Towards better healthcare in care homes
Findings from the NIHR-funded Optimal study identify how the NHS and care homes can work better together to deliver consistently high-quality healthcare to care home residents.
Nearly half a million people live in care homes in the UK; 70 per cent of them have dementia. The vast majority of care homes rely on the NHS for access to medical and specialist care, which can be provided by as many as 27 different NHS services. As commissioners seek to reduce demand on hospital services, care homes are increasingly being asked to provide end of life care. However, while identifying some examples of successful partnership working between the NHS and care homes, the Optimal study found healthcare provision to care home residents is ‘erratic and inequitable’. The study set out to establish a much-needed consensus among care home management and staff, NHS practitioners and health and social care policymakers on how the NHS and care homes should work better together to improve healthcare delivery.
Key findings and recommendations
- Commissioners should consider targeted investment that gives NHS staff more time to work closely with care home staff to discuss, plan and review care. The study found that commissioning several NHS services to work with care homes on a regular, ongoing basis created a network of expertise and increased the confidence and ability of NHS staff. This improved residents’ access to care, reduced demand on urgent care services and decreased hospital admissions and length of stay.
- In planning service provision to care homes the NHS should ensure residents have access to healthcare that is equitable and equivalent to those received by older people living at home. The research found access to this standard of healthcare was ‘erratic’ and ‘unpredictable’. While one care home could receive dedicated support from NHS nurse specialists and therapists, residents in a home a few miles away could struggle to see a GP, who would only visit if a resident was in acute need.
- NHS decision makers and managers need to recognise care homes as equal partners and ensure they are not viewed as a drain on NHS resources. Researchers reported that a formal acknowledgment among health providers that working with care homes is important and valued work had a legitimising function that gave NHS staff permission to engage with care home staff and co-design care protocols. This led to improved access to NHS services, crises avoided and higher satisfaction among care home staff and residents with healthcare provision.
- The provision of financial incentives to achieve minimum standards of care (e.g. payments to GPs to work with care homes) must support closer collaboration between NHS and care home staff otherwise it will have limited long-term impact. Payments in isolation — to increase contact time with residents or tell care home staff what to do — did not improve healthcare provision. Researchers found the costs of dedicated care home teams working with other specialist teams were very similar to extra payments to GPs and the funding of individual specialists.
- Care home providers’ referral guidance needs to fit with NHS referral protocols with opportunities for dialogue where care home staff are uncertain about how to identify different NHS services. The study found care home staff were often unsure who to involve when they were concerned about a resident. Established relationships that had developed over time between care home staff and NHS practitioners were found to facilitate appropriate referrals, which in turn supported continuity of care and the management of acute episodes in the care home.
- GPs need to play a central role in integrated care delivery teams; how their work complements other care home-focused services should be specified and agreed between all those involved. Regular GP clinics or patterns of visiting that were predictable were associated with higher levels of care home staff and resident satisfaction with healthcare, fewer medication-related problems and more frequent medication reviews.
- Care home-based training should include all care home staff working with residents, not just nurses or senior carers, and specific support around monitoring and managing residents’ medication. The study findings suggested that when care home based training included all members of the workforce (e.g. catering staff and junior staff) there was more likely to be engagement at an organisational level and sustained implementation of service improvements.
- Dementia expertise needs to be integral to regular service provision, not part of a separate service. The presence of dementia complicates care provision and some health services struggled with this complexity. Many NHS staff reported how difficult they found visiting care home residents with dementia, especially when there was no ready access to specialist services across the NHS. Access to specialist services gave NHS staff confidence and skills in providing care, which lowered levels of distress among residents and increased a willingness to find non pharmacological solutions to behaviours that staff found challenging.
A video animation also captures some of the key findings and recommendations from the Optimal study:
Study background
The Optimal study, funded by the National Institute of Health Research’s (NIHR) Health Service and Delivery Research (HS&DR) programme, was a collaboration between seven universities: the University of Hertfordshire, the University of Nottingham, the University of Surrey, Brunel University, City University, Kings College London and University College London.
Claire Goodman, Professor of Healthcare Research at the Centre for Research in Primary and Community Care, University of Hertfordshire, led the study.
The three-year study had two stages. The first stage mapped all the ways in which the NHS works with care homes, interviewed NHS and local authority commissioners, providers of services to care homes, regulators, care home managers, care home residents and their families, and reviewed the evidence of what works and in what circumstances.
For the second stage researchers tracked the impact of different approaches used by the NHS to provide healthcare to 242 older people living in 12 care homes across three geographically disparate areas. Researchers interviewed residents, family members, healthcare professionals and commissioners. Eighty-three residents died during the course of the study.
