Overcoming the challenges to improve health and wellbeing in care homes

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Currently there are more than 400,000 people living in care homes in the United Kingdom. That’s around three times the number of hospital beds. The umbrella term ‘care homes’ covers a very diverse range of places, including those classified as nursing or residential, whether specially designed and staffed for people with dementia, mental health needs or complex physical or learning disabilities.

Although these facilities are sometimes used for temporary respite, rehabilitation or end-of-life care, the term ‘homes’ is crucial. They are places where people live. And although average length of stay in a nursing home is only 15 months, it’s important to make what is often a person’s last home as comfortable as possible. It’s increasingly rare for anyone to enter a care home now without very high levels of frailty, complex health care needs, dementia or disability. The fact that the number of care home places has reduced even during a period of rapid population ageing and significant reduction in hospital bed capacity shows the pressure that care providers must be under.

Of course, there is always more we could do to keep people in their own homes for longer and avoid or postpone the need for residential or nursing home care. This includes a greater focus on prevention, an adequately staffed and funded primary care workforce able to work in different ways, more emphasis on age-friendly housing and support for carers, better integrated health and care systems, use of technology, and support for end-of-life care. More capacity in intermediate care rehabilitation and in home-based social care support for older people and their carers could reduce care home use.

But as we have highlighted in recent reports on social care and district nursing services, there are major gaps in all those areas which means for the foreseeable future there is unlikely to be a reduction in need for care homes. The growing focus on this group of citizens and the staff and services who support them – not just by The King’s Fund but many other organisations too – is timely and overdue. Our second conference devoted to improving care for people in residential and nursing homes will take place in December, bringing together experts in the field to showcase innovative practice and discuss the challenges.

As we highlighted in our recent report, the social care funding crisis is exacerbating the pressures on all parts of the health and care system. Care homes are struggling to maintain a viable business model, to recruit and retain a workforce; often competing with the local NHS. Post-Brexit there is uncertainty around the status of thousands of EU workers in the care sector. There are also growing concerns about over-reliance on self-funding residents, whose financial contribution cannot be matched by constrained local authority social care budgets. NHS continuing care funding decisions are also increasingly contested.

We also need new solutions to meet the complex health needs of residents, including people living with frailty and those who are towards the end of their lives. General practitioners have expressed major reservations about their ability to continue with the current levels of provision for care home residents, given their own workforce and funding crises. In particular, too many care home residents are admitted to hospital acutely – often close to the end of life, and then staying too long or worsening during hospitalisation. Integrated approaches are now being implemented and evaluated as a potential solution, not only in the vanguards but also in many other health economies. These include Walsall Clinical Commissioning Group and Ashford and St Peter’s Hospitals NHS Foundation Trust, both of which will be presenting their transformative programmes at the conference.

Most of all, care home residents have some of the highest needs for both health and personal care in our society. Their carers are often older people and can be considerably distressed – and sometimes also relieved – by their loved one’s move into care. How we look after residents and their families is a barometer for care and compassion in society as a whole, and for our attempts to make services more integrated, co-ordinated and person-centred.

To make these aims a reality we need practical solutions, deliverable even within our current pressurised health and care system. But when we think about solutions we must focus on the residents whose health and wellbeing we are trying to improve. We should never lose sight of that in the face of our focus on systems, processes, money and targets.

Comments

Dr Shibley Rahman

Position
Academic physician,
Comment date
22 October 2016
I found this brief piece very helpful in raising important issues concerning enhancing health and wellbeing in dementia.

Thank you.

It’s often forgotten that wellbeing needs physical and mental health (though wellbeing is not simply the absence of illbeing). A right to health is a fundamental international human right. And ’dementia rarely travels alone’, meaning in part that a person living with a dementia is likely to live with a number of other conditions, and be subject to complex polypharmacy.

It should be a matter of pride for someone to be moving into a new home, which happens to be a care home, not a source of personal embarrasssment. This piece, however, sets out correctly the strain on the care home sector, which is of course working with the backdrop of a NHS working at full throttle already.

