Why aren’t care homes higher on the agenda in the health debate?

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Much has been said in recent weeks about the role of the GP. The political mantra seems to be that GPs are not accessible and are not providing continuity of care, and that this causes unnecessary and unscheduled hospital admissions for some of the most vulnerable adults in our society – the elderly.

But why has there been little mention of the quality of services in care homes? This is despite the fact that 20 per cent of over 85 year olds in the UK are in permanent care home residence, and that reports by the Care Quality Commission consistently demonstrate lower quality of care in nursing and residential homes compared to hospitals.

With multiple co-morbidities and multiple medication use, patients in care homes are the most medically complex group of patients in the community. So much so that in the Netherlands, nursing home medicine has been a recognised specialty since 1990, distinct from general practice or traditional elderly care medicine. Yet in the UK, NHS beds have been closed and support for the resulting increased care home population withdrawn, shifting the responsibility of caring for this group from NHS geriatricians to…well that is the issue, to whom? Only 1 per cent of total UK consultant geriatrician time is contractually allocated to care homes, and the needs of residents go well beyond what is covered by the General Medical Services contract.

Nevertheless, GPs have been expected to fill the void, but less than 40 per cent have had specialist training in the care of older people. In a 2010 survey by Pulse, 68 per cent of GPs reported that care home work was a ‘major source of stress’, and 61 per cent felt existing arrangements were unsatisfactory. Formal support is also limited: only 14 per cent of elderly care departments hold regular forums where GPs can discuss more complex cases with hospital colleagues.

Given all of this, and with care homes neatly straddling the health and social care divide, it is perhaps no surprise that, according to figures from the British Geriatrics Society, nationally 68 per cent of care home residents have no regular medical review, 44 per cent have no regular review of medications and just 3 per cent have occupational therapy – a critical service to promote independence

More than 50 years after Peter Townsend concluded that UK care homes were a poorly resourced ‘Last Refuge’ which should be replaced by enhanced community support, it appears their basic remit is unchanged. They remain a place of last resort, and the 29-fold national variation in rates of transition (going from home, to hospital, to care home residence) reflects the ongoing disparity in access to the community services that would enable independent living.

So what is the way forward? The key seems to be recognising the need for dedicated, multidisciplinary teams to provide services within care homes. Creating a national policy to set out the standards required would be a crucial first step, and the forthcoming GP contract negotiations may prove to be both an opportunity and a barrier to this process.

GPs are increasingly using local enhanced services contracts, to enable them to establish committed care home services, in which they can conduct care home visits at the same time and on the same days each week.

Under this model, care becomes more pro-active, with residents having a comprehensive individualised assessment on arrival at the care home to identify issues and ease the distress of transition, with a scheduled review every six months. The regular GP contact ensures referrals are made to specialist NHS services as needed, and having a single team facilitates co-ordination of care. Carers are less inclined to call out-of-hours services for patients with acute problems, since they know a doctor will be attending at a set time. The result is a significant reduction in emergency department attendances, increased confidence amongst care staff and improved quality of life for patients.

The benefits are also financial - in the pilot study reported by Briggs and Bright, medication reviews combined with reduced admission rates saved £18,000 per care home, more than covering the £15,000 annual cost of the service.

There are many similar examples of good practice across the country, including North East London Foundation Trust’s dementia outreach programme that has reduced hospital bed use by 33 per cent, saving an estimated £400,000. The Royal College of General Practitioners has also established a ‘GP with a Special Interest’ training framework around elderly care and care homes, and the British Geriatric Society has already published advice on commissioning services for care homes. Our forthcoming conference will be exploring a range of examples of service re-designs in health and social care services that are successfully meeting the needs of an ageing population.

With all this in mind, care homes could become the ‘house of care’ for integrated ‘community medicine’ services that could involve the voluntary sector and encompass the vulnerable elderly living at home.

So much of our effort is spent trying to extend life that our ageing society should be a success story, a cause for celebration. Why then aren’t care homes firmly on the agenda in political debates on the NHS? It’s time we established them as a positive option, not the only one.

