Avoiding Unnecessary Hospital Admissions: the headlines

Avoiding Unnecessary Hospital Admissions: the headlines


By 2050, one in four people in the UK will be over
65. The ageing population is already a challenge to the National Health Service and social care
services, both under pressure to cut costs. This film examines the reality behind the
headlines that surround the health and wellbeing of the most vulnerable group in society. Something like 60% of admissions to hospital are in
people over 65, about two thirds of the bed days are in people over 65, and we know from the research
that some of those admissions are preventable. And they could be prevented by managing people
better who have long term medical conditions so that they stay well and don’t deteriorate,
they could also be prevented sometimes when people do become ill by responding more quickly
to their concerns and maintaining them at home. And we know we’re not going to solve the problems
of the NHS unless we do start delivering more care closer to home as the population ages. So how do we define an unnecessary
hospital admission for an older person, whether they live in their own home
or a residential home? In the immediate situation that’s an older
person who has an illness which from the medical point of view can probably be dealt with quite
adequately in for an example a domestic setting, with community health resources – but cannot be
unless there is the adequacy of social care immediately available and the social care and
the health care working collectively together. So that could be an immediately avoidable
hospital admission. My view is that there is a lot of emphasis on
trying to keep people at home, and I think that’s quite legitimate if it’s based on the needs of
the individual, but too often it’s based in the needs of the system and the budget. So what I
would say is what we want is the right service for a person at the right time in their life. It can be difficult to identify what the right thing
is because older people are a hugely diverse group. When Mum goes into hospital, you know like,
if she’s had a fall and they’ve taken her, the surroundings really disturb her because
she doesn’t recognise the sounds and what’s going on around and she gets very distressed. I’m living here on my own, but at least,
it’s mine. I don’t want to be in hospital. I don’t want him in hospital, they think I do,
I don’t. But when it gets serious, I have to. These are just a few voices from the 10 million
British people who are currently aged over 65. Including three million who are over 80. The
majority of them continue to live independently. Yet increasing age inevitably brings its problems. We are carrying a much larger burden of ill
health in the community than we were perhaps 20 years ago, because we have many more people
who are the elderly old, who have many health problems including frailty, which is
not a diagnosis, it is just a state of health The ageing population is increasingly reliant
on quality care, either in a residential setting or at home. Home carers in particular, with the
right training, can play a vital role in helping to prevent unnecessary hospital admissions. The home carer is in a unique position to be
able to pick up when somebody is beginning to get more frail, beginning to – maybe beginning to
become ill, maybe beginning to develop dementia and so on. And it’s really crucial that people
have the training and the confidence to actually take the right action when that happens. People don’t necessarily you know want to spend a
disproportionate amount of their time in hospital, therefore if you can have home carers playing a key
role, and they’re trained in that, in identifying you know early warning signs that people are
actually becoming more confused, or becoming increasingly more frail, we can put in
additional support to help people stay at home. When we’re talking about home care staff, who are
vital in terms of maintaining people’s independence at home, again there’s an issue about their
skills, about the support they get from their own organisation, but also the access to health care
inputs when required. So if you’re a home care worker and you find that someone’s having problems
with their medication, or they’re falling, or they’re becoming confused, you need that
rapid access to input from community nursing, from general practitioners, if you’re going
to enable people to remain safe at home. Better prevention programmes, and innovations like
telehealth, are beginning to make staying at home in later life safer and more realistic.
The result is that when people finally go into care homes, they are often very frail and ill. It’s important to remember that many years ago
care homes were not places where people with very severe frailty went. And in fact if you go
back to the 70’s, you’ll find care homes with large car parks, because lots of the residents
still had their own cars. We’re now in a scenario where care homes are delivering very very high
levels of care to people with multiple morbidities and some serious health issues. So I think the
world has changed in terms of the population of care homes but the health care system
has not caught up with that. People in care homes are among the ill-est people
in our society really. They only go into care homes because they’re very frail, vulnerable,
often on multiple medications, they often have conditions like dementia or falls or immobility.
And we know that care homes have been a bit of a black hole for health care input really. People
in long term care often get much less access to not just GP input but other community health
services like chiropody or dieticians or physiotherapists than they would in their own
