Adam Gordon is a Consultant and Honorary Associate Professor in Medicine of Older People based in Nottingham, UK. He also edits this blog.
A lot of excellent practice takes place in care homes. This is contrary to the image portrayed in the lay media, where there seems to be near-universal agreement that long-term care in the UK is “broken”. The same media reveals less agreement about what aspects of long-term care, precisely, are broken. Conversely, there is no shortage of suggestions about how one might go about fixing it.
Often overlooked in these discussions is the fact that healthcare provision to care home residents is the responsibility of the National Health Service.
Failure to meet the healthcare needs of residents must therefore reflect, to some extent, on the NHS and how it organises care for them.
There has been growing consensus – and an emerging body of evidence – that the NHS is failing to meet the healthcare needs of care home residents. This is summarised nicely in two documents published by the British Geriatrics Society – Quest for Quality and Failing the Frail.
Why is the NHS failing this group? To get to the bottom of this we need to consider what the health and functional status of care home residents is like and also to reflect upon how current models of healthcare provision to care home residents operate. Two recent publications from the National Institute for Health Research (NIHR) funded Medical Crises in Older People (MCOP) programme help to fill in these blanks.
The Care Home Outcome Study, published recently in Age and Ageing, shows that care home residents are functionally very dependent. Over half of those included in this study were incontinent of urine and three quarters needed help using the toilet. Half needed help to mobilise and a third were entirely immobile. Three quarters had dementia and two thirds had some form of behavioural disturbance. The average number of diagnoses per resident was 6 and the average number of medications was 8. For the cohort of 227 residents followed for 6 months, there were 41 hospital admissions which resulted in an overnight stay, comprising 503 inpatient days and a further 11 day case admissions. There were 763 general practice contacts over the same period.
The Staff Interviews in Care Home Study, published in BMJ Open, shows that existing healthcare teams are unable to meet the needs of this cohort. It described that the relationship between care home managers and general practitioners was central to effective healthcare delivery. Yet the majority of managers and GPs interviewed described difficulty identifying and anticipating medical crises in frail older people and considered their own training in healthcare for care home residents to be incomplete. Representatives of both groups suggested that existing NHS arrangements did not provide either the time or structure for delivery of healthcare which was sufficiently detailed to meet the needs of care home residents. A further issue was that both GPs and Care Home Managers struggled to identify and negotiate the boundaries of health and social care – meaning that some tasks went undone, as neither group felt adequately empowered to take them on.
So which way now? These findings show that care home residents need care which enshrines expertise in management of frailty, immobility, incontinence, cognitive impairment and behavioural disturbance. Care will also have to take account of the high incidence of polypharmacy and multiple diagnoses. Staff will need to have enough training – and see residents with sufficient detail and regularity – to enable them to recognise emerging medical problems and associated deterioration. Relationships and responsibilities between health care and care home staff will have to be structured so that residents don’t fall into the gaps left by uncertainty over who ought to do what.
As a geriatrician, these data represent a compelling case for Comprehensive Geriatric Assessment having some role in UK care homes. But it may not be the only way to structure care and there are number of ways in which it could be used in the care home setting.
Whilst the MCOP team have been conducting these research projects, the NHS has engaged in a bold experiment to revolutionise healthcare in care homes. Almost every part of the UK has done something new, something innovative. The approaches are varied and wide-ranging. This natural experiment could, potentially, give us the data we need to consider what the “essential ingredients” are in order to make healthcare work for care home residents.
A new NIHR-funded project, the Optimal study, led by Prof Claire Goodman at the University of Hertfordshire, will look at several of the approaches in detail and will hopefully generate robust data on what does, and does not, work in which context. We’ll report back through this blog as this study starts to provide answers.
The British Geriatrics Society will be launching its guidance for commissioning healthcare services for care home residents on 11th October (i.e. one week from now). We’ll post a link from this site on the day it goes live. Please check back next Friday for this.
Also reflects the gap/needs of greater geriatric exposure of current GP and junior doctor in-training. Raises the issue of particularly whether there should be a compulsory full year in elderly care for all trainnees as highlighted by the future hospital commissions report. along with perhaps restructuring the Diploma of geriatric medicine to better reflect community geriatrics rather than geriatric as a whole which reflects a predominantly hospital-orientated approach towards care of older patients.
So right in so many ways and of course being overly critical seriously undermines the excellent work that both primary and secondary care provide in some locations for some people!
A clear problem is that this population lack ownership, it’s just not the issue of integrated budgets or for that matter CGA (though a prerequisite) its about recognising that neither a pure traditional health model works or a traditional social care model and that needs recognition top down bottom up. So here are several slightly radical ideas not entirely lacking substance
1) Care homes pose both a great risk (through failure) to the NHS and opportunity (an optiuon to strech the use of budgets), that there is a practical limit to home care and the failure of prevention/intervention to stop the tide of dementia and dependence means that long term institutional care will continue to consume a large proportion of social care funding. There needs to be a new way of addressing this population and the polarisation of health and care is unhelpful from top to bottom.
2) Most care home funding is from local authorities across the UK. Local authorities have the remit for Public Health could that extend to care home medicine? Could we see Medical Directors of care home medicine overseeing programmes of CGA, risk control (e.g. polypharmacy or infection control) and providing assurance on care through QI surveillance
3) A capitated fee approach for care home medical care and institution of an Evercare type solution (not the Evercare pilots that were done in England but the validated Care Home Evercare)
Unfortunately many gps tend to think if the elderly as a nuisance and an added burden compared to other if their patients. This is a real problem. Some care homes actually pay an Nhs gp to visit their care home and this creates a relationship between care home mznagement and GP that isn’t always in best interests of the patient. Other care homes offer ‘own GP ‘ but not many gps care enough to visit a care home – they send instead a junior dr totally unfamiliar with the patient and often not even a member of the GP practice .
Care homes often have very inexperienced nurses – many who’s English is pretty bad and care hones are a stepping stone into Nhs from their qualification abroad. Recently my dad had optiflow left in his bladder by an inexperienced Romanian ‘nurse’ who says to me ‘that is what we do in Romania’ – my dad a week later was admitted to hospital with uro sepsis.
The Nhs have a duty of care to our elderly population just like to our children and should in fact police the care homes in a more proactive way.
After many years of caring for elderly parents I have never been Ivey impressed with geriatric drs in hospital – I find a good consultant with a kind heart and non geriatric in speciality far more helpful.