A&E and the over 90s: digging deeper than the headlines

Nuffield Trust Senior Research Analyst Ian Blunt explores emergency hospital admissions for the over-90s.

Blog post

Published: 30/01/2014

It is a well-established fact that people tend to need more and more support from health and social care services as they get older. For that reason, the NHS is particularly focused on meeting the needs of older people, and concerned about the impact the increasing number of older people in our society will have.

It also means that if the quality of care services deteriorates – as many suspect it might during this period of austerity – it will be older people who bear the brunt of those changes.

Many studies have shown how demand for urgent and emergency care in the NHS has been rising – and much of the current health policies are seeking ways to reverse this long term trend. Our analysis of trends in emergency admissions showed the difficulty of pinning this trend down to any one explanation. There are many different changes in the population and the services available that are contributing to this – and one of the key indicators is in care for older people.

So for example our QualityWatch programme includes a study of potential preventable admissions which showed they disproportionately affect older people and are linked with certain health problems.

We also looked at one of the most serious conditions affecting many older people – a hip fracture – and showed that though the prevalence of hip fractures had stayed constant over time, and mortality rates improved, the rate of readmissions following hip fracture had risen – an indication that there is something different about the way the health and care systems react to health crises.

The case for a change in quality is not clear cut, but it is definitely an area where we must continue to apply independent scrutiny.

In light of these sorts of findings it’s probably not surprising to read stories today suggesting that the number of people aged over 90 being taken to A&E by ambulance has risen by 81% in the last four years. There have been some quick responses from commentators: it’s related to cuts in social care budget; it’s related to the GP contract; it’s the lack of community care. We can still infer changes in the way people receive care by comparing patterns between years

These may all be valid arguments, but if it is important to measure the quality of services people receive it is just as important to properly scrutinise the data themselves. In fact, there are a couple of possible problems with the way these data have been presented that may not be immediately obvious to the uninitiated:

  1. The numbers being reported, drawn from the Health and Social Care Information Centre (HSCIC) summaries of A&E attendances, say that 165,910 people over 90 arrived in A&E by ambulance in 2009/10. This number rose to 300,370 in 2012/13 – an increase of 81%.

    However, this increase is partly due to a change in the way the data are reported (the new data include people aged 90 as well as those aged over 90). When we go back to the raw data, we can see that the number for people aged over 90 in 2012/13 was 237,318 – reducing the rise to just 43%.

  2. The recording of person-level activity in A&E suffers from being a relatively new data set – the earlier years of this dataset (like 2009/10) did not record all of the A&E attendances that actually happened. That means whenever we compare raw numbers in 2012 to those from 2009 we are likely to see a large increase.

Does this mean the data are useless? Not at all. We can still infer changes in the way people receive care by comparing patterns between years. For example between 2011/12 and 2012/13 (years with much more complete data), the number of people aged over 90 attending by ambulance increased by 11% (which is more than the 3% increase for all other ages).

But we also have more people over 90 in the population – if you adjust for this the between those two years, the actual increase is 5% – but still a lot of older people.

So, is there a growing problem in care for older people? Possibly – we certainly need to keep watching. And the various arguments put forward as to the cause are all worth investigating. However, when presented with data which seem to tell one story, it’s usually wise for all sides of the debate to dig deeper into that data before drawing firm conclusions.