Comments

Jeanne Carlin

Position
Carer,
Comment date
09 October 2013
An article which reflect so many of my thoughts. Have had to put both my parents into residential care in the last few month - both have complex health needs. Your article reflects many of the questions that have been going through my mind - with some answers as well. Thanks for sharing your thoughts.

david oliver

Position
consultant physician/visiting fellow,
Organisation
Royal Berks/Kings Fund
Comment date
09 October 2013
Great Blog. And as the president elect of the BGS I am very pleased that you mentioned our various recent reports on better healthcare for care home residents. I am just wondering (for those reading the blog who are not GPs) if you could clarify for readers

1. If care home residents are on GPs's lists and they have a contractual obligation to provide care for all people on their list, why their should have to be a LES to incentivise them to do this?

2. What your view is on a model such as the Salford Royal Care Home Medical Practice where one group of GPs employed by the integrated FT delivers most of the primary care to care home residents? Likewise your view on community geriatricians as key providers of regular medical review

3. Because care home residents also benefit from Physio/Rehab/Speech Therapy/Pharmacy/Dietetics etc how you feel about dedicated, integrated teams commissioned to deliver this

David Oliver

Adam Gordon

Position
Consultant Geriatrician,
Organisation
Nottingham University Hospitals NHS Trust
Comment date
09 October 2013
Duncan, thanks. This echoes many of the sentiments in my own entry on the British Geriatrics Society blog last week. It is important to realise that some of the difficulties faced in providing quality care to care homes are not the fault of the care home sector, but the NHS.

Given the diversity of care homes, care home residents and CCGs around the country it is possible that there will be no "one size fits all" response to care homes but, rather, common philosophies or active ingredients in care models that ensure that the needs of residents are met. Important aspects of any service will be access to expertise in long-term conditions, multimorbidity and functional dependency; comprehensive multidisciplinary models of assessment; and care management so that plans are iterated forward appropriately.

I think the commissioning guidance that we've issued through the British Geriatrics Society reflects this.

My entry on the BGS blog can be found at: http://britishgeriatricssociety.wordpress.com/2013/10/04/healthcare-for-uk-care-home-residents-is-broken-how-should-we-go-about-fixing-it/

Jeanne Carlin

Position
Carer,
Comment date
09 October 2013
I read the comments from David and your reply with interest. As a lay person I would like to add my thoughts. One of the main reasons for choosing the care home I choose for my parents was that it is in the same area in which they lived which meant they could remain with the same GP. For my mother in particular she did not want to consider other options which meant moving out of her area and changing GP's was top of her list in terms of what she did not want.

I think many older people go into care following a hospital admission or because they partner becomes ill or dies. Following that scenario continuity of care is vital.

Once in care my parents have been reliant on their GP to manage and co-ordinate their health care and ensure that referrals are made to other health professionals. A multi-agency team working within the care home sounds wonderful and as a non-professional I think would save a lot of time and resources and provide a more focussed service.

james

Position
GP,
Organisation
NHS
Comment date
10 October 2013
As a GP who has been involved with care in nursing homes for seven years I recognise the themes in Duncan's blog. We hold a contract with Care UK to provide "augmented" GP input. We were given the contract because no other GP practice in the area wanted to register patients who were moving into the care home.
Since then we have organised input from a Geriatrician, hospital based pharmacy teams, the local palliative care team and some voluntary sector organisations. These initiatives have come from us (the GPs) or from the local hospital. The private organisation which holds the contract with the Council (a 25 year contract which stipulates that they must have one qualified nurse in the building - 100 beds of elderly frail,dementia and palliation - at all times......just one) has no contractual obligation to raise standards above the minimum required by the contract they signed.
Thus my recommendation is a review of these contracts and a move towards joint commissioning between elderly care departments and GP services with the council being obliged to take the view of local providers into account when handing out these contracts

