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

Faced with an ageing population and a growing number of people with long-term conditions, a common concern for policy makers has been that high levels of emergency hospital admissions concentrate too many resources in expensive, acute care, leaving insufficient funding to invest in community-based alternatives. Under successive governments, this has led to a series of attempts to make more effective use of hospital beds, recognising that these are scarce resources for which demand outstrips supply.

While various approaches have been adopted over time, pressures on acute care remain intense and the received wisdom is that admissions continue to be influenced in part by the help-seeking behaviour of patients, of their carers and sometimes of paid care workers in the community (with patients and professionals alike ‘still ‘defaulting’ to hospital in a crisis).

Overall, we believe that part of the problem is that emergency hospital admissions occur for diverse and complex reasons – and that different stakeholders often have different views as to the nature of the problem and the best course of action. In response, this study sought to draw on multiple methods of exploring emergency admissions and on different perspectives from research, from practice and from the lived experience older people and their families. This is crucial if an issue as multi-faceted as emergency admissions is to be fully understood in the round and – where appropriate – reduced.

With this in mind, our research reviewed the formal evidence about the rate and cause of potentially avoidable admissions. However, we it supplemented this with original research to explore older people’s experiences of emergency admission and their ideas for more preventative approaches. Where the older people and their families would like to, this also included consideration of a family/carer perspective. In addition we worked with local health and social care professionals to examine their ideas about the scale and cause of potentially avoidable admissions, and any service developments that could prevent admissions altogether.

Overall, the study included: 

• A review of the literature on the appropriateness of emergency admissions identifying the rate and cause of potentially avoidable admissions and any potential solutions proposed. 
• Interviews to identify clinical and managerial views on actions being taken locally to reduce the number of admissions (15-20 interviews per site in 3 case study areas).
• Detailed insights into the cause and experience of admission from older people and their carers (40 older people and/or their carers per site in 3 case study sites).
• Additional information from a lead medic, GP and social worker about whether or not the admission could have be avoided (for each of the older people interviewed above).
• A focus group in each site which will comment on vignettes derived from the interviews with older people and develop practical service/policy responses.

Outputs and Resources

The research was overseen by a national sounding board of researchers, professionals, managers and older people’s organisations, who helped us to integrate insights from these different perspectives. We also included as partners several leading national organisations who helped us share any lessons learnt through a good practice guide that was sent to all hospitals across England and through a potential short video on ‘Social Care TV’. The research was also informed by an older people’s reference group, who helped us design material that is as accessible as possible for older participants and identify key themes emerging from the study.

• Who knows best? Older people’s contribution to understanding and preventing avoidable hospital admissions - full report (2MB)
• Good practice guide, with a graphic exploring older people’s journey through the health and social care system (2.5MB)
• A review of the literature around avoidable emergency admissions
• Editorials from our clinical lead, David Oliver, on ‘who is to blame for older people’s readmission?’ and ‘why I let some patients stay longer’ 
• A training video summarising the key findings of the project

Publications

Thwaites, R., Glasby, J., Le Mesurier, N., and Littlechild, R. (2019) Interviewing older people about their experiences of emergency hospital admission: methodology in health services research. Journal of Health Services Research & Policy, Vol 24, 2. pp.124-129 https://doi.org/10.1177/1355819618801696

Glasby, J., Littlechild, R.  Le Mesurier, N. and  Thwaites, R. (2019) Who knows best? Older people’s and practitioner contributions to understanding and preventing avoidable hospital admissions, Health Economics, Policy and Law. 1-22. https://doi.org/10.1017/S1744133118000518

Blog posts and media

Glasby, J. (2017) Admission impossible? Understanding and reducing the emergency admissions of older people, National Institute for Health Research blog, 5 July

Glasby, J. (2017) Older people don’t choose to take up hospital beds, The Conversation, 6 February

Glasby, J. (2017) Who knows best when it comes to emergency hospital admissions?, NHS Voices/NHS Confederation blog, 12 December

Glasby, J. and Littlechild, R. (2016) Who knows best? Understanding older people's experience of emergency hospital admission, Policy and Politics Journal blog, 26 October 2016

Glasby, J. and Littlechild, R. (2016) Policy briefing:  Who knows best? Understanding older people's experience of emergency hospital admission, Discover Society, 4 October 2016

Glasby, J. and Littlechild, R. (2016) Admission impossible?, SCIE Prevention Library blog, 8 September 2016

Glasby, J. and Littlechild, R. (2016) ‘Who knows best?’  Older people’s contribution to understanding and preventing avoidable hospital admissions, Birmingham Brief, 8 September 2016

Dates

2014-2016

Researchers

• Prof. Jon Glasby, Director of the Health Services Management Centre, University of Birmingham
• Ms Rosemary Littlechild, Senior Lecturer, Department of Social Policy and Social Work, University of Birmingham 
• Prof. David Oliver, National Clinical Director for Older People’s Services and Consultant Geriatrician, Royal Berkshire NHS Foundation Trust 
• Dr Sally Jones, Consultant Physician in Geriatric Medicine and General Internal Medicine, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust 
• Dr Natalie Powell, Consultant Physician in Acute and Geriatric Medicine, Surrey and Sussex Healthcare NHS Trust 
• Nick le Mesurier, Research Fellow, University of Birmingham
• Dr Rachel Thwaites, Research fellow, University of Birmingham

National partners/steering group:

• NHS Confederation
• Association of Directors of Adult Social Services 
• Age UK 
• Social Care Institute for Excellence

Local partners/older people’s reference group: 

• Agewell (Sandwell)

Funder

NIHR Research for Patient Benefit programme.

Related links

• Health and Social Wellbeing research
• News item announcing good practice guide - older people's experience of emergency hospital admission
• News item announcing full report - 'Who knows best?' Older people's contribution to understanding and preventing avoidable hospital admissions