What now for the ‘medically dispossessed’?
We asked British Geriatrics Society president Dr Finbarr Martin what the future holds for care home residents when GPs take over
We asked British Geriatrics Society president Dr Finbarr Martin what the future holds for care home residents when GPs take over
What is the current state of healthcare for patients in care homes?
The British Geriatrics Society (BGS) has serious concerns about the quality of healthcare received by care home residents. There are about 400,000 older people living in care homes in the UK and many have complex healthcare needs.
The care home population includes the most frail members of our society, yet this vulnerable group of people has been described by the BGS, the Royal College of Physicians and the Royal College of Nursing as ‘the medically dispossessed' as they are frequently denied access to routine NHS healthcare.
Research shows that many residents have difficulty accessing the GP input they require as individuals. In addition, many cannot access therapy services, out-of-hours services or specialist dementia services such as memory clinics. This is particularly shocking given that at least 40% of care home residents in England, for example, have particular needs as a result of dementia.
Over the past three decades, the independent sector has played an increasing role in the provision and management of care homes. The old long-stay wards and hospitals have gone.
A benefit has been new buildings and innovations. But equally, a major consequence has been withdrawal of the expertise and support from specialist clinicians. Most geriatricians and old-age psychiatrists now play no part in providing healthcare support – or at least they are not commissioned to do so.
Although all residents are entitled to free GMS and fair access – according to need – to other community health services such as physiotherapy, evidence shows quite clearly there is huge variation in local provision.
Some care homes have had to pay GPs a significant retainer (often as visiting medical officers) in order to secure the necessary time commitment for adequate clinical care of residents.
This is a contentious area as care home fees are therefore in reality supplementing GPs' GMS contract. There are also issues around maintaining continuity of care as there are different models for attaching GPs to care homes and residents are not always able to keep the GP they had prior to their care home admission.
But most relevant from the clinical quality viewpoint is that primary care is largely unsupported in this complex clinical work, managing multiple comorbidities in frail older people, often near the end of life. Clinics and occasional domiciliary visits are no substitute for a planned, partnership approach.
It would be a dereliction of duty for clinical commissioning groups (CCGs) not to take action to meet the obligations of the NHS to provide quality healthcare for care home residents. CCGs need to ensure that clear service specifications are agreed with their local NHS providers. These need to be linked to quality standards based on residents' or patients' experiences and appropriate clinical outcomes.
Is there more or less regulation of care homes these days? What's the effect of this on residents' health?
The regulations that govern care homes are based on national minimum standards set out in the Care Standards Act 2000. In the different nations of the UK, these are in turn interpreted by specific sets of regulations which determine the responsibilities of care home providers to maintain and promote the health of their residents. They refer to activities such as record keeping, planning and health monitoring.
All regulators have a responsibility to regulate not only the care home provision but also the NHS services providing support to care homes. We are looking forward to the publication of a special review by the Care Quality Commission in England that has been investigating whether people living in care homes have equitable access to the full range of necessary NHS services. The CQC has also been examining the choice and control residents have over their healthcare and whether the healthcare they receive is safe and respects their dignity.
However, there is only so much that regulation can do. It can highlight problems, but care home providers cannot improve residents' quality of healthcare without the support of the right professionals. Furthermore, providers can be discouraged from adopting innovations such as in end-of-life care as there is no additional resource provided to assist with training and implementation.
There is often a perception that care homes are making a profit at the expense of their residents and that they want to use NHS services to avoid providing the care and equipment they have been paid to provide. In fact, reports illustrate that the majority of care homes work within a low margin of profitability. The Equalities Act 2010 may well drive improvements in care. From April 2012, discrimination in distribution of health and social care services on the grounds of age, explicitly or implicitly, will be illegal.
There have been reports that PCTs have cut funding for care homes by more than 10%. Is this sensible commissioning?
This is very worrying and shortsighted. As matters stand, healthcare support for care homes is rarely commissioned or planned as a specific service – as a result, we see medication errors, cases of preventable ill health and unnecessary admissions.
If the little dedicated funding is further reduced, things are hardly going to improve. A big issue is the need for more integrated working between health and social care services. PCT and social care commissioners cannot keep trying to shift responsibility to each other for this vulnerable patient group.
The needs of care home residents keep changing, but it is clear that we need a planned approach based on partnership between primary care and specialist services to provide appropriate care, especially in view of the growing prevalence of dementia. Otherwise we will continue to fail in our duty of care.
Where would you advise CCGs to start?
Our recent research has highlighted a number of ways in which CCGs could improve the quality of healthcare that care home residents receive.
Service specification for providing healthcare support for care homes should guarantee a holistic review for any individual within a set period from their move into a care home, leading to healthcare plans with clear goals. This will guide medication reviews and modifications and clinical interventions both in and out of hours. All the following suggestions are flagged up in our report Quest for Quality, which was published with the support of a broad coalition of generalist and specialist NHS, social care and care home professionals:
• Prompt transfer of clinical information to the care home can enable healthcare staff to build on the wealth of assessment that will have been conducted prior to the transfer of care. The exact format of this varies in the UK, but there is plenty of evidence that detailed multidisciplinary assessments prior to an individual moving into a care home can identify remedial problems and ongoing healthcare priorities. This will facilitate continuity of care where a change of GP or other professional occurs.
• Discussion and planning of future care for older people in care homes (including the use of advance directives) can reduce unplanned admission to hospital care services and inappropriate interventions at the end of life.
• Nurses working as case managers could compensate for deficiencies in the scope of usual primary care. This could supplement GMS and serve as a clinical and communication bridge to specialists and other community health services, thus improving outcomes and resource use.
