Age and Ageing Advance Access originally published online on October 1, 2008
Age and Ageing 2008 37(6):613-615; doi:10.1093/ageing/afn206
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The geriatric day hospital: past, present and future
The day hospital concept was initially developed for psychiatric services and was modified in the 1950s in the UK as a key service for the emerging speciality for geriatric medicine [1]. At a time when hospital geriatric medicine was embryonic, and community services sparse, the geriatric day hospital (GDH) fulfilled an obvious need. It became a hugely successful service model for older people and was referred to by Arie as ‘one of psychiatry's gifts to medicine’ [2]. The GDH became a display case for the big new idea of multi-disciplinary team working, and departmental open days were held to promote day hospitals and their work. They were championed by health care planners who produced national GDH targets in relation to a key objective of ‘saving hospital beds’ [3]. There was inspirational language: (the GDH) ‘as a window through which the staff of the whole geriatric department can see the fruits of their labours as their elderly patients are resettled and maintained in the community’ [4]. In 1991/92, a national survey provided an estimate of over 400 day hospitals in the UK [5]. However, just over a decade later the major UK policy report on community health services contained not a single reference to the GDH [6]. What caused this apparent collapse in the identity of a core service for older people?First, the GDH was always more contentious than generally acknowledged by its protagonists. There was a long-standing, smouldering debate around the extent to which the GDH emphasis should be on short-term rehabilitation (where the objective was rapid restoration of independence), or longer term maintenance rehabilitation (where the objective was prevention of deterioration) [7]. The former required a fast through-put style of GDH care; the later, a slow track approach. Secondly, a report by the National Audit Office underscored a widely held view that the GDH was an expensive service [8]. It became increasingly apparent that the GDH was associated with a high opportunity cost as, if closed, it could largely secure the funding for an acute elderly care assessment ward. This made the GDH an attractive ‘cost improvement programme’ for the newer generation of more acutely orientated geriatricians. Thirdly, competition emerged in the shape of other community rehabilitation services; the GDH was no longer a monopoly provider. Lastly, high-quality evaluation studies gradually accrued which, simplistically, appeared to offer little support for GDH effectiveness.
The randomised controlled trial (RCT) evidence was eventually summarised in a systematic review [9]. The findings were complex with a mixture of both supportive evidence and uncertainties. The current Cochrane review of the GDH incorporates 12 RCTs involving 22 day hospitals and over 2,500 subjects. Three trials have compared GDH care with a non-active treatment control group, and the pooled results for observations over a median follow-up of 12 months demonstrate less functional deterioration and less use of institutional care in favour of day hospital attendance. Thus, the GDH can enhance outcomes compared to the ‘do nothing’ option. When GDH care was compared with comprehensive geriatric assessment (i.e. integrated inpatient, outpatient and domiciliary services) as an active control group (5 RCTs), the pooled outcomes were largely similar. One interpretation of these pooled results is that the clinical effectiveness of the GDH is comparable to comprehensive elderly care for which there is a considerable independent body of evidence of effectiveness [10].
A third group of trials has compared GDH care with home-based rehabilitation: the main competitor service for the GDH [9, 11]. Here, considerable statistical uncertainty exists with the possibility of clinically inferior, or superior, clinical outcomes for GDH care being equally plausible. Clearly, more evidence is required and therefore the new research published by Crotty et al. in this edition of Age and Ageing is important [12].
In a well-designed and well-conducted study, Crotty et al., randomised 229 patients with mixed conditions to a hospital-based day rehabilitation centre (DH) or a home rehabilitation programme (HR), following hospital admission. Outcomes included instrumental activities of daily living, use of inpatient care and need for institutional care over 6 months of follow-up. Both treatment programmes were multi-disciplinary, intensive and appeared well resourced (DH: 3–5 attendances per week over 4–6 weeks; HR: 3–5 sessions per week). The trial was pragmatic and the rehabilitation programmes were customised to individual patients according to the assessments made by the treating rehabilitation teams. This resulted in a considerably longer duration of rehabilitation for the DH group (DH: median 78 days; HR: median 28 days), and considerably more treatment sessions (DH: 68; HR: 24). Despite the lighter rehabilitation touch of the HR programme, both groups made similar and statistically significant improvements between baseline and 3 months such that the between-group comparisons for functional independence were similar. However, the patients in the DH group were over twice as likely to be readmitted to hospital (odds ratio for relative risk of readmission = 2.1). It was postulated that the lower threshold for hospital admission in the DH group was a consequence of the co-location of the day hospital and general hospital leading to a more medically dominant model of care. Although no cost information was collected in this study, the longer period of rehabilitation, and the greater use of hospital bed days, implies greater expense. This would be consistent with the Cochrane review in which 9 of the 12 included trails had included a comparison of treatment costs and six studies reported that GDH attendance was more expensive than the comparison treatment [9].
What might be the future for GDH care? The attraction of an outpatient-based multi-disciplinary team focussing on the needs of frail older people remains compelling. Most of the trial evidence for GDH care has evaluated a traditional day hospital service model. Anecdotally, many contemporary, day hospitals offer a more flexible, locality-based service approach characterised by therapy outreach, brief assessments, specialist clinics such as falls assessment and Parkinson's disease management, and its potential for admission avoidance has been highlighted [13]. A key current UK policy initiative for primary and community care is that of the locality-based polyclinic [14]. Perhaps the best service response for frail older people in respect of the polyclinic should be a flexible, patient responsive GDH providing multi-disciplinary assessment and rehabilitation. In this way the GDH could still have a secure future in the modern UK health service.
Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Temple Bank House, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ, UK
* To whom correspondence should be addressed Email: A.Forster{at}leeds.ac.uk
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- HMSO. (1994) Report by the Comptroller and Auditor General. National Health Service Day Hospitals for Elderly People in England. National Audit Office.
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[Abstract/Free Full Text] - Crotty M, Giles LC, Halbert J, Harding J, Miller M. Home versus day rehabilitation: a randomised controlled trial. Age Ageing (2008) 37:628–34.
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[Abstract/Free Full Text] - High quality care for all: NHS next stage review final report (Darzi Report). (2008) Department of Health, June.
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  S. A. Khan The geriatric day hospital: past, present and future Age Ageing, May 1, 2009; 38(3): 354 - 355. [Full Text] [PDF]
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