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 Yet in the UK, NHS beds have been closed and support for the resulting increased care home population withdrawn, shifting the responsibility of caring for this group from NHS geriatricians to…well that is the issue, to whom?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

Tron Sleek

Position
Care Home Web Designer,
Organisation
Prestwick Care
Comment date
02 November 2015
Great article for those involved with care homes www.prestwickcare.co.uk

Anthony

Organisation
http://www.sovahealthcare.co.uk/
Comment date
29 September 2015
I completely agree with what this article is saying there needs to be awareness for the need of care home's in the UK.

mike

Position
Care Home Furniture,
Organisation
http://www.cavendish-furniture.co.uk/
Comment date
15 August 2014
I think care homes get left behind in the healthcare debate and they should be right up there with the most important issues, its too often we see some horrific story in the news where someone has been abused by a carer.

James Smith

Position
Care Home Manager,
Organisation
North East Care Homes
Comment date
13 August 2014
Visiting care homes as part of the process of choosing who will care for you or a relative can be an overwhelming experience. With the worry of getting it wrong weighing heavily on your mind, it can seem almost impossible to think straight and such visits go by in a blur.

James Brown

Position
Care Home Assistant,
Comment date
13 August 2014
Visiting care homes as part of the process of choosing who will care for you or a relative can be an overwhelming experience. With the worry of getting it wrong weighing heavily on your mind, it can seem almost impossible to think straight and such visits go by in a blur. So i choose www.stainton.northeastcarehomes.com

Daniel Gill

Position
Care Home Assistant,
Organisation
Vestacare
Comment date
14 May 2014
Very good read, I agree with you completely.
I do believe that care homes are neglected to a certain extent but all I can say is, why?
It's a widely debated topic but with this current coalition government, there seems to be little focus on GP's and more on privatising the NHS which I think is absolutely absurd!
This is having a detrimental effect on care homes across the UK; some are not getting the correct amount of supplies or the right supplies for that matter whereas others are hiring staff that simply cannot be bothered to do the job and treat it as your run on the mill office job.

These are just a few of the reasons why i became a care home assistant for Vestacare, situated at Oakdene in North Manchester. I have always wanted to care for people as I did so with my late grandfather but I never thought I'd make a career out of it.

We post weekly on various topics including the treatment of residents in care homes, what medicine is being used and generally, health and well-being as a whole.

We'd love to hear some feedback as well :)

www.vestacare.co.uk

Take care!

lenin nightingale

Position
human being,
Organisation
life
Comment date
19 February 2014
Yes GPS intervention etc lacking in care homes. Recall no nurses in residential homes. My concern is poor care which may be related to attitudes and may go way beyond patient's bedside. Free updates on qualityofnursingcare.webs.com
Forever commenting- care homes and the private sector are neglected in debates. Who ultimately owns them-- is a massive issue.

senior

Comment date
06 February 2014
Glad to read your post...Thanks for sharing such a nice information, its beneficial for me.

Ken Holton

Position
Lead medical partner,
Organisation
Holbrooks Health Team
Comment date
06 November 2013
Our practice (11,000 population) has nearly 400 residents in care homes of which 180 are in nursing homes. For the care homes we cover, every resident is registered. It is fantastic for the care home staff, with vastly reduced emergency admissions and much improved medicines management, but the work load is unsustainable. I clip below an extract from a series of emails in which the partners indicated that they considered it unsafe to provide the necessary input without any support:
"I think the partners would drop it because it isn't safe, not because it is hard work. The practice can put in the work mainly because I have free time I can use for this, and put in about 22 additional hours a week, but when I go on leave the income isn't there to pay for a doctor to do what I do for free.

The 380 patients [manager] refers to take 37 hours of medical time a week. If all patients created work at that rate we would need 60 partners. It isn't possible to safely do the work with the medical time that can be purchased from the income generated.

Alan Beale

Position
Dementia Care Home Operator,
Organisation
South West Care Homes
Comment date
23 October 2013
Some interesting views and information in this blog. The idea that care homes become 'Houses of Care' and embrace a wider role is a really good suggestion. In my view a principle obstacle to this and reason for some of the other well made points has already been made, and is that we (as a society) do not seem to want to face up to the scale of the social care need. I often hear rhetoric but don't often see meaningful actions to address the real issues. Part of the problem is cost of course.

For example, as a provider of dementia residential care I, like most other similar providers, am sometimes told that we 'should have more staff'. We know we would provide a better environment and far more interaction with a higher staffing level. There is of course a great deal of research and various models of dementia care which indicate that particular ratios of staff to residents give much better outcomes.

People outside the care home sector do not always know that many Local Authorities now actually calculate their fees for care homes, based on various cost models (a by product of the Judicial Review 'wave'). It is instructive to look at these models. In Devon for example (I am part of the Dementia Kitemark initiative in Devon that George Coxon refers to above) The Council only allow for either 17 hours or 22 hours care per week for any resident of a residential care home (in theory an 'exceptional needs' additional staff time payment is available subject to negotiation, but in practise....). On typical shift patterns that would allow a daytime staffing ratio of about 1:7. Most of the models of good quality dementia care suggest a minimum ratio of 1:5 is needed. Because we have homes around the South West I know that many other Councils in the South West have a similar calculation (Somerset, Torbay, probably Plymouth (but their cost model is still 'under wraps'), Cornwall.

My point is that this is not a vague debate about whether fees are 'too low' (they are, but that's another point). The problem here is that it is demonstrably true that Councils simply do not even pay for the necessary amount of care time needed to provide good quality dementia care, regardless of any other discussion about fees.

That is a fundamental problem, and one we struggle with every day.

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