Understanding variation in acute admissions of people aged 85 and over: a systems-based approach

Problem

The number of unplanned admissions in England is rising steadily, particularly in people aged 85 and over, but there are marked geographical variations. We aimed to identify opportunities for quality improvement by examining system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over.

Approach

Primary Care Trusts were ranked according to changes in admission rates for people aged 85+ between 2007 and 2009, and study sites selected from each end of the distribution: three ‘improving’ sites where rates had declined by more than 4% and three ‘deteriorating’ sites where rates had increased by more than 20%. Each site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. Representatives from these organisations at strategic and operational levels were interviewed to understand how policies had been developed and implemented. A total of 142 respondents took part. McKinsey’s 7S framework was used as a structure for investigation and analysis of transcripts. This stresses the interrelationships beween strategy, structure, systems, style, staff and skills, with shared being values being central to the system.

Findings

Improving sites had strong strategic leadership, enabling the development of a comprehensive system-wide strategy for managing unplanned care, including specific policies and procedures for older people, which were shared across a more integrated health and social care setting. This encouraged longer-term, consistent development of evidence based strategies. This stability also allowed trust and shared commitment to be established and the emergence of common values across components of the system. In improving sites, primary care appeared stronger, both in terms of service provision and strategic engagement. Intermediate care was also more developed in these sites. These services worked best when provided at scale and fully integrated with each other, offering round-the-clock availability with a single point of access, shared information systems and specialist nursing and geriatric support. Improving sites also seemed more equipped to reduce admissions of older people from ED, through a variety of initiatives, including more senior staffing, involvement of GPs and provision of specialist nurses or geriatricians.

Consequences

This study demonstrates the importance of taking a whole system approach in designing services for older people. This is best achieved by developing a sustained and shared vision focusing on outcomes that matter to older people, establishing strong leadership without dominance by one organisational element, maximising integration and unity and minimising complexity within the system. These findings have potential to inform the practical implementation in England of Strategic Transformation Partnerships and Accountable Care Organisations, vehicles designed to promote system-based collaboration.