• Involvement of community pharmacy services to support medication reviews can improve prescribing practices.
• Close links with community mental health teams may improve assessment and care of residents with behavioural and mental health problems.
• Close links with community rehabilitation services, such as links with skilled therapists to support day-to-day care, can prevent or minimise complications with disabling conditions such as spasticity, contractures and pain.
• The use of support tools and care frameworks encourages a shared and systematic approach to joint working between care homes, community nursing and other health professionals. Used in partnership, these tools can provide a basis for continuity and consistency of approach (even where there is rapid staff turnover).
What are the opportunities for CCGs to enhance the care of these patients?
There is evidence that involving community geriatricians in the management of care home residents is beneficial.
For example, a recent pilot in Leicester trialled sharing the management of patients in residential homes between GP practices and community geriatricians.
The pilot offered practices access to comprehensive geriatric assessments, care planning, rapid written feedback and a telephone advisory service. After six months, out-of-hours consultations fell by 16% and requests for visits by 37%. Hospital admissions were also reduced by more than half. The total cost of admissions fell by 60%.
What lessons can commissioners learn from high-profile cases such as Castlebeck and Southern Cross? What went wrong?
Staffing and staff training is a key issue. Care workers are a massive unregulated workforce, with a wide range of aptitude and experience.
Only in care homes registered to provide nursing care is there an obligation for carers to be supported or supervised by qualified nurses. Those working in other care homes are also in desperate need of support, not least in dementia care. It is essential that health and social care professionals build relationships with the staff working in care homes to develop their confidence and to raise their awareness and understanding of basic healthcare issues.
To help with this, when commissioning specific services such as continence care, commissioners should ensure there is time built in to enable healthcare professionals to share information with staff working in the home.
How strong is the evidence base for what GP commissioners can do to have a significant effect on these patients?
Emerging evidence from across the UK suggests that commissioning health-related inputs for care homes can improve the quality of care, reduce hospital admissions and save money.
In Sheffield, an evaluation of a local enhanced service demonstrated that overall care planning was carried out well and there was widespread evidence of good relationships developing between practices and homes (see case study below).
Feedback from the pilot showed that, of care home residents, 94% agreed that the GP service gave them the help they needed, and 84% agreed they received better care with the new GP service.
For care home staff, 97% agreed their relationship with GPs had improved and 86% agreed that the new service helped them understand more about residents' health. Finally, 97% of residents' family members agreed the care was better.
A study by the Joseph Rowntree Foundation in Bath and north-east Somerset looked at a joint NHS and local authority initiative providing a dedicated nursing and physiotherapy team to three residential care homes (see box, above left).
Dr Finbarr Martin is consultant physician at Guys and St Thomas' Hospital and president of the British Geriatrics Society
• The British Geriatric Society, Royal College of Physicians and Royal College of Nursing have all described the care home population as the ‘medically dispossessed' as
they are frequently denied access to routine NHS care
• CCGs have an opportunity to introduce clear service specifications for providers to meet patients' needs, including:
– holistic reviews of new residents
– nurse case management
– prompt transfer of clinical information
• Care workers are a massive unregulated workforce with many training needs. Only in homes registered to provide nursing care is there an obligation for qualified nursing support
• A pilot in Leicester where care was shared between GPs and geriatricians saw admissions costs fall by 60%
Case study – a dedicated nursing and physiotherapy team
A study by the Joseph Rowntree Foundation in Bath and north-east Somerset looked at a joint PCT and local authority initiative providing a dedicated nursing and physiotherapy team to up to 131 residents in three residential care homes.
The researchers, from the Faculty of Health and Life Sciences, University of the West of England, Bristol and Warwick Medical School and the University of Warwick aimed to meet the nursing needs of residents where they live and to train care home staff in basic nursing.
The results included a reduction in admissions and prevention of transfers to nursing homes.
Evidence from interviews and focus groups suggested that enabling residents to stay in their home when they were ill was preferred by care staff, managers and, most importantly, by residents.
Audit data suggested that the nursing and physiotherapy expertise, combined with their support for the development of new types of working among designated care home staff, was able to prevent between 81 and 197 admissions over the first two years (between July 2005 and June 2007). In addition, 20 early discharges were facilitated.
Over the same period, a comparison of hospital data from the homes in the scheme showed a decrease in admissions for more than 48 hours and an increase in those of less than 48 hours. This suggests the model prevents longer admissions and facilitates early discharge.
However, the time span of two years was too short to demonstrate a meaningful trend in either type of hospital stay.
Audit data also suggested that the nursing team's work prevented 20 (or possibly up to 28) residents from being transferred to a nursing home.
The research also found the following:
• Enhancing health-orientated education and training of care home staff was challenging at first, but relationships improved and the confidence and professionalism of staff grew.
• Residents' nursing needs cannot simply be equated with their level of dependency. For example, a resident with dementia can be functionally independent yet have major, often uncommunicated, health needs.
• The early detection of illness and the opportunity for intervention was a major part of the team's work.
• Overall, estimates of costs and savings ranged from a worst-case scenario of £2.70 more per resident per week to a more likely scenario of £36.90 saved. Savings were mainly in reduced use of NHS services. The PCT and adult social services both funded the intervention, highlighting the need for partnership working to sustain funding.
The researchers concluded that any increase in cost should be measured against the benefits of promoting long-term quality of life, quality of care and providing a firm foundation for workforce development.
Source: Wild D, Nelson S and Szczepura A. Providing nursing support within residential care homes. Joseph Rowntree Foundation. April 2008