1 Section 7 Secondary Care Secondary care comprises the health care services provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, psychiatrists, cardiologists, geriatricians, urologists and dermatologists. Secondary care includes acute care, i.e. treatment for a short period of time for a brief but serious illness, injury or other health condition, such as in a hospital Accident and Emergency Department. It also includes skilled clinical input during childbirth, intensive care, and medical imaging services. The term "secondary care" is sometimes used to mean "hospital care". However, many secondary care providers do not necessarily work in hospitals, e.g. psychiatrists, clinical psychologists, occupational therapists or physiotherapists, and some primary care services are delivered within hospitals. Except for most acute cases, patients in the UK are generally required to see a primary care provider for a referral before they can access secondary care. Secondary Care in Bradford and Airedale Bradford and Airedale is covered by a number of hospitals and secondary care services. From the perspective of hospital admission, it is largely the ‘acute’ hospitals (i.e. the general hospitals) that concern us in respect of the issues outlined above, although many of them can apply to patients who are admitted to a specialist mental health facility. In short, if a person with dementia becomes unwell, in any number of ways, such as heart problems, falls, respiratory illness, urinary tract infection etc., an admission, if deemed necessary, would be to an acute/general hospital such as Bradford Royal Infirmary. Admissions to specialist mental health facilities are often on a slightly different basis, usually crisis admissions based on specific mental health need as opposed to acute physical health need. There are two major acute hospitals in the Bradford area: Bradford Royal Infirmary and St Luke's Hospital. Both are teaching hospitals and are operated by Bradford Teaching Hospitals NHS Foundation Trust (BTHNFT). The Airedale part of the district is served by Airedale General Hospital, part of Airedale NHS Foundation Trust (ANFT). From a Mental Health perspective the key provider is Bradford District Care Trust which is a provider of mental health, community health and specialist learning disability services. In patient services are delivered across two main sites:
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Section 7 -‐ Secondary Care
Secondary care comprises the health care services provided by medical specialists and other
health professionals who generally do not have first contact with patients, for example,
psychiatrists, cardiologists, geriatricians, urologists and dermatologists.
Secondary care includes acute care, i.e. treatment for a short period of time for a brief but
serious illness, injury or other health condition, such as in a hospital Accident and Emergency
Department. It also includes skilled clinical input during childbirth, intensive care, and
medical imaging services.
The term "secondary care" is sometimes used to mean "hospital care". However, many
secondary care providers do not necessarily work in hospitals, e.g. psychiatrists, clinical
psychologists, occupational therapists or physiotherapists, and some primary care services
are delivered within hospitals. Except for most acute cases, patients in the UK are generally
required to see a primary care provider for a referral before they can access secondary care.
Secondary Care in Bradford and Airedale
Bradford and Airedale is covered by a number of hospitals and secondary care services.
From the perspective of hospital admission, it is largely the ‘acute’ hospitals (i.e. the general
hospitals) that concern us in respect of the issues outlined above, although many of them
can apply to patients who are admitted to a specialist mental health facility. In short, if a
person with dementia becomes unwell, in any number of ways, such as heart problems,
falls, respiratory illness, urinary tract infection etc., an admission, if deemed necessary,
would be to an acute/general hospital such as Bradford Royal Infirmary. Admissions to
specialist mental health facilities are often on a slightly different basis, usually crisis
admissions based on specific mental health need as opposed to acute physical health need.
There are two major acute hospitals in the Bradford area: Bradford Royal Infirmary and St
Luke's Hospital. Both are teaching hospitals and are operated by Bradford Teaching Hospitals
NHS Foundation Trust (BTHNFT). The Airedale part of the district is served by Airedale
General Hospital, part of Airedale NHS Foundation Trust (ANFT).
From a Mental Health perspective the key provider is Bradford District Care Trust which is a
provider of mental health, community health and specialist learning disability services. In-‐
patient services are delivered across two main sites:
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• Airedale Centre for Mental Health, situated on the Airedale Hospital site
• Lynfield Mount Hospital, situated on Heights Lane in Central Bradford, close to
Bradford Royal Infirmary
In the community BDCT provides a number of Adult Services which include District Nurses,
Out of Hours, Case Managers, Community Matrons.
