Hospital or ‘hospital at home’ – what’s best for older people?
Thanks to advances in medical care and public health, we’re lucky to be living longer lives. Currently there are 10 million people in the UK who are over 65 years old and three million over the age of 80, and these figures are set to double over the next 20 years.
This growing elderly population is one of the biggest challenges facing the NHS today. Older people are being admitted to hospital in ever greater numbers, putting increasing pressure on an already stretched service facing ever tighter budgets.
In an emergency situation, such as a fall or sudden illness, doctors may recommend that a frail older person should be admitted to hospital. But there are concerns that this may not provide the right kind of care that they need. So is hospital really the best place for them, or would they be better cared for at home by a specialist team? Professor Sasha Shepperd and her team at the NDPH want to find out.
Not only is the number of older people in the population increasing, they also have complex health needs – including physical frailty, decreasing mental ability (cognitive decline) and dementia – on top of any long-term health conditions.
Today, nearly two thirds of the people admitted into hospital are over 65 years old, and an increasing number are frail or have dementia. At the same time, there are a third fewer emergency hospital beds than there were 25 years ago, despite the fact that these admissions rise at a rate of 2 to 3 per cent every year. The numbers just don’t add up.
One way to cope with this problem is to cut the length of time that people stay in hospital, but this duration is actually rising for people over the age of 85. Working out how to solve this challenge is a major concern for the 21st century, if we want to provide the best healthcare for as many people as possible with dignity, respect and compassion.
Home or hospital – the evidence
At first glance it might seem obvious that hospital would be the best place to look after someone, but in fact there is evidence to show that this may not be the case.
Small studies have suggested that admitting frail older people to hospital can lead to a decline in their physical ability. There’s also a risk of picking a hospital-acquired infection, which can cause serious complications or even death. And if someone is already receiving regular care at home, sending someone into hospital can interrupt the relationship with their carer. This bond can be hard to re-establish.
Older people are also at significantly increased risk of developing a condition called delirium if they are admitted to hospital. A little-known but common condition in the elderly, delirium is a state of acute confusion. It can have serious effects, such as accelerating or triggering dementia, and often leads to people spending a longer time in hospital and eventually ending up in residential care. It’s not known exactly why hospital admissions should lead to delirium, but the unfamiliar and stressful surroundings of the ward and loss of a comforting home routine doubtless plays a part.
There are also financial as well as personal costs associated with hospital care. Keeping people in hospital is costly, and people over 85 account for a quarter of all bed days in the NHS. Avoiding this would be better for older people, reduce admission to residential care and keep people living at home longer, and also save money.
As an alternative, some health authorities offer something known as ‘Hospital at Home with Comprehensive Geriatric Assessment (CGA)’ – effectively taking the hospital to the patient instead of taking the patient to hospital. Rather than admitting an elderly person into hospital after a fall or sudden illness, a multidisciplinary team of experts – including specialist nurses, a physiotherapist and occupational therapist and other professionals such as psychiatrists, dieticians, speech therapists and social workers – will assess the patient’s individual health needs and work out a plan for delivering appropriate care in their own home. Of course, they can always be admitted into hospital if it’s required, and they still have access to their usual GP and local care as before.
Overall, there seems to be a lower risk of death six months after a fall or sudden illness for people who are cared for in their own homes in this way, compared with those who are admitted into hospital, although this has only been shown in small research studies. So it’s still not clear whether Hospital at Home can really make a difference to outcomes.
Trialling Hospital at Home
Dr Sasha Shepperd and her team at the NDPH are running the largest trial ever undertaken comparing hospital admission with Hospital at Home. They’re recruiting more than 1,300 frail older people over the age of 65 from seven centres across the UK over two and a half years, randomly allocating them in a two to one ratio to either Hospital at Home or admission to hospital. The study launched in 2015, and more than 400 patients have already been recruited.
Every person will be asked to give informed consent to take part in the study, or from their relatives if the patient isn’t capable to consent themselves. There are some types of patients who won’t be considered for the trial, such as people who’ve had an acute coronary event (e.g. a heart attack) or suspected stroke, and those at end of life requiring palliative care or needing urgent surgical assessment. More generally, if anyone is considered to be too high risk to be sent home or simply wants to choose their own care option, then they won’t be considered for the trial.
Once the patients have been recruited, Professor Shepperd’s team will follow them up after 6 and 12 months to find out what has happened. Are they still living at home, are they in hospital or residential care, or have they died? The team will also look at a range of measures, including overall health and cognitive impairment, and will interview patients, carers and medical staff to find out about their experiences and quality of life. They also want to investigate the numbers that develop delirium or other cognitive impairment, as well as finding out whether people are still able to carry out normal daily activities.
Another aspect of the study is analysing the costs of the two different approaches, as at the moment it’s not clear whether hospital admission or Hospital at Home is cheaper overall. This doesn’t just include the purely financial costs of hospital versus home care, but also takes into account informal care from family members as well as the broader social care costs.
Making a difference
The Hospital at Home study is an important part of the process of evidence-based healthcare, planning and policy. People aren’t simple and delivering healthcare for a whole population is a complex problem, with limited budgets and a complicated system. So we urgently need research like this in order to work out what best to do.
However, as was made clear in the Francis report into the Stafford Hospital scandal – targets and financial considerations must never be allowed to come before the quality of care. Politicians and healthcare chiefs need to use public money well, but with compassion, dignity and respect, putting patients at the heart of the NHS.
The Hospital at Home trial isn’t just about the potential economic benefits. It could be better all round for patients, their families, carers and medical staff. And if you ask them, most older people want to stay in their own homes as long as possible.
“It’s not a new service,” explains Shepperd, “it’s using services that are currently existing in little pockets across the country. Nobody knows whether to fully invest in it nationwide, or to focus on hospital care. But whether it’s less expensive or the same cost or even more expensive – we don’t know until we’ve done the analysis! – if it means better health outcomes for patients then we should do it.”
Whatever the outcomes of the study, Shepperd and her team will be communicating them to the scientific and medical community, as well as policy-makers, politicians and healthcare management. They even plan to engage people through online forums and social media, to raise awareness of the study and its results. Finally, the results will feed into a wider analysis of studies investigating the benefits and costs of Hospital at Home, strengthening the evidence base around this vital but often overlooked healthcare issue.
Find out more about the Hospital at Home study at https://hahstudy.org/
Update: Results from the Hospital at Home study were published in April 2021. The results of an analysis of the cost-effectiveness of Hospital at Home were published in December 2021.