Enhanced health in care homes can be achieved by close co-ordination between care homes and the range of health services required to meet the needs of older people living in the care homes. When these services work closely together – for example, through regular GP visits to care homes and regular comprehensive assessments – they can actively promote good health rather than just reacting to ill health.
Unfortunately, there is no single set of actions that will achieve enhanced health in care homes: although we interviewed people in areas that were all making progress, this was a result of carefully designed approaches which they developed over time. Processes developed in one area and simply imported into another, are unlikely to be effective. Tailoring arrangements to each area’s context and developing relationships that lead to the services working together on the basis of trust and partnership are essential.
But ‘tailoring arrangements’ and ‘developing relationships’ are imprecise phrases: it can be hard to pin down the specific actions involved. We set out to collect information from different areas of the country about their experiences of developing approaches for enhanced health in care homes, which would enable us to describe what is happening in practice. Although this information will not remove the need for each area to do its own thinking about what will work for them, reflecting on experiences to date should assist the process and help areas to avoid pitfalls.
Two developments prompted this study.
- NHS England issued comprehensive guidance and designated six areas as ‘vanguards’ (demonstrator sites for what can be achieved), which underlined the importance of realising the potential that enhanced health in care homes offers.
- Recent King’s Fund conferences and a learning network run in partnership with My Home Life highlighted services working closely together in many areas beyond the vanguards. We wanted to exploit the wealth of learning available from these areas.
We spoke to people in 15 areas, selected from the learning network and other areas, that would provide a range of different experiences, and we reviewed published research and guidance.
Our report is written for people working in care homes, NHS services, local authorities and clinical commissioning groups, who want to develop enhanced health in care homes approaches. Its focus is on practice and leadership rather than, for example, understanding service users’ experiences or overall policy.
What is the case for enhanced health in care homes?
The people we spoke to described significant benefits from closer working between care homes and health services. In general, these areas we studied did not have special advantages (such as exceptional resourcing) to support this work and this suggests that it could be feasible for any area to develop enhanced health in care homes.
However, we noted that there was most focus on measurement of benefits through the avoidance of NHS activity and costs (eg, reductions in preventable hospital admissions), with less detailed focus on the impact on quality of care. Most areas were not monitoring impact on overall quality of life.
In contrast to the strong emphasis that all areas placed on involving people in decisions about their own care, care home residents and their families usually did not have prominent roles in defining ‘what good looks like’ when joining up care homes and health services.
Why do areas start developing enhanced health in care homes?
Interviewees’ responses illustrated that there is no single way to develop enhanced health in care homes. Some started from broad strategic plans, others started from individuals or groups of individuals, but these particular areas all saw positive impacts.
However, system-wide approaches tended to be more strategic with a clearer path for scaling-up, compared to those that started ‘bottom-up’ from highly motivated individuals.
How do areas start implementing enhanced health in care homes?
Areas adopted different approaches to implementation, reflecting the range of approaches described in research studies and guidance.
In about half the areas, approaches were targeted either at care homes with high rates of hospital admissions or at a small number of care homes that acted as a pilot. Challenges included the effort needed to overcome initial apprehension from the care homes involved, and the time needed for scaling up. Other areas took an ‘organic’ approach, open to all care homes and health services and enabling them to propose priorities and work on them, or to make referrals so that they could get support with specific issues. This approach involved care homes more easily (although not necessarily GPs), but had its own challenges, such as avoiding requests and referrals becoming overwhelming and ensuring a fit with governance requirements. Regardless of how they started, over time, all these areas needed to strike a balance between bottom-up and top-down perspectives.
Both research studies and interviewees emphasised the need to start engaging services before finalising plans and to work with care homes in an open, developmental way as partners. Interviewees described journeys from doing things ‘to’ care homes, to doing things ‘with’ them. Sustained effort and leadership was required to get care homes, GPs and NHS trusts on board.
Local authorities and clinical commissioning groups (CCGs) could provide essential leadership by ensuring priority, unblocking obstacles and modelling ways of working across organisational boundaries. In practice, usually either the local authority or the CCG led the approaches, with consequential stronger involvement of either social care or the NHS.
There was consensus that some additional resource was needed to develop enhanced health in care homes approaches, at least initially, but there was a large variation in the actual levels of resourcing, including one area with no specific resources. Each area needed to develop its own information to monitor costs and returns on investment as there was no clarity on what the level should be.
Research and evaluations emphasise the need to allow time for partnership working to develop, and the benefit of a history of working together. Interviewees confirmed this, but they also said that results started to become visible as relationships began to develop, rather than only after they were embedded. This could mean that significant results were seen within just a few months, even in areas without a history of joint working.
How do areas develop and sustain enhanced health in care homes?
Research and guidance have identified various activities that help develop and embed processes and relationships needed for enhanced health in care homes. These include training care home staff with NHS staff, regular GP visits to care homes, explicit (funded) time for working together, and shared ownership of goals (not seeing care homes as consumers of NHS resource). Although managerial processes, such as incentives and governance, can help, it is relationships that are essential.
Interviewees described the leadership needed, both across the local health and care system and at service level (eg, care home managers, community health team leaders, GPs). Examples included how to engage services, maintain visibility and overcome concerns; encourage innovation and share good practice. They described this as requiring long-term effort, and being very demanding.
All areas had arrangements to develop the workforce, often enabling care home staff to access NHS courses, NHS staff going to care homes to deliver training, or sometimes leadership development for care home managers. This varied widely, with no clarity about the extent to which it was appropriate for local authorities and CCGs to invest public funds in training for care home staff (because most care homes are in the independent sector). Most areas began by training only care home staff, but over time NHS staff found that they also benefited from learning more about how care homes worked. Some areas went beyond training to focus on learning and reflective practice – for example, learning from root-cause analysis for each admission to hospital from a care home.
Several areas were concerned about recruitment and retention of care home staff, although there was limited planning to influence the social care workforce. Some care homes experienced practical difficulties in joining up with local strategic plans, such as sustainability and transformation partnerships, to align their business and staffing models with other local plans for the future.
Although engaging care homes initially required significant effort from those leading the initiatives, as word spread others came on board more readily. To engage more GPs, areas emphasised the need to engage early with robust data from audits and evaluations. However, this was often not sufficient without additional support (such as creating contractual incentives or facilitating peer discussion) from CCGs. Hospitals were frequently difficult to engage, with interviewees reporting that hospitals were often focused on their internal difficulties, which reduced their input into partnership working.
In all areas, even those with a longstanding history of cross-organisational working, there was a need to keep reinforcing the need for equal partnerships, as old cultures of doing things without involving care homes were likely to reappear. Those in leadership roles described engaging with and helping to re-balance power relationships between the NHS and care homes as one of their key roles.
Areas making good progress had developed ways of sharing information across organisations. This included accessing or contributing to each other’s IT systems, and using information to reflect on and develop practice. Just as with staff training, there was a lack of clarity about how much public sector organisations should include independent care homes in their information strategies, and significant variation in the level of investment and support for joining up information systems. Most areas carried out evaluations of the new ways of working that they introduced, as well as monitoring data routinely. Interviewees emphasised the need for evaluation to be formative and to avoid claiming conclusive results too quickly.
Areas were generally focused on developing care processes and the relationships to support them. We did not see many examples of progress on underlying enablers of sustained change, such as developing co-commissioning, joining up governance arrangements, or inclusion of enhanced health in care homes as part of broader strategies for IT, the workforce or market shaping. Although it is understandable to start with care processes that directly impact on improving care, these underlying enablers also need to be considered if improvements and new ways of working are to be sustained over the long term.
Reflections and recommendations
We observed that developing enhanced health in care homes is often about removing inequalities that care home residents experience in accessing the range of NHS services to meet their needs. Others have reached similar conclusions in the past, but the problem of lower expectations for care home residents remains.
Developing enhanced health in care homes is not just about quality improvement within care homes, but is part of the wider direction of travel towards integrated and co-ordinated local systems of care. As such, these approaches should be reflected in local strategic plans for integration, with providers as well as commissioners involved.
Enhanced health in care homes approaches can achieve significant results, but these were often hard to pin down, especially when they were the combined effect of many small changes rather than a simple, visible ‘cause and effect’. Several research studies have measured impacts on people’s quality of life and their experience of quality of care, rather than only reduced hospital activity and incidents (such as safeguarding alerts), but this has not followed through into routine practice – even though staff consistently said that improving quality of life was their main objective and motivator. More practical guidance is needed on measuring impact, and care home residents themselves should be involved in defining what good co-ordination looks like.
We highlight the important but challenging roles for leaders at every level – from the front line in care homes and health services to local system level. Networks and communities of practice can help to support these roles and share learning. NHS England’s leadership at national level has been appreciated, and care is needed to avoid a vacuum when the support programme for vanguards ends in 2018.
We have made recommendations for extending enhanced health in care homes to all areas, supporting and developing leaders, and ensuring that people living in care homes can access high-quality health care.
Making care homes more like hospitals is a way of getting people to pay for their social care themselves. Given that such moves are an obvious distortion pushing care homes into a position they were never designed for wouldn't an alternative policy to ensure a level playing field be to charge hospital patients a social care fee per night in hospital.
Healthcare would remain free but a new source of income would be found and there wouldn't be foot draggers in hospital beds.
Thanks for your thoughts. In interviews, although our questions were all about experiences of working in partnership, concerns about financial pressure (and, as it happens, the role of CQC) were additional themes that interviewees almost without exception brought up. We saw that financial incentives (usually for GPs) could have a role, but we also saw that they could be unhelpful (where they caused lip-service behaviours or where different CCGs' incentives conflicted) and the literature suggests they can help but are not enough to achieve sustainable change on their own. The crucial thing is understanding of each other's service, trust and mutual respect - that basis of good working relationships is the first priority to get in place, incentives (financial, governance, reputational etc) can then be considered to build on it!