Policy Briefing: Who knows best? Understanding older people’s experience of emergency hospital admission

Policy Briefing: Who knows best? Understanding older people’s experience of emergency hospital admission

Jon Glasby and Rosemary Littlechild

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The Policy Briefing section of Discover Society is provided in collaboration with the journal Policy & Politics. The section is curated by Sarah Brown.  

 

Every year, the NHS experiences more than 2 million unplanned hospital admissions 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).  With an ageing population and a challenging financial context, such pressures show no sign of abating – and the NHS is having to find ways of reducing emergency hospital admissions (in situations where care can be provided as effectively elsewhere).

Often, the assumption in policy and media debates seems to be that potentially large numbers of older people are admitted to hospital without really needing the services provided there, but because there is nowhere else for them to go or because other services are not operating effectively.  Depending on the commentator, the culprit may be slightly different – from a lack of social care to difficulties accessing out-of-hours GP care, and from the limitations of community health services to problems with 111 or the ambulance service.  In earlier debates, hospitals themselves were the focus of significant blame and mistrust, with suggestions that some older people were being admitted unnecessarily to ‘game’ NHS access targets and payment mechanisms.  However, most accounts are much better at identifying alleged problems than they are at exploring the detail of the claims made or proposing practical solutions.

In response, our ‘Who Knows Best?’ research is believed to be the first study in the UK to explore the issue of ‘inappropriate’ hospital admissions from the perspective of older people – and quite possibly the first English-language study to do so internationally.  Working with older people and their families, as well as with front-line staff, in three case study sites – our research found that most older people needed to be in hospital (Box 1).

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Contrary to media stereotypes, some older people may have delayed seeking help in a crisis, perhaps through a desire not to be seen as a burden on scarce NHS resources.  By talking to people with in-depth

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personal experience of the issues at stake, we also identified a series of broader issues that may help to improve services and to develop more preventative approaches over time.  These have been captured in a national guide to good practice, which sets out ‘ten top tips’ which could only have been developed by engaging with older people themselves (Box 2).

This guide will go to every hospital, social services directorate and clinical commissioning group in the country, and is accompanied by a free online video summarising key issues for front-line practitioners.

Box 2: Ten ‘top tips’ 

  1. Create conditions where older people don’t feel they are a ‘burden’ – rather than being admitted to hospital unnecessarily, our impression was of people trying their best to stay out of hospital and very aware of the need to make appropriate use of scarce NHS resources.
  2. Community alternatives need to be easier to access – while there were a series of local services seeking to divert older people away from hospital, these were perceived as patchy and almost impossible for local professionals (let alone older people) to understand. 
  3. This is a two-way process, and hospitals need to play their part – sometimes participants felt that the problem lay with someone else (for example, services in the community), without necessarily acknowledging their own potential role.
  4. Language matters – there’s a difference between ‘inappropriate’ and preventable admissions – older people often had a more sophisticated notion of prevention than some health and social care professionals, recognising that admissions could be ‘appropriate’ (needed at that moment in time), but still preventable (something different could have been done to stop someone’s health deteriorating to the stage where hospital was required).
  5. Don’t leave it too late to explore alternatives – the closer people get to hospital/the further they penetrate into the hospital, the harder it is to prevent admission.
  6. Every contact counts – while they identified few easy answers, participants pointed to a potentially large number of contacts with the NHS which could have been used to resolve the older person’s underlying health problems once and for all. Sometimes, the older people had not felt listened to, with underlying health problems left to culminate in a subsequent admission. 
  7. GPs and paramedics have a key role to play – many older people contacted their GP or were brought to hospital by a paramedic, so any potential for prevention must surely start with these two professionals.
  8. Don’t neglect adult social care – none of the older people in our study said they were in current contact with a social worker, and few reported receiving social care services in the run-up to admission. Health professionals felt that adult social care was too under-funded at national level to be able to play a key role in prevention.
  9. Ensure services are set up to work well with people with dementia – a minority of participants in our sample had dementia, but many of their families felt that support for people with dementia was poor.
  10. Older people are experts by experience – and we neglect this expertise at our peril.

Ultimately, we believe that older people have a key role to play in understanding and responding to the rising number of emergency admissions.  While health and social care professionals can only ever know the person from the moment they walk in the front door, it is older people and their families who have a longer-term sense of how their health has changed, what response they got when they sought help and what might work best for them.  Until we start to value and learn from this expertise, the contested and problematic issue of emergency hospital admissions is unlikely to be resolved.

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Jon Glasby is Professor of Health and Social Care and Head of the School of Social Policy at the University of Birmingham. Rosemary Littlechild is Senior Lecturer in the School of Social Policy at the University of Birmingham. This article 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 (SCIE).  A ‘Social Care TV’ video summary is available from SCIE and the full report and a national guide to good practice will be available via the University of Birmingham website (see here and here).