The BBC has reported that if urgent care services in England were better organised this would “free up 7,000 beds – 6% of the total – saving the NHS nearly £500m a year”. This headline is based on a think tank report that looked at how people over the age of 65 in England used urgent care services.
The report found that there was a four-fold difference between the number of beds used after emergency admissions and length of stay between the areas at the top and bottom of the scale.
Some of this difference can be put down to demographic factors, such as some areas having a largely rural environment, the report said. However, its authors suggested the marked difference may be caused in part by differences in the way care services work in different areas.
The authors suggested that if areas that had the largest acute care usage reduced their emergency admissions and lengths of stay to the levels seen in areas with the lowest use, there would be 7,000 fewer beds needed across England. It is worth pointing out that if the NHS had 7,000 fewer beds, it could spend the money it saved on other parts of the health service, such as on medical research or keeping prescription costs down.
This, the authors said, is an opportunity to reduce the overall usage of urgent and emergency care by elderly patients without compromising quality of care. They have advocated a greater emphasis on “joined-up care”, in other words, more effective co-ordination between local healthcare services, GPs and community care. The authors said that there is evidence that such co-ordination and integration can lead to both good quality care and lower usage of emergency beds.
What is the story based on?
This story is based on a recent report by the King’s Fund, a charitable health policy think-tank that examined the use of in-patient urgent care services by elderly people in England. The report specifically looked at variation in the use of services across the country, and examined the many complex factors that influence this variation.
What was the report considering?
The report examined patterns in the use of urgent and emergency care by elderly people across hospitals in England. The authors emphasised that such admissions are often a “disruptive and unsettling experience, particularly for older people”. In order to avoid these negative experiences, the authors examined the factors, both patient and organisational, that influence the amount of in-patient urgent care beds used. It then considered how much urgent care use could be reduced by reducing variation in these driving factors.
What kind of data were the researchers looking at?
The report used England’s national Hospital Episode Statistics database, as well as data from the Office for National Statistics from 2009 and 2010. This was the most recent available, but the authors do point out that there may have been a change in services in many areas since that time.
What did the researchers find?
The report found that there are over 2 million unplanned hospital admissions each year among elderly people, and that this accounts for 68% of total hospital emergency bed use. However, the patterns of care are not uniform throughout the country, with a four-fold variation in urgent care bed usage between areas. The lowest usage of hospital emergency beds was seen in Torbay, with an approximate average of one bed-day per person over the age of 65 each year. The highest rate was seen in Trafford, with each person over the age of 65 using an average of four bed-days each year.
The report found that this variation is due to two main factors:
- differences in the rate of urgent and emergency care admissions
- differences in the number of days admitted patients remain in hospital
The report found that people over the age of 65 spend an average of nine days in hospital when admitted through urgent and emergency care, compared with around three days for those under the age of 65. The authors said that if those areas with the highest use of acute care beds were able to reduce their admission rates and average lengths of stay to the levels seen in the PCTs with the lowest usage, they would expect that 7,000 fewer beds would be needed.
The report said that several variables combine to determine the number of urgent and emergency care admissions and length of stay. While older patients tended to be in hospital more often and for longer, there are other changeable factors that may help reduce emergency bed usage, said the authors.
These changeable factors include community services. However, the authors said that their findings contradict previous reports suggesting a link between local community health and social services and the number and duration of emergency hospital stays among elderly people. The King’s Fund report did find that in areas where hospital is used as a transition service between living at home and in a supported setting, the length of stay tended to be excessive.
The way hospitals are set up is another potentially changeable factor, the authors argued. They found that:
- Rural location was associated with lower bed use, and older patients who lived closer to A&E services were more likely to use them.
- Internal hospital policies on admission, treatment and discharge policies can also influence the admission rate and length of stay. They cited previous evidence suggesting that hospitals with a senior clinician present in the emergency department can lead to a reduction in admissions.
- The length of stay has been found to be reduced by frequent review, co-ordination of care with specialists, and patient or carer involvement in making decisions about their care.
What are the wider implications of the report?
The report suggested that there is room to reduce the number of urgent care admissions as well as the length of stay in acute care wards. While this is true, it is impossible to entirely eradicate differences in patient care between areas – there will always be a “best” and a “worst” area.
The report found that areas with a higher proportion of elderly people tended to have lower rates of acute bed usage. They said this suggested that “in areas with a relatively high proportion of older people more attention may have been paid to service improvements [for older people]”.
The authors concluded that an integrated approach to care for elderly people emphasises four points across the entire system of care, not just within an urgent and emergency care setting. Those advisory points are:
- Only admit those older patients who have evidence of a life-threatening illness or need for surgery.
- Provide early (with 24 hours of admission) access a clinician specialising in treating elderly patients.
- Discharge patients as soon as possible, and plan post-discharge care in the patient’s home.
- Complete a comprehensive review of the patient after discharge in order to identify any need for longer-term care.
It is unclear from the report to what extent the NHS in different areas has introduced this integrated approach. The authors pointed out that such integration and co-ordination may be difficult. They authors said: “The key to improvement lies in changing the ways of working across the whole system rather than piecemeal initiatives.”