AL

Position
Gp,
Comment date
10 October 2013
I am a GP in an urban practice. 3y ago I was visiting patients in more than 10 practice. Frustrated and confused.
My five partners each agreed to take only one care home from where we would register new patients. Now I have 30/70 in one care home. I known all the managers, nurses, senior carers and many of the other staff. The staff can ring me, email me and we have agreement about ways of working. I know all my residents and believe care is better. We definitely have a better grip on admission, DNAR, EoL care and relations with families.
I have not removed a single resident from other care homes and will honour commitments to my other patients if they go into another care home. I just won't take an new patient (no capacity & lots of other GPS /practices).
Much better. We did this unilaterally as a practice. We could wait forever for a local agreement which in my opinion would be a flawed compromise.
Do it if you can.

John Adams

Position
Social Care Professional,
Organisation
VODG http://www.vodg.org.uk/
Comment date
10 October 2013
This is an extremely helpful/thoughtful blog - thanks.

I regularly visit care and nursing homes for the elderly (often expensive private equity owned businesses) and was in one such establishment just yesterday. Among some of the lovely people I met were a former GP, a retired Psychiatrist, a High Court Judge, a husband, a wife, a mother and father and an author. As well as lots of other interesting people. But sadly I'm constantly struck by the thought that these formerly 'significant' people are now almost completely 'insignificant.' they are out of sight and all too often out of mind. They seem to me rather like 'shipwrecks- well and truly on the rocks. But being 'conveniently' warehoused until death comes. All in all it's a pretty rotten end to look forward to. Surely a big part of this problem is our attitude to old age and elderly people?

Mick Smith

Position
Partner Governor,
Organisation
West Suffolk NHSFT
Comment date
10 October 2013
It seems to me that the contracts issued to run care for our elderly are a problem. If they stipulate adequately high standards of care the care homes will push their prices up through the roof I think and there is the problem.
Considering the low wages and poor conditions the staff in care homes get I am amazed that they can keep any staff at all. I take my hat off to those that stay and do that work.
I have no answer to this problem other than to say that I would be prepared to pay more in taxes if that provided us all with a good high quality elderly care service. That is me and I doubt I am in the majority.

george coxon

Position
care home owner and ex MH nurse and commissioner,
Organisation
various in Devon and beyond
Comment date
10 October 2013
A really excellent blog and one that triggers a combination of thoughts and views on this issue and question - I own care homes and am leading an exciting programme with a growing coalition of independent care providers (care home and nursing home owners and managers) developing and rolling out a QUALITY KITE MARK for dementia. I am also a continuing advocate for KPOOH and GPOOH - keeping and getting people out of hospital (particularly those with dementia) after many years as a senior clinical manager in mental health and then a senior commissioner at PCT level across all health care spectrums. Our work has developed a real momentum - we are at a point now where real cross over health and social care engagement has the real potential to enable more people to live well in positive, safe and fun care home environments with kind and committed staff. Our kite mark strap line is 'we are on a journey - we're not there yet' with a recognition that care homes are often seen as a place of last resort for the frail elderly or those with progressing impairment but we all are striving to be better - pretty much all the time amidst huge economic and system pressures

This blog gives a voice and a call to action for greater shared learning and openness such as the peer review system at the heart of what makes our work unique and credible in levelling up skills, knowledge and confidence in care home teams. More important still is the impact we have on the lives of those receiving much needed 24/7 care

Great hyperlinks and references too big thanks Duncan

Andrew WALL

Position
retired NHS CEO,
Organisation
ex Bath HA
Comment date
11 October 2013
Recently a friend spent his last few weeks in a newly built Home allegedly catering for nursing as well as social admissions.
The nursing care was inadequate: I had to suggest that my friend's mouth needed regular care and a sucker would be useful but the RGN didn't seem to know where the sucker was. Another aspect was the room itself with the bed against the wall making safe and comfortable lifting impossible. Who I wondered approved the plans that made it impossible to get both sides of the bed?
I did talk to the Manager who was a nurse and she took the observations with a good grace but said my friend had been really too difficult for them.

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