Figure 1 below sets out the geographical location of these services across the district.
Figure 1 Distribution of Mental Health Secondary Care Providers
A = Daisy Bank, BD96RL B = Bradford Royal Infirmary, BD96RJ C = St Luke’s Hospital, BD50NA D = Lynfield Mount, BD96DP E = Airedale Hospital, BD206TD F = Airedale Centre for Mental Health, BD206PD
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Dementia and Admission to Hospital
Dementia is a challenge for hospitals. Surveys and consensus agree that around a quarter of
hospital beds are occupied by somebody with dementia, a figure which increases in older
people and individuals with a superimposed delirium (1). Currently around 40% of patients
over the age of 75 who are admitted to general hospitals have dementia, with only half
having prior diagnosis (2).
People with dementia may be repeatedly admitted to hospital because they are not
otherwise in touch with any statutory services, and their dementia means they are neither
aware of their disability nor able to ask for assistance (3).
Many admissions happen when people with dementia are unwell – but not acutely ill
enough to need the specialist care provided in acute hospitals – this can be because it is
difficult to diagnose and manage their care within A&E target times without any prior
knowledge of the person (3).
Being an inpatient in a general hospital can be detrimental to the well-‐being of a person with
dementia. It is often the case that the presence of a dementia prolongs the length of stay.
This may be because treatment can take longer, partially due to lack of staff expertise in
caring for the person with dementia (3). In addition, the presence of frailty (see Section 9 –
Comorbidities and Frailty) can complicate these admissions, as can the presence of delirium,
where the patient is acutely confused, for example as the result of infection.
Patients with dementia in acute hospitals are older, require more hours of nursing care,
have longer hospital stays, and are more at risk of delayed discharge and functional decline
during admission (4).
Inpatients with dementia are at an increased risk of crisis owing to physical health-‐related
factors, including orthopedic, respiratory, and urologic, than inpatients who do not have
dementia (5). Again, this is frequently complicated by delirium.
People with dementia in general hospitals have worse outcomes in terms of length of stay,
mortality and institutionalisation (6)
There are many factors contributing to any older person’s admission to hospital. The drivers
of variation are complex, and their relative strength varies. They include (7):
o Patient attributes
o Availability of community services
o Access to hospital services
o The way in which hospital services are managed
o Most importantly -‐ the way in which services and staff relate to each other.
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Analysis confirms other evidence that age, deprivation and geographical access are also
major drivers of emergency bed use.
Figure 2 below, taken from a large American study, demonstrates the effect of dementia on
hospital admission graphically. The vertical red line indicates where there is no increase
effect, with blue marks to the right indicating an increased risk of admission. Where the
horizontal lines passing through the blue boxes cross the red line the effect was not
statistically significant. It is clear to see the stark effect of dementia on risk of admission to
hospital in community residents, with all subgroups showing a marked, statistically
significant effect. Although a smaller effect is seen in nursing home residents, none were
statistically significant (8).
Figure 2 Effects Of Dementia On Hospitalization And Emergency Department Use
Source: Feng, Health Affairs April 2014
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Hospital Admissions for Dementia Patients in Bradford and Airedale
Admissions by CCG
Table 1 and Figure 3 below show the numbers of patients with dementia who are admitted
to hospital every year (primary and secondary diagnoses) from 2009 to 2013, broken down
by the CCG with which they are registered. Bradford Districts CCG shows a slight rise from
2009 to 2012 but then a downward tail off in 2013. AWCCG shows a notable rise between
2011 and 2012 which levels off as it reaches 2013. The apparent year on year increase in the
proportion of patients from Craven within AWCCCG has the appearance of statistical
artefact and is likely due to changes in coding practice. Bradford City CCG slows a steady
yearly number which is significantly lower than the other two CCGs. The overall picture
across the District is of a rising trend up to 2012 which tails off into 2013. Clearly the most
important characteristics of these figures are the rising numbers observed in BDCCG and
AWCCG, although the tail off in 2013 is encouraging.
