'Who knows best?' Older people's contribution to understanding and preventing avoidable hospital admissions

Regardless of the time of year, the pressures on acute hospital care are intense. In the context of an ageing population, growing demand and ongoing funding challenges, these pressures are likely to continue. With estimates of over 2 million unplanned hospital admissions per year of people aged over 65 questions are often asked such as: 'Do they really need to be there? Is there nowhere more suitable for them to go? What might prevent them coming into hospital?'

Until now, studies which seek to address these questions have relied largely on retrospective accounts by health professionals, with little attention to the views of older people themselves, focusing more on the problems of emergency admissions rather than looking at possible practical solutions.

However, a new study by the Health Services Management Centre and Department of Social Policy and Social Work, at the University of Birmingham, has addressed these issues from a different perspective.  

104 older people were interviewed, exploring their experiences of emergency admissions. The research focused on whether the older people felt it was appropriate to be admitted to hospital and whether they thought anything could have prevented their admission.

45 surveys were received back from GPs or hospital doctors of the older people in the study. The study also involved interviews or focus groups with 47 health and social care professionals. Birmingham researchers believe this may be the first study in the UK (and possibly internationally) to estimate a rate of ‘inappropriate admissions’ from the perspective of older people.

Some key findings from the study include:

• Only nine older people (nine per cent) felt they could have been cared for elsewhere. Their GPs or hospital doctors disagreed and felt their admissions (and those of other people on whom they commented) were entirely appropriate.
• Contrary to some media speculation, some older people appeared to have delayed getting in touch with emergency services, being very aware of the need to use scarce NHS resources wisely.
• While there was evidence of good initiatives to try and divert older people from hospital, the ways into these services were sometimes complicated, for older people and professionals alike.
• In the run up to admission, GPs and other primary care professionals were often in touch with the older people and at the point of admission, ambulance staff played a key role.
• Health staff felt that hospital admission was more likely to be avoided if older people had early access to specialist staff who understood the complexity of the health and social problems which older people may experience.
• Few older people mentioned receiving social care services prior to admission and staff felt that social care services needed more funding and capacity in order to prevent emergency admissions.
• A minority of respondents had dementia and their family members felt that some hospital services did not meet the needs of patients with dementia. They also felt that social care services were inadequate.

A number of themes for good practice emerged from the key findings:

• Conditions where older people don’t feel a ‘burden’ need to be created. The study did not find large numbers of older people being inappropriately admitted to hospital; rather evidence was found of older people doing their best to stay out of hospital.
• Community services which could prevent hospital admissions and/or ensure a speedy discharge should be accessible and timely. Both hospital and community services need to be clear with staff and patients about their priorities and criteria for access.
• Avoiding admissions needs experienced, timely assessment – GPs, paramedics and hospital staff have a key role to play.
• Issues of capacity and funding in social care services need to be addressed if they are to play an active role in preventing hospital admissions.
• Increased dementia training for hospital staff and dementia-friendly environments are important considerations.

These key themes and other ‘top tips’ appear in a national guide to good practice which is being sent to every hospital, social services directorate and clinical commissioning group in the country. There is also a video summarising the key findings and highlighting the implications for practice.

The findings of this study confirm the belief that older people have an important role to play in helping understand the nature of emergency admissions and to devise appropriate responses to their rising numbers. Ignoring this expertise could be detrimental to ensuring older people get the appropriate care they need.

Professor Jon Glasby, Professor of Health and Social Care

Rosemary Littlechild, Senior Lecturer in Social Work

School of Social Policy, University of Birmingham 

The research was funded by the NIHR Research for Patient Benefit programme (PB-PG-0712-28045). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.