homes. So they get a raw deal. But they are on the list of general practitioners, and general
practitioners, or commissioning groups, need to start providing more services for
those people. And it will be win win as well, because often they end up in hospital because
their medical problems haven’t been well managed. Medical issues include physical and mental
wellbeing. Well over 70% of care home residents have some form of cognitive impairment, ranging
from depression and confusion to dementia. Care homes are really centres of excellence for
end of life care and for dementia. Places where frail older people who can no longer manage
themselves at home can be supported to live and to end their lives. They’re also places
where people can go for respite care and for re-ablement and rehabilitation. No matter where older people live, or the
state of their mental or physical health, the main reason for admissions to A&E
remains some sort of crisis. At the moment that an older person is as it
were turning up at the front door of a hospital, looking like in their view or their GP’s view
that they need to be admitted to hospital, actually there are few safe alternatives. But
for some individuals, getting prompt diagnosis, and getting a rapid response team combining health
and social care, supporting people at home, is definitely an option. The key to that is a very
rapid assessment diagnostically at the front door of the hospital. Which is where we need to
collaborate. So if you can get that clarity, so you can then have a sense of what’s actually
going to happen to this individual in the next day or two, what’s likely, then you can arrange
care around them. That’s important, though it’s not going to be the majority of older
people that arrive at hospital. When older people need hospital, they need
hospital just as much as younger people. So they should never be denied admission
when that’s the right thing for their needs. But the other thing is, when people are in beds,
they sometimes stay too long, and that’s partly about having enough step down services when people
leave hospital, but it’s also if you manage people better in hospital, they’ll often stay for
a shorter time. So we avoid letting them become immobile, we avoid moving them four times, we
avoid causing confusion and having them lose function while they are in hospital and often
their length of stay will be shorter if we do the right thing across the whole pathway of care. Government initiatives such as the 2012 Health
and Social Care Act, and legislation on care and support, emphasise the need for integrated
working between health and social care. But ongoing research into integrated working
and unnecessary hospital admissions amongst older people, has so far not shown a
reduction in emergency admissions. It has however shown up other potential benefits. There was a reduction in planned hospital
admissions and a reduction in outpatient usage. So as a result, the overall costs of
hospital care for people who were receiving the integrated care were actually slightly lower. It’s not just about money, it’s about
better outcomes for individuals. The things that really seemed to work are where
patients – people can take some control of their health, so they become more empowered. For
example patient education in people with chronic obstructive pulmonary disease, which is a long
term respiratory condition, can reduce admissions by 40%. And there are very few interventions that
we could put in as a health service that would be as effective as that. And we know that things like
rehabilitation after somebody’s had an admission, can be really effective as well. So for example in
some of the heart failure research where they’ve seen their best results, patients have been able to
access a specialist nurse, they’ve had education, they’ve learned how to look after their own
condition, they know where to go, where to seek help if their condition deteriorates, so you’ve
got a number of smaller interventions in there building up to one big one, and perhaps
it’s there that we’ll see the biggest hits. The jury may still be out on the best ways to
reduce unnecessary hospital admissions amongst older people, but the challenge remains.
Are the health and social care sectors ready and able to join forces to face up to it? We know what’s coming, we shouldn’t pretend we
don’t know what’s coming. Are we preparing for it? I don’t see any evidence of that. I worry
enormously that the current squeeze on everything means that some small home care providers are
going out of business, we’re going to be losing quite a lot of the skills and expertise, and as
the numbers increase we actually going to be less and less well equipped to deliver the
services that are needed. And I don’t think we should be tolerating that. I think the debate about the medical model and
the social care model has become increasingly redundant, conceptually and definitely in
practice. So I think that we – whilst we have different bodies of expertise and to some extent
work within different paradigms, the reality is that we need to coalesce around the needs of
older people. And where that’s done actually, people don’t necessarily always agree. But what
they do is they cooperate to do the job properly. Our life is most impacted as clinicians when
social care is struggling. It’s exactly the same for social care professionals. Their life gets
more difficult when the doctors are unresponsive. We do have the knowledge actually within the
systems of care and the professionals and others involved. It would be good to have a
period of less meddling, and less reorganisation, so we actually have the time to get together
and turn these things into viable solutions. I think we can do it.

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