Table 1 Patients with Dementia admitted to Hospital, by CCG, 2009-‐2013
CCG 31/03/2009 31/03/2010 31/03/2011 31/03/2012 31/03/2013 Grand Total
AWCCCG 385 412 512 840 908 3057
AWCCG 382 395 491 570 600 2438
BCCCG 304 288 299 307 302 1500
BDCCG 1523 1686 1722 1930 1868 8729
Grand Total 2212 2386 2533 3077 3078 13286
YEAR
Figure 3 Patients with Dementia admitted to Hospital, by CCG, 2009-‐2013
0
500
1000
1500
2000
2500
3000
3500
2009 2010 2011 2012 2013
Adm
issi
ons
Year
AWCCCG
AWCCG
BCCCG
BDCCG
Grand Total
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Admissions by Hospital Trust
Table 2 and Figure 4 below show the numbers of patients with dementia who are admitted
to hospital every year (primary and secondary diagnoses) from 2009 to 2013, broken down
by the hospital to which they are admitted. Both acute trusts show a general upward trend,
although again there is a clear tailing off over 2012-‐2013, particularly at BTHFT, this being
reflected in the total figures for the district. The numbers admitted to BDCT remain steady
and low, which is to be expected given the nature of these admissions as explained above.
Table 2 Patients with Dementia admitted to Hospital, by Trust, 2009-‐2013
2009 2010 2011 2012 2013 TOTAL
ANFT 439 475 595 890 968 3367
BDCT 43 70 37 79 86 315
BTHFT 1730 1842 1901 2106 2026 9605
Total 2212 2387 2533 3075 3080 13287
Figure 4 Patients with Dementia admitted to Hospital, by Trust, 2009-‐2013
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500
1000
1500
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3000
3500
2009 2010 2011 2012 2013
Year
Admissions
ANFT
BDCT
BTHFT
Total
Admissions by Gender
The general larger prevalence of dementia in females (see Section 2 – Epidemiology) would
lead us to expect larger numbers of admissions in females and this is reflected in table 3 and
figure 5 below, which show the numbers of patients with dementia who are admitted to
hospital every year from 2009 to 2013, broken down by gender. There is no discernible
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difference in pattern of change in numbers over the time period, suggesting that there is no
gender effect influencing admissions.
Table 3 Patients with Dementia admitted to Hospital, by Gender, 2009-‐2013
2009 2010 2011 2012 2013 TOTAL
Male 825 913 981 1203 1233 5155
Female 1387 1474 1552 1872 1847 8132
Total 2212 2387 2533 3075 3080 13287
Figure 5 Patients with Dementia admitted to Hospital, by Trust, 2009-‐2013
0
500
1000
1500
2000
2500
3000
3500
2009 2010 2011 2012 2013
Adm
issi
ons
Year
Male
Female
Total
Admissions by Ethnicity
Section 3 – Ethnicity, outlines several factors which can lead to people from BME groups
having poor access to services and tending to present less and in crisis. These factors might
be expected to lead to both underrepresentation in hospital admission figures (e.g. due to
lack of knowledge of available services) or to overrepresentation due to increasing likelihood
of presenting in crisis.
Table 4 and figure 6 below set out a breakdown of hospital admissions (primary and
secondary diagnoses) for the hospital trusts, by ethnicity. South Asian groups are appended
at the bottom of table 4 for comparison (note -‐ Bangladeshi and any other Asian have been
merged as numbers are very small when disaggregated).
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Three are three major groups observed:
• British – this group shows a steady rise with a slight tail off at 2013
• Pakistani – this group shows a steady rise sustained through to 2013
• Any Other White Background – this group shows a gradual rise through the five
years, potentially due to rising of numbers of people from Central and Eastern
