For years the health and care sector has sought to reduce the numbers of A&E attendances and emergency hospital admissions while supporting people to remain independent in the community for longer and treating people in more appropriate, and mostly, less expensive settings.
With demand growing every year for mental health, community and acute care, it feels as if the solution to this capacity problem is continuously out of reach. This issue is particularly pertinent for older patients, resident in care homes, who are much more likely to be admitted to hospital than their counterparts in the community.
For older, frailer people, an unnecessary hospital admission can do more harm than good. A stay in hospital can lessen mobility, which can result in reduced bone and muscle mass, increased dependency and confusion. Initiatives such as 'end pyjama paralysis' have been rolled out across the NHS. Getting patients out of bed, dressed, sitting up and active is in the best interests of the patient. At the same time, these interventions help reduce the amount of time someone spends in hospital, which allows the NHS to free up more capacity to treat those in need of a bed.
For older, frailer people, an unnecessary hospital admission can do more harm than good.
Senior Analysis Manager
A significant proportion of older people who are admitted to hospital tend to live permanently in care homes. Care homes include both nursing and residential homes, which can be self-funded, NHS funded, or funded by the local authority.
In 2016/17, 7.9% of people aged 65 and over who attended A&E were care home residents. Unnecessary admissions from this group are particularly interesting as the patient arrives from a constituent part of the local health and care system, where personal or nursing care is already being provided. Findings from a recent think tank improvement study found that 41% of emergency hospital admissions from care homes were avoidable. The research also showed that people in residential care homes attended A&E on average 1.12 times in the year 2016/7, compared with 0.85 times for those staying in nursing care homes.
In 2016/17, 7.9% of people aged 65 and over who attended A&E were care home residents.
So, what can the NHS do to try and get ahead of the curve?
Increasingly, trusts are using quality improvement methodologies to help modify patient pathways and improve patient outcomes. With no broad-brush formula to quickly reduce emergency admissions, trusts are busy analysing the profile of their patient populations to see what they can do to prevent unnecessary admissions or reduce stays in hospital.
Although there is more to do to build strong local relationships and collaborative working, NHS and local authority colleagues are also working together much more closely to make sure older people are cared for in the most appropriate clinical, care home or domiciliary setting. And it is critical that commissioning and care packages are aligned as quickly as possible to prevent older people staying in hospital or another care setting longer than they need.
It is critical that commissioning and care packages are aligned as quickly as possible to prevent older people staying in hospital or another care setting longer than they need.
Senior Analysis Manager
The NHS long term plan includes a welcome commitment to improving NHS support in care homes. The plan also sets out the framework for how and why system partners need to work together. It will be important that these commitments are co-designed with colleagues from the sector and that we learn from what worked well in the 'enhanced health for care homes' vanguard programme and in other initiatives across the country.
Integration and strong positive relationships at a system and neighbourhood level will be the prerequisite for success. In this example, local collaboration between care homes, GPs, district nurses, hospices and the ambulance service will be instrumental to improving patient outcomes by guaranteeing that only those in need of acute medical care are transferred from a care home to hospital.
Integration and strong positive relationships at a system and neighbourhood level will be the prerequisite for success.
Senior Analysis Manager
It is encouraging that the study shows that we can reduce emergency admissions for a subset of patients who don’t need to be in hospital. These findings need to be shared and adopted appropriately in different local settings. However, we would be mistaken in thinking that a particular blueprint approach is a winning formula.
We only need to look at the rising demand for mental health services to know that, unfortunately, there isn’t a straightforward answer to how we better manage the rising demand for NHS services.
This was first published in Public Finance. It was later published in Public Sector Focus.
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