Countless policy developments have of course signposted a wish to promote independent living at home, and realism dictates that we’re a long way from more people living at home having been socially prescribed a pet, robot or other assistive technologies, or even a home for ambient-assisted living. There are, notwithstanding, important developments elsewhere in hospital at home and nursing home at home. There has been a long held wish for some time to move towards better integrated health and care systems, but implementation of the infrastructure needed for this (e.g. technical interoperability) could be much faster. It’s likely that integration will cost more in the short term initially, which, given the current much publicised ‘financial gap’, could be a major barrier to progress.

This piece above is indeed useful to set in context of not only pressures on the acute care system, but also social care, district nursing and general practice. This piece frames accurately, in my opinion, the need to improve care in residential and nursing homes, but there is no doubt for me that this is a complicated debate. There is a huge amount to learn across different parts of the system, for example in learning from the hospice movement in end of life care, but there is still the reasonable aspiration that people will have their health needs met in the right place in the right way in the right time. The reality of delayed transfers of care, a care sector under considerable financial distress, and the impact of Brexit are factors, however, which you can’t though escape from - and ones which David Oliver is absolutely correct to mention.

All the integrated approaches, not only in the “vanguards” but also in other health economies, do interest me. At an organisational level, I am hoping that there are reliable ‘things that work’ to be learned. The problem with "letting a thousand flowers" bloom is that a few of them, by the law of probabilities, will be wilting fast. But also, likewise, I can think of good number of examples of good practice, including shared electronic care records, case management, effective advance care planning, pooled budgets, rapid access to professional help, which I think have worked quite well?

Care homes, I strongly feel, are at the heart of a community of the integrated, co-ordinated, person-centred care approach. I feel that, whilst they have the potential to be exemplary self-standing communities (communities of real people as well as communities of practice), they’re fundamentally dependent on other parts of the health and social care system to succeed.

I look forward to the frank discussion about this which is about to happen.

George Coxon

Position
Various inc care home owner & Devon carekitemark lead,
Organisation
Various
Comment date
22 October 2016
I am tremendously heartened by both David Oliver's piece and Shibley Rahman's supporting words. As a enthusiastic yet frustrated care home owner I always read such pieces with bated breathe waiting for the direct or implied criticism or blame placed on care homes for the current struggle affecting so many providers. On this occasion, and in fairness in what David always says and writes, we see a fair appraisal of how things are. We say of our own care homes and those that are part of our provider led likeminded movement 'looking forward to 24/7 care in the kind of care home you can have a good life in is something we should all be able to look forward to when the time is right'. So not too late or in a negative crisis or unplanned agonised way. The word pride was mentioned by Dr Rahman for me that's one of the essential elements of what we are about and what most care & nursing homes are determined to instil in their ethos and culture. It's the case of our Devon Care Kite Mark as much as the state of care re care homes. 'It's a journey and we're not there yet' however but we're working hard with positive attitudes and energy in difficult conditions (the perfect storm as they say re workforce, complexity/ frailty increases, expectations, inspection rigour, funding pressures etc) but are very reliant upon a shared care approach with partners including families, primary care, secondary care, specialist services like mental health as well as hospice experts and you know what. We've got a pretty decent record down here in sunny Devon. I'm involved in the 6th December 'enhancing health in care homes' event so will share more then. Also we've put 3rd annual Christmas Care Kite Mark Jamboree on the 8th in Exeter so we are promoting living well, having fun and being proud living and working in care homes Thanks for a great blog.

Dr Shibley Rahman

Position
Academic physician,
Comment date
22 October 2016
@George

Great comment.

Your enthusiasm and dedication shine through absolutely. I wish you continued success in your outstanding work.

Peter Rogers

Position
Nursing Lecturer,
Organisation
University of Bradford
Comment date
24 October 2016
With the exception of the risk to the care home workforce posed by the Brexit vote, there really isn’t very much in this piece that couldn’t and indeed wasn’t said after the publication of the Dilnot report 5 years ago; it is nonetheless a useful summary of the current situation albeit one that glosses over one or two of the less palatable aspects of the current aged care system.