The three sites had organised healthcare to care homes differently. One had designated care home services; one had invested in extra GP provision to care homes with specialist support; one had limited care home specific provision. Researchers sought to identify the features of varying delivery models that were associated with positive outcomes across the sites for care home residents in five key areas: medication use; use of out-of-hours services; resident, relative and staff satisfaction; unplanned hospital admissions; length of hospital stay.
They then sought to identify a configuration of these features that could maximise the delivery of high quality healthcare to care home residents at reasonable cost.
Discussion of findings
The NHS works with care homes in multiple ways and it is unlikely that there is a single ‘right’ way of working or model of service delivery. However the Optimal study has identified common features or aspects of how care home and NHS staff work together that are more — or less — likely to support residents’ access to high quality healthcare.
The findings have practical implications for commissioners of services for care homes, health practitioners, care home staff and their organisations, and residents and their relatives. They also suggest that the social care sector — in this case care homes — can make an important contribution to informing the commissioning of optimal healthcare for older citizens. However this resource is currently underutilised.
“Optimal recognises and articulates the value of relationships between people who work across health and social care. In helping care home staff to talk about the complexity of the care they provide and NHS staff to understand the breadth and depth of the expertise within the care home sector, the study is of direct benefit to care home residents and their families — an excellent outcome.”– Sharon Blackburn, Policy and Communications Director, National Care Forum
‘Inequitable, inadequate and erratic’ service provision
While researchers did find examples of successful partnership working between the NHS and care homes, the study concluded that inequitable, inadequate and erratic care are a persistent feature of healthcare provision to residents in care homes.
Healthcare delivery was often characterised by an ad hoc, reactive approach and a wide variability in the availability of services, for example a widespread lack of dental services or speech and language therapy services.
Researchers found in one care home that up to 27 different NHS services (e.g. GPs, nurses, therapists, specialists) were involved in delivering care. Care more generally was uncoordinated and the paucity of strategic planning for care home residents is compounded by limited data about the residents and the costs and benefits of the services that are received by care homes.
‘Relational working’ between NHS and care home staff is crucial
The research found high quality healthcare provision to residents in care homes cannot be achieved without visiting health care professionals and care home staff working closely together to identify, plan and implement protocols for care — characterised in the study as those activities that support ‘relational working’.
Contextual factors such as financial incentives or sanctions, agreed protocols and structured approaches to assessment and care planning could support relational working to occur. However, of themselves these measures were unlikely to achieve change if they did not lead to visiting healthcare professionals and care home staff developing long-term relationships that involved joint priority setting, shared use of assessments and agreed protocols.
“Care homes don’t always know who to contact or can’t get anybody to respond, and because there is a need they just say I’m going to refer to everybody and see who comes fastest. This can create delays elsewhere and result in somebody sitting on a waiting list for the wrong clinician.” — Occupational therapist interviewed for the study
Researchers found little evidence of NHS services organising provision to fit with the wishes and suggestions of care home staff or residents. Where there were different patterns of NHS provision they were defined and controlled by the NHS.
However, where the patterns of working and visiting by healthcare professionals created opportunities to meet and discuss care, there was a greater mutual appreciation of the challenges both NHS and care home staff faced each day.
Seeing care homes as partners not problems
The targeting of additional investment at the provision of NHS services to care homes was often seen as a formal acknowledgement that working with care homes was important and valued, and not something that could be squeezed into an already full caseload. This enabled NHS staff to engage more fully with care homes and their residents, and potentially freed them from anxiety that they were abrogating other competing responsibilities.
This was most apparent when practitioners saw their role as focused on providing continuity of support and access to expertise. Where this was the case, the funding acknowledged that working with care homes takes time. Perhaps more importantly it also recognised the need for the NHS to engage with care homes at an institutional level as well as with individual residents.
A different response and pattern of involvement was triggered when the need for investment was expressed predominantly as concern about care homes as a drain on NHS resources. This negative mindset did not appear to allow for shared discussions about what kind of health care or services residents needed. Instead, it led to a focus on single issues, such as falls prevention and reduction of emergency callouts.
When activities were mainly focused on reducing expenditure, this triggered short term, negative responses. In these circumstances, commissioners assumed the worst, and measured outcomes in terms of what had not happened and how resources had not been used, rather than focusing on the benefits to residents and potential job satisfaction for NHS and care home staff.
Where practitioners or services had an ongoing commitment to the care homes, concerns about quality of care were more likely to be presented as problems to be worked through rather than declaimed and reported. Without opportunities to work with care home staff, NHS practitioners experienced frustration, focused on care home staff shortcomings or what care home staff should (following extra education and training) be able to do to support residents.
