Hospitals: something to be avoided?
The importance of individual experiences, addressing underlying health inequalities and reducing the cost of health care is widely promoted as the benchmark of the impact of integrated care. However, the increase in acute hospital activity over recent years has been seen as a problem.
The concept of the 'triple aim' is widely promoted in the UK and internationally as the benchmark for understanding the impacts of integrated care. The three elements are laid out as:
- improving the individual’s experience of care;
- improving the health of the population;
- and reducing the cost of health care.
It explicitly sets out the importance of the experiences of the individual and addressing underlying health inequalities, alongside resource-based objectives.
However, it is notable how quickly the first two fade away to leave an emphasis on integration as a means to reduce costs. That is not to say that this is not vital, but rather that without considering the other two 'aims' we may make savings but increase inequalities and reduce positive personal outcomes.
When financial efficiency takes centre stage, it is then only a matter of time before the focus becomes reducing activity in acute hospitals (www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/urgent-and-emergency-care/). This is understandable – hospitals are expensive resources to maintain and there is evidence to show that hospital stays lead to a loss of independence and quality of life for those who are detained longer than is required. Furthermore there has been a general consensus that we can reduce people's need for hospital if we only had better primary care services and that we could enable people to leave quicker if we only had the right social care services in place.
The increase in acute hospital activity over recent years is therefore seen as a problem. There are a number of circumstances influencing hospital activity, including:
- The rise of people with more than one long-term condition leading to more admissions.
- Deprived areas have higher rates of hospital activity than those which are more prosperous.
- The physical accessibility of accident and emergency departments in urban areas leads to a greater uptake of services.
- Government policies regarding waiting times have encouraged admissions to avoid breaches of targets.
- The presence of experienced clinicians enables more confident judgement about who can return home with community-based support.
Looking at the varied factors above, it is important to remember that service configurations will play a role but will never be the whole answer.
Common ways to reduce admissions, and in particular emergency or unplanned ones, include intermediary care, enhanced support for care homes, care management for those with complex needs, and addressing loneliness. However, the research evidence for all of these is inconclusive, with many studies suggesting that they make little difference and in some cases can increase hospital activity (perhaps rightly if unmet need is uncovered).
Evidence is stronger for approaches that support people to be better able to self-manage their long-term conditions, and when multiple interventions are introduced in a coordinated programme. Social care has an important contribution to these more successful approaches through its skill in building on people's own assets and developing positive engagements with wider community resources. Frontline staff who support people in their own home or in care settings can reinforce skills of self-management, and social workers can contribute their person-centred thinking to inter-professional teams. On a strategic level, commissioners can challenge too simple assumptions about the causes of admissions.
At a recent event for the integrated care pioneers we noted the need to address hospital admissions and then agreed not to mention them again during the course of the day. It was notable how much more fruitful the discussions became when we were liberated from this focus, and it is arguably more important than ever to remember all of the three triple aims to ensure that we do not save money at the price of not serving people and populations effectively.
About the author
Robin Miller is an applied health and care researcher with a particular interest in new models of integrated and primary care. He is the current Joint Editor in Chief of the International Journal of Integrated Care and a Fellow of the School for Social Care Research.
This briefing by RiPfA explores how services can adopt strengths-based approaches when working with older people, to reduce the need for hospital admissions. It also builds an understanding of how preventable factors, such as loneliness, contribute to hospital admissions.