Older People in acute settings benchmarking report - April 2015

This report presents the findings from the first phase of a national benchmarking project looking at older people in acute settings. The project has been led by the NHS Benchmarking Network (NHSBN), and developed in partnership with the British Geriatrics Society. The topic was identified as a priority area for the Network’s work programme for 2014/15.

• The project was available for participation from all members of the NHS Benchmarking Network who offer care of older people in the acute setting. There were 47 participating Trusts and Local Health Boards (LHBs) in this first iteration of the project.
• The report and online toolkit present the findings of the project across the four areas of the pathway that are explored. The four elements of the acute pathway reviewed are admission avoidance in A&E, assessment units, inpatient care and
• supported discharge. Within each area of the pathway the service models, activity, workforce and finance data is explored. Key quality indicators are also presented, as well as an extensive good practice and innovation section.
• The NHS is faced with the demands of an ageing population and increasing numbers of people are living with multiple long term conditions. The NHS Five Year Forward View (NHS England, October 2014) acknowledges that the service is facing enormous challenges in continuing to provide support to frail, older people. Whilst data exists looking at the care of older people in specialist areas, for example stroke, there is little data looking at the pathway as a whole, as older people navigate through secondary care. This project provides a unique data set on the pathway of older people in secondary care, from what happens in A&E and assessment units, through inpatient care and finally ending with supported discharge processes.
• It is worth noting that the NHS Benchmarking Network runs a number of other benchmarking projects where data on the care of older people is collected and benchmarked. Most notably, the combined Mental Health Inpatients and Community project,
• the National Audit of Intermediate Care from 2012 to 2014, and the Integrated Care project, which is a commissioner based benchmarking project reviewing the commissioning of services for older people. It is worth examining the outputs from these projects to give a wider perspective on the care of older people in your locality.
• This benchmarking project reviews the activity of older people in secondary care by examining the proportion of activity that is related to those aged 65 and over. This approach was agreed at the scoping session for the project due to the difficulties with a finding a common technical definition for “frailty”.
• The project also aims to explore links with other sectors, including primary care, community and mental health. The involvement of social care during admissions and discharges was of particular interest when designing the project. Findings presented within this report have been validated with participating Trusts / LHBs, and the report aims to give an overview of the findings of the project. An online tool is available to participating organisations, where they are able to view their own benchmarked position on key indicators, and drill down further to explore how their services compare with others nationally.
• Older people living with frailty, dementia and complex co-morbidities are now core business for both the statutory and the independent sector in all care settings. The recent Commission on Hospital Care for Older People (Health Service Journal / Serco, March 2015) recognised that people aged 65 in England can expect to live two more decades. By 2030, projected life expectancy at 65 will be 88 for men and 91 for women. One in four hospital inpatients has dementia, and 1 in 3 adults admitted acutely to hospital are in the last year of their life. The care of older people in acute settings continues to be a priority area, with most Trusts / LHBs facing pressures from increased A&E attendances at the front door of the hospital and delayed transfers of care at the back end.
• The NHS Benchmarking Network intends to run the project again in the 2015/16 work programme.

Key findings

Overview

• 35% of Trusts / LHBs have a recognised frailty tool/pathway in use in the health and social care economy.
• 57% of Trusts / LHBs have a clearly defined strategy/operational policy for the delivery of acute medical care to older people.
• 90% of Trusts / LHBs have a designated Clinical Lead for Older People’s services in the Trust/LHB.
• 37% of organisations have an outliers policy which specifically mentions the management of Older People in acute care, and 50% reported that they have a policy locally which related to the movement of older people once admitted to hospital. The cost of each area of the pathway was explored, and it was found that 65% of expenditure on older people’s services was for care of elderly wards and inpatient care. 30% of total spend was on assessment units, 4% on the supported discharge process and 1% on admissions avoidance in A&E.
• Spend on bank, agency and overtime staff varies significantly between Trusts / LHBs. It is noted that where Trusts / LHBs spend more on overtime and bank staff, they typically spend less on agency staff.

Older people in A&E

Service models

• 24% of participating Trusts / LHBs have a dedicated geriatric team located in the A&E department. 85% report therapists are available in A&E to assist with admission avoidance of older people. 62% of organisations have rapid access to social workers in A&E, and 44% report that in-reach is provided by the Hospital Discharge Team.
• Hours of availability of teams in A&E typically decrease at weekends. A dedicated geriatric team is typically available for 9 hours per day during the week, reducing to 6.5 hours per day at weekends. Availability of other teams is explored later in the report.

Activity

• 23% of A&E attendances are by those aged 65 and over, and 46% of admissions from A&E are aged 65 and over.

Workforce

• The skill mix of nursing staff, AHPs and social care professionals is typically rich in this area, with staff generally being from higher bandings than compared to inpatient care.
• The presence of locums within the medical team is highest in the A&E department, with 7% of the dedicated geriatric team being locums.

Read the full presentation here