“When a care home was seen by the NHS as a valued partner, rather than a problem or a drain on resources, then tension and a culture of blame receded, and the healthcare that older people received tended to be better.” — Professor Claire Goodman, University of Hertfordshire
Importance of the role of GPs
In all three study sites the involvement of the GP was important. Taking specific tasks away from GPs, such as regular medication reviews, initial health assessments when resident enter a home or dealing with day-to-day queries about residents, allowed their contact with care homes to be more focused. GPs were in effect allowed to ‘concentrate on being a doctor’.
Services that provided intensive care home support, through a model of relational working, still relied on links to GPs for diagnosis, urgent care and discussions about unresolved issues of care with care home staff, residents and family. The Optimal study did not support arguments that GPs should not work in care homes but it did suggest that involving other NHS practitioners in supporting care homes was key.
“For me an example of ‘good care’ is a GP who proactively goes into care homes, has good relationships and communicates well with staff, is prepared to be reactive when needed and has good links to their general hospital so that they know when to admit.” — Care home representative interviewed for the study
The importance of the GP role is reflected in the larger number of hospitalisations in one of the study sites. This could be explained by two factors: a lack of GPs and NHS staff who were available and known to care home staff, and an absence of referral systems that functioned between the NHS and care homes, or between the different NHS services.
When GPs held regular clinics in care homes, it was much easier for residents to secure prescriptions and reviews of their medication reviews, and care home staff reported higher levels of satisfaction with access to health care services for their residents.
Direct payments to GP surgeries incentivised GPs to spend more time in care homes. However this did not necessarily lead to more proactive care, as it did not trigger a change in GP behaviour. That required the involvement of other services.
Dementia expertise integral to high quality service provision
The study findings suggested access to NHS expertise in dementia care is particularly important. Researchers found that the greater the severity of cognitive impairment, the less likely it was that a resident would see a primary care professional. The presence of dementia complicated care provision and not all services could deal with this complexity.
Accounts from NHS staff described how difficult they found visiting residents with dementia, notably where there was no ready access to specialist dementia services. The detailed and sometimes extreme accounts of distress, police involvement and practitioners’ anxieties about helping care home staff to deal with violent episodes underlined the importance of access to, and integration of, dementia care expertise.
Where specialist dementia expertise was provided, the specialists needed a remit to work with care home staff around referrals and linking up other NHS visiting services. Care home staff could then be more confident in caring for residents with behavioural and psychological symptoms of dementia.
In some instances, however, services worked in parallel when they visited care homes or could only be mobilised at a time of crisis, so that residents were passed from one service to another without a clinician coordinating that process. This could result in the resident being admitted to hospital.
Positive scenario: Collaborating to improve care
Concerns about the quality of residents’ care can escalate into safeguarding issues, leading to an intervention from the regulator. In one care home studied, visiting NHS staff would sit alongside care home staff to review and monitor the quality of care provided and discuss issues at specific quality meetings attended by NHS service leads. These quality meetings augmented the teaching that NHS staff offered and were seen as a vehicle to highlight and share good practice, learn from care homes and address concerns before they became serious.
“We want to identify and share examples of good practice of healthcare in care homes. Homes get bashed so much so it’s about saying, ‘Actually this is really good, can we share this? How have you done that? Can we use it as a model and pass that knowledge on to other homes?’”- Member of a dedicated care home nursing team
Negative scenario: Viewing care homes as problems
In more than one home studied NHS community nurses adopted a role of monitoring the standards of the care home during their visits. They tended to focus on shortcomings and the inadequacy of care provided to residents. However the training and support of care homes by NHS staff was not seen as their responsibility, reinforcing a sense of ‘them and us’, and they failed to recognise that they could offer help beyond pointing out when mistakes were made.
“There should be better training for care home staff because at the end of the day some of our referrals, we aren’t actually required in a home…their competence when it comes to pressure area care is poor, very poor. And also their moving and handling skills are atrocious, I mean I’ve had to report quite a few times the way I’ve seen people handled in a home.” - Community nurse, district nursing team
About the lead study author
Claire Goodman is Professor of Healthcare Research at the Centre for Research in Primary and Community Care, University of Hertfordshire. She is a NIHR Senior Investigator and Deputy Director of East of England Collaboration for Leadership in Applied Health Research and Care (CLAHRC).
She has a clinical background in nursing and district nursing. Her research focuses on the oldest old and how primary health care works with social care and long-term care providers to support this population, especially when there is a degree of cognitive impairment. She is a founder member of the Enabling Research in Care Homes (ENRICH) project network and is currently leading a national evaluation of dementia friendly communities.
Further reading
This policy brief summarise the findings of the NIHR-funded Optimal study. The full, open-access report, published in the HS&DR journal, can be accessed through the NIHR Journals Library website:
Professor Claire Goodman writes for the Guardian’s Social Care Network:
This briefing document by My Home Life, a UK-wide initiative that promotes quality of life and delivers positive change in care homes for older people, explores how care home staff can build better relationships with health colleagues:
