As winter approaches we will no doubt see recurring news stories about the National Health Service (NHS) facing intense pressure to keep up with demand for its services. This increased demand is often attributed to our ageing population, with people in the UK now living longer than they did in the past. As many of us develop chronic illness or disability as we get into old age, issues occur that require complex medical assistance and it is easy to understand how this can impact the NHS.
In the case of hospitals, this problem is particularly acute as the number of hospital beds has more than halved over the past 30 years, from 299,000 to 112,000. Recent data from the National Audit Office suggests that 65% of hospital bed days are occupied by patients aged 65 or over, reinforcing the observation that there is a disproportionate allocation of resources towards this age group as only around 18% of the UK population is aged over 65 according to the Office for National Statistics.
Whilst increased illness and disability are key factors that drive this level of bed occupancy, the problem is also fuelled by delayed discharges due to a lack of sufficient social care (so-called ‘bed blocking’) and emergency readmissions of patients who are discharged whilst still having issues that require medical attention. Currently, around 15% of older adults are readmitted within 28 days of discharge from hospital. As these admissions are almost exclusively through emergency departments, this not only impacts upon bed occupancy, but also the emergency services and waiting times.
The ‘NHS Long Term Plan’ acknowledges that ‘the balance of need for hospital beds will be a product of continuing pressures from an ageing population’ in the coming five years but does little to articulate how this will be dealt with, other than to advocate better community-based care. Improving and expanding social care provision is a complex and expensive problem that successive governments have not been able to solve, and it is unlikely that within the next five years we will see significant movement in this area. It is almost impossible, as of yet, to simply and quickly improve the health of older adults. In order to reduce unnecessary hospital bed occupancy and pressure on the NHS, policy makers should look to innovative but simple solutions.
It has been estimated that the average cost of an emergency admission is £1,700 but this is across the age range and the cost for older adults is often far higher, running into multiple thousands of pounds. Many of these readmissions are preventable, with estimates suggesting that as many as 79% of hospital readmissions could be prevented. This presents a real opportunity for reducing pressure on the NHS and for planning for winter increases in demand for services.
A recent study from a team at Aston University, Solihull Hospital and Solihull Council investigated a simple and cost-effective telephone-based system of post-discharge care, in order to attempt to reduce readmissions. The study was devised after a local audit showed that most readmissions of patients over 65 years of age occurred before discharge letters had reached the patients’ GP surgeries, which meant patients were readmitted to hospital before even their GP knew they had been admitted the first time. Clearly, this suggests there is a communication issue between hospitals and community services that can allow some patients to slip between the cracks, leading to emergency readmissions.
The telephone service employed in the study used hospital-based nurses to contact patients over 65 years of age who were discharged from a set list of wards, whilst no attempt to contact patients discharged from other wards was made. The service was run for a year before data was analysed. The results, published in the Royal College of Physicians’ Future Healthcare Journal showed that in the group where an attempt was made to contact them, 30-day readmission rates were cut by an impressive 41% (from 15.67% overall in the non-contact group to just 9.24% in the attempt to contact group). This meant that where no attempt was made to contact patients, they had twice as high a chance of emergency readmission compared to those where an attempt to contact was made.
When looking into the data more deeply, it became clear that most of the problems reported by patients who were contacted were simply solved using available community services. Amongst the services required 26% of patients required medications advice, 22% required a GP appointment and 10% required equipment. Only 25% of patients contacted required no follow up at all. These data reinforce that existing community services, which cost significantly less than emergency hospital readmissions are an important tool in preventing older adults from requiring a costly admission to hospital.
Whilst this study was relatively small in size and more research is needed, it still has clear implications for clinicians and policy makers. Improving the discharge process, and ensuring better communication with community services could have a significant impact on the demand for hospital services and bed occupancy and may be a lifeline for an NHS that is increasingly struggling to cope with the demands of our ageing society.
Dr James Brown, Director of Aston Research Centre for Healthy Ageing (ARCHA) and Associate Professor in Biosciences in School of Life and Health Sciences, Aston University