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REACH: Pre-hospital care for older people living with frailty - a mixed methods evaluation

Principal Investigator: Simon Conroy
LSE team: Andrew Street, Huixuan Gao
Start Date: 1 Janaury 2026
End Date: 30 June 2028
Funder: Barts Charity
Partners: Barts Health NHS Trust; Queen Mary University of London; University of Barcelona; London Ambulance Service; University of Cambridge
Region(s): Europe
Countries: United Kingdom
Keywords: Older people; frailty; urgent and emergency care; pre-hospital care; ambulance services; hospital at home; difference-in-differences; linked data; Normalisation Process Theory; health economics

Older people are the main users of urgent and emergency care in the NHS. Around two-thirds of older people assessed by an ambulance crew are taken to hospital. Many would prefer to be cared for at home, and hospital admission can lead to poor outcomes for older people living with frailty.

Since 2020, Barts Health NHS Trust has run the Remote Emergency Access Coordination Hub (REACH) in North East London. Through REACH, senior emergency physicians give real-time advice to London Ambulance Service paramedics attending older people. Together they consider clinical risk, discuss whether hospital admission is needed, and arrange safe alternatives such as rapid community follow-up and feedback to the patient’s GP. Service evaluations suggest that around two-thirds of older people discussed with REACH could have their needs met in the community. What remains unclear is what happens next: whether patients are admitted later, whether the scheme is cost-effective, and how acceptable it is to patients, families and community services.

This mixed methods study will evaluate REACH across three work packages.

Work package 1 will use qualitative methods to understand how REACH works in practice. Guided by Normalisation Process Theory, the team will:

  • interview emergency physicians, paramedics, community health and social care professionals, GPs, and older people and their families
  • review recordings of REACH calls and analyse local documents
  • develop five to seven in-depth patient case studies

Work package 2 will use London Ambulance Service data and national hospital records for people aged 65 and over, covering 2015 to 2025. LSE’s Andrew Street and Huixuan Gao and the University of Barcelona’s Laia Maynou will undertake this econometric analysis. They will use a difference-in-differences approach to compare outcomes in North East London boroughs with REACH against other parts of London without it. The primary outcome is the number of days spent in hospital in the three months after an ambulance call-out. Secondary outcomes include conveyance to hospital, repeat call-outs, emergency department attendance, admissions, length of stay, readmissions and deaths. A cost-effectiveness analysis will compare savings from reduced hospital use with the costs of running REACH.

Work package 3 will bring the findings together into a theory of change. This will be refined with patient and public involvement advisors and in a workshop with patients, carers, and ambulance, community, primary care and hospital clinicians.

Patient and public involvement is embedded throughout. A panel of older adult advisors, supported by the Academic Centre for Healthy Ageing, will work with the team, with a focus on reaching underserved communities.

Planned outputs include:

  • journal publications and conference presentations
  • business cases and implementation guides for North East London and other systems
  • patient case study videos and public-facing information leaflets
  • an updated system dynamics tool so other areas can model the impact of similar services

Earlier modelling suggests a service like REACH could free up around half a hospital ward per day in an area of one million people. This would ease pressure on emergency departments and allow more older people to be cared for safely at home.

Find out more on the Queen Mary, University of London website.