeing lots of
other members of the multidisciplinary team in
the community as well.
And I think a lot become very confused by that and
there are so many people involved in their care that
when something starts to go wrong, they start to
become unwell or if they are needing more support
they are not sure which person to turn to.
And unfortunately at that point I think a lot will
then turn to A&E.
It's the place that comes into their mind and they feel
that that's the place where they'll receive some
immediate support.
More generally, poor communication was
identified as an issue.
I found a lack of communication between different
departments and everything and they say, oh,
we sent the letter and another one says
we didn't receive it.
You know, it's really, nobody chases anything up.
And they did feel that a more proactive, more
community-oriented response might help to divert
some people away from hospital.
Some of these patients are perhaps running
into problems but they are not acutely unwell
enough to come into hospital and there are
things that we can access and facilitate in the
community or within our day hospital.
The situation is exacerbated by the misconception
that hospitals are inherently safe places
for older people to be.
People in the community often feel that they
have twenty four hour care, they are watched
all the time and they think that they are safe as
a result and that's quite a barrier, we get that
from professionals as well as carers and relatives.
If you languish in hospital you can be exposed
to infection you can lose confidence, it can be
harder to go home, you may fall over, you may
become acutely confused, delirious.
It’s the idea that somehow hospital is safe and
home is dangerous is not a zero sum game.
The research identified the scope for more
proactive initial approaches when older people
first contact services.
For one person on his own to decide does
this person you’re looking after need to go
to hospital or not would be difficult.
If you could have community care where you
could phone up someone and say, this is how…
and they could come and see you and say,
well, if you do this or we do that, you
might not have to go into hospital.
There has to be a credible, single point of
access, seven days a week when things
are going wrong.
Whether it’s the home care worker, whether
it’s the care home worker, whether it’s the
community nurse, the GP the older person
or their carer, when things are starting to go
wrong when they’re struggling you need someone
to phone who will respond quickly, will be on
the scene quickly and provide that kind of
wraparound service that might keep them at home.
Because at the moment people go where
the lights are on which is the A&E department
and once they’re in with a four hour wait they
get inevitably sucked into a bed.
It would be good to have an organisation where
there were a team of people, a specific job
description which covers potential emergency
admissions at home in the community.
That’s really what needs to be done.
A small number of people felt that an earlier
hospital stay or assessment might have resolved
an underlying problem sooner.
Perhaps a more proactive response from a GP.
Perhaps an earlier test or a hospital stay
where there could have been scope to
clear up an underlying health problem once
and for all without it re-emerging later on and
contributing to the particular admission that
we were studying.
Managing them well when they come here, getting them
properly back on their feet when they go to
a step-down service has long term benefits.
And we need to remember that it’s one window
to try and get things right.
In this trust alone there were twenty eight
thousand A&E attendances last year with
patients over the age of seventy five.
What I can do is to try when I’m there to work
with the A&E teams in helping to train them
to give the junior doctors in particular more
confidence and more expertise in assessing
older patients living with frailty, older patients
living with dementia, groups of patients that
they find quite difficult if they’ve not done a
lot of that type of work before.
A number of older people in the study were
in contact with their GP or contacted
the ambulance service.
If we are to develop a more preventative
approach, working with GPs and paramedics
could be a good place to start.
I think with an elderly person, over ninety,
if there’s any doubt that there may be problems,
internal problems or broken bones or whatever,
I think the right thing to do is to call the paramedics,
get her assessed by the paramedics, and
if they believe that she should go and be
checked out in hospital then that’s
the best place for her.
And of course we mustn’t forget the
ambulance trust, it’s the ambulances that
respond to most people in their own homes and
in some parts of the country good, shared working
the ambulance trust means a lot of these people,
for instance if they’ve fallen over, can be
diverted to an alternative assessment
and away from the hospital.
Most older people pitching up at the front door
of hospitals have not been referred by their GP
or out of hours, they’re defaulting straight to
the ambulance or emergency care system.
When they do arrive, it’s often hard to piece
together what’s been happening and because
we don’t have that GP or referral letter we
don’t have access to the notes.
They often don’t have a care plan that
everybody’s signed up to.
People taking part on behalf of family members
with dementia felt that some health services
are not set up to work well with people with dementia
and that social care support is currently insufficient.
One big group we see are people with dementia
who come into hospital because they need a
safe haven, they need a place to go so quite often
they’re found by neighbours wandering in the
street or at night and distressed and there is no
community placement so they come in to hospital.
That often feels totally inappropriate.
People perceive, both carers, relatives, professionals
that we are safe place for people with dementia
but it doesn’t feel like that at all.
We are taking people away from their familiar
environments where they’re working on old memory,
they know everything within their homes.
They know every foothold, every step and we’re
bringing them into a large, busy, hostile, noisy,
strange environment where our focus is really
on treating people who are acutely medically ill.
So there’s two things.
There’s the one where you can actually see
when somebody passes out, vomits, does all
the things that someone… that you think
is having possibly a stroke or being unwell,
maybe a heart attack or something and
we saw that with Mum.
And each time she was admitted that was the
only time we called because she was having
palpitations or having a vomit or passing out,
so we’d call it.
But there were other times when she didn’t
do any of that.
She didn’t have any palpitations, she didn’t
have heart problems, she didn’t pass out
she was just in a mental state where she was
screaming, shouting and there was
just me and my wife.
And all we could do was just keep quiet
and let her get on with it.
In many cases, it was found that there was
simply an absence of social care.
It’s the care that is key to keeping people at home.
We shouldn’t be doing home at hospital and
there’s far too many people staying too long staying
for things that should be provided outside the building.
The large majority of the problem comes from
the softer sides, the social sides that impact
significantly on an individual’s health and as
a doctor I struggle to influence that.
And we see, more and more that people that
could have had more support, more
occupational therapy, more caring support,
more help with mobility, more help with food,
simply just eating results when that’s
deficient in them becoming unwell.
Becoming dehydrated, becoming malnourished,
becoming weak, becoming vulnerable,
increasing their risk of falls, increasing
their risk of being at harm.
And ultimately that makes them more vulnerable
and more prone to having a urinary tract infection,
developing a pneumonia, having a fall, breaking a hip.
With ever increasing demands placed upon social care,
a widely held belief expressed through the research
was that social care was simply under-funded.
Social care has been cut savagely and we don’t
have enough capacity in social care.
There needs to be much more investment
in terms of how we look after our elderly.
Either we do it ourselves or we have to pay for it.
Overall, this study argues that older people have
a crucial role to play in understanding the issues
at stake regarding emergency admissions.
It’s often older people who have a long term
overview of what’s happened to them as their
health has deteriorated as they’ve sought help
from different services, what has or hasn’t
happened next, what happened on the day when
their health really started to deteriorate and
they ended up in hospital and indeed some
insights into the hospital stay itself
and what happened next.
The professionals no matter how well trained
or how well educated only ever see the person
after they walk in through the front door.
So they can comment on what happened on
the day or when they first met the patient,
they haven’t got that sense of how life has
changed and what’s happened over time.
And actually, that’s a vital source of expertise
which we neglect at our peril.
This need to listen more to
the experiences of older people
is supported by a more general opinion
amongst professionals to make
the service more patient-focused as a whole.
What I think we’re not getting right is making sure
that service first of all fits around the patient.
I think it’s quite hospital-focused rather
than patient-focused.
I think sometimes in our rush to save money,
to prevent admissions, to create beds even
well-meaning, caring health professionals can
medicalise and prodecuralise the process.
And I think we’ve got a long way to go making care
and support more personalised for older people.