2.1 Rationale for service changes

The population of England is ageing (Box 3.1), a fact that will lead to an ongoing rise in demand for services for health and social care. The effects of this demographic change first generated widespread concern towards the end of the 1990s when individuals faced difficulties in obtaining services for unplanned acute inpatient care, particularly during winter months (2).

Drawing on research that estimated that approximately 20% of acute bed use by older people was ‘avoidable’ (3), the national beds inquiry argued that the way to reduce demands for acute hospital beds was to offer alternative care options that delivered care in patient’s homes or other non-acute settings. This policy of developing and expanding care options closer to home was endorsed by subsequent policy documents including the NHS Plan (4) and the National Service Framework for Older People (5). As a result, there has been a growth of care closer-to-home services, often delivered by teams of health and social care staff, which aim to reduce or delay older people’s demands for high-cost services such as acute care (Box 3.2).

2.2 Research evidence about the impacts of care closer-to-home services

Research studies have investigated the impacts of care closer-to-home schemes on the health of older people and their use of acute hospital services. Randomized controlled trials and/or systematic reviews of randomized controlled trials are regarded as providing the most reliable source of evidence.

Evidence about the impacts of schemes that aim to prevent hospital admissions is somewhat mixed. A systematic review commissioned by the World Health Organization found that falls-prevention schemes, such as multifactorial falls programmes, can reduce an individual’s risk of falling, acute events (such as hip fracture), and the associated use of health care resources (14). A systematic review by Shepperd et al. (11) concluded that preventing hospital admissions through the use of hospital-at-home schemes does not adversely affect health outcomes and that patients prefer home care. They also found that hospital-at-home care can be less costly than hospital-based care. However, an evidence review by Purdy (15) found that other than for people with mental health problems, proactively case managing people with long-term conditions does not reduce hospital admissions.

Results from individual trials demonstrate that early-discharge schemes can provide an effective and cost-effective alternative to an extended stay in an acute hospital for patients admitted for conditions such as stroke and chronic obstructive pulmonary disease (COPD) (11,16). A systematic review by Shepperd et al. (17) also found that early-discharge schemes did not have an adverse effect on health outcomes, but the claim that they result in cost savings was questioned. However, this review argued that patients may prefer to have their care delivered in their home.

3.1 Rationale for service changes

While recent developments have increased the options available for patient care, they have also created a more complex landscape for patients and staff to navigate because care closer-to-home-type services are delivered by staff from different disciplines working in different organizations and settings (Box 3.3). Research studies have examined the extent to which patients, such as those with COPD, currently obtain timely and ‘seamless’ access to needed services for health and social care.

A recent study examined the delivery of front-line services received by patients in response to a health crisis that resulted in a 999 call and/or an emergency attendance at an acute hospital (18). Interviews with patients, carers, and staff were used to explore the coordination of services received by patients prior to a health crisis, immediately following the health crisis, and during the ongoing rehabilitation phase. The study found examples of good practice but problems surrounding the delivery of services were evident.

There was underuse of services for preventing health crises. In part this was due to individuals’ being slow to access care, or having difficulties in accessing care, following accidents such as a fall or when they felt unwell. In addition, health professionals, such as GPs and staff working in Accident and Emergency Departments, often failed to refer patients to preventative services. For example, frequent fallers were not always directed to falls-prevention services. At the time of a health crisis, there was underuse of services for preventing hospital admissions. This was due to a lack of knowledge about the existence and nature of care closer-to-home services among staff that provided immediate care for patients following a crisis. Finally, during the ongoing rehabilitation phase, communication difficulties between health and social care staff, particularly those working in different organizations and settings, led to a poor patient experience and delays in them gaining timely access to services for ongoing care.

Research elsewhere has generated similar findings. For example, studies by McLeod et al. (19) and Toscan et al. (20,21) have examined care for patients following hip fractures. Both found that communication problems between staff working in different settings led to a poor patient experience and delays in the delivery of care. Reports by the NHS Future Forum and Age UK have also stressed that efforts to improve the integration of health and social care services for older people are now needed as a means of improving patient experience and ensuring that they obtain timely access to appropriate care (22,23).