GPs may well have reservations about their ability to provided adequate services for the frail elderly but why single out those living in a nursing or residential care homes? Every care home resident has as much right to NHS services as those living at home or occupying an acute hospital bed, however the current levels of service provided to this group by GPs is rather like the Curate’s egg. As a consequence some care home operators feel the need to pay GP practices annual retainers to ensure their residents get the services to which they are entitled by right.

As for the ‘growing concerns about over-reliance on self-funding residents’ who’s concerns are being referred to? Most care home operators are eager to take more self-funding residents and reduce their exposure to local authority and NHS commissioners who think it’s OK to demand a nursing care bed for a frail elderly person with complex needs for less than the price of B&B in a Manchester Premier Inn.

Perhaps it is the NHS and local authority commissioners who are concerned, not so much with the ethics of self-paying residents cross subsidising those who are publicly funded (they have after all turned a blind eye to that issue for years), but by the falling number of beds which is the result of this no longer being sufficient to cover the gap between what they are prepared to pay and the actual cost of care.

David Oliver

Position
visiting fellow,
Organisation
king's fund
Comment date
24 October 2016
I thank Peter Rogers for his comments
However, the point of the blog wasn't to show off any brilliant new insights into the problem (which in any case i doubt i have) but to pull together some thoughts about the state of play in 2016 and to discuss our forthcoming event on care homes and healthcare for their residents.
He can rest assured that in my role as BGS President i have led an organisation which for several years, through resources such as "quest for quality" "failing the frail" and "care home commissioning guidance" has highlighted serially (and well before NHS ENgland Vanguards) the gaps in health care for care home residents. We also put out strong statements when there were suggestions of GPs withdrawing suport for care homes and when the issue of retainers was identified. However, General Practice has severe workforce and funding crises of its own, as the Kings Fund highlighted this year and we would rather focus both in the BGS and at the fund on constructive solutions, which go well beyond GPs and the (depleted) comnmunity nursing workforce but also incorporate community geriatrics and a whole range of community health services including palliative care. For me to attack GPs in the blog would have been ill-judged and antagonistic and i make no apologies for not doing so. They are my NHS colleagues

With regard to differential fees paid by self-funders and local authorities, we at the the kings fund, where I also work, highlighted in a major report in September 2016 the pernicious effects of persistent year on year cuts to local government and social care funding and the impact on the lives of older people and their carers. We also highlighted in the Barker Commission report the need for radically different approaches to social care funding. Again, i am not inclined to be using the language of blame against local authorities, whose funding has been so drastically reduced. Though i am happy to blame government policy.

As for the care homes, clearly they have an increasingly unsustainable business model, with Brexit, the living wage, reduced local authority fees and funding and i don't want to blame them either especially. But i do pity anyone who is local authority funded and trying to "compete" for a place with people who though self funded are able to pay much higher rates.

I dont minimise any of these issues. One just cant cover everything in a 700 word blog

David Oliver

Philip McMillan

Position
Geriatrician,
Comment date
26 October 2016
The observation that I have made after many years working in the NHS is that quality tends to follow finance. As a society this is also relevant that those who can pay more tend to get a higher standard of support (this is not just in health).

The issue for the elderly is that high quality care is expensive and there are limited financial rewards in the private sector. Until this fact is changed very little will happen.

Legislatively, the elderly need to have funding separately assigned to their requirements and the quality of care will automatically fall into place. This is made obvious when you see the standard of care for a hip fracture compared to a shoulder fracture.

This has to come from the top. Local councils have their own problems and struggle to balance the books as well as have services for the elderly. There are too many variations across the country.

As a society we must ask if the elderly are important and if so be willing to choose to fund their care appropriately.

Who will lead the challenge for change?

Big daddy

Comment date
27 October 2016
Are there any known studies or research on the life quality and law imposed on elderly in their own home vs in the care home?

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