Major three-year study finds NHS needs to see care homes as partners not problems

Healthcare provision to residents in care homes across England is often ‘erratic and inequitable’, a major three-year study funded by the National Institute of Health Research (NIHR) has found.

Led by the University of Hertfordshire, and involving Professor Julienne Meyer CBE from City, University of London, the Optimal study found a narrow focus by NHS decision makers on care homes as a drain on resources, rather than as a solution, can result in short-term interventions that compromise relationships between NHS and care home staff, and affect care home staff confidence in being able to meet residents’ health needs.

The study, which involved seven UK universities, analysed the impact of different approaches by the NHS in providing healthcare to people living in care homes across England and identified several examples of successful partnership working between NHS and care homes.

However it concluded that high quality healthcare provision to care homes can only be achieved nationwide if close collaboration between the NHS and care homes becomes part of the ‘landscape of care’. This means ensuring, through targeted investment, that visiting healthcare professionals and care home staff are given the opportunity to work closely together to identify, plan and implement care protocols.

Other key findings:

• Care homes rely on the NHS for access to medical and specialist care. As many as 27 different NHS services can visit to provide care and treatment for residents.
• Access to healthcare for care home residents was highly unpredictable. While one care home could receive a significant amount of NHS support, for example through visits from nurse specialists and therapists, residents in another care home could struggle to see a GP.
• The best results were achieved when healthcare professionals working with care homes on a regular, ongoing basis were linked in with other NHS services as part of a wider network of expertise. This created naturally occurring opportunities to meet and discuss care, and nurtured a mutual appreciation of the challenges both NHS and care home staff face. It also reduced demand on stretched urgent and emergency care services, and increased staff confidence around decisions not to admit a resident to hospital or to discharge patients from hospitals earlier.
• Researchers found NHS initiatives that ‘threw money’ at care homes to achieve minimum standards of care without any meaningful interactions with care home staff – for example paying certain GP practices more money to work with care homes – were unlikely to work.
• Where the same amount of money was used to provide ongoing support and to enable NHS and care home staff to work together more closely, the investment delivered positive outcomes, the study said.
• Seventy per cent of people living in UK care homes have dementia, which complicates healthcare provision. Some health services struggle to deal with this complexity and many NHS staff reported how difficult they found visiting care home residents with dementia, especially when they had no ready access to specialist dementia services from elsewhere in the NHS.
• The study revealed examples of residents being admitted to A&E departments if care home staff needed a psychiatric opinion, putting further pressure on hospital wards. In contrast, when visiting nurses from a care home specialist team were linked to other NHS services they were able to involve, and work with, specialist services and hospital admissions were avoided.

Lead author Professor Claire Goodman (pictured) from the University of Hertfordshire’s Centre for Research in Primary and Community Care, said: “It is essential that residents in care homes – some of the oldest and frailest in society – have access to healthcare that is equitable and equivalent to those received by older people living at home.

“The Optimal study shows what needs to be in place for this to happen and found many examples of effective integrated working. Across England, however, access to healthcare for care home residents continues to be highly unpredictable.”

Goodman, who is also a NIHR Senior Investigator, continued: “There is an unrelentingly negative narrative in the public consciousness around bad care in care homes. Yet with 460,000 people living in UK care homes, occupying three times the number of NHS hospital beds, care homes should be seen as an integral and important part of the health and social care system.

“Just as we talk about ‘improving’ and ‘outstanding’ schools, we need to develop a positive vision for what a good care home looks like and the Optimal study has sought to support this. If we see care homes as part of the landscape of care – as a solution not a problem – then we have a real opportunity to get the delivery of healthcare in care homes right.

“Our study has shown that the provision of healthcare services to care homes is likely to be most effective when NHS services have time to learn how to work with care homes and value the work. Access to expertise in dementia care is important for both NHS and care home staff, as is ongoing GP involvement.”

“When the NHS views a care home as a valued partner then there is a greater willingness to work together to solve problems and a culture of blame recedes. When healthcare for care homes is co-ordinated and recognised as important by the NHS then residents benefit and there is a much more appropriate use of hospital services.”

Professor Julienne Meyer, Professor of Nursing Care for Older Adult at City, University of London and co-author of the paper, said: “Our report shows that it’s time for the NHS to see care homes as partners not problems, and to achieve this we have identified a number of ways that the NHS and care homes can work better together to deliver high quality, cost-effective healthcare to the near half million people in residential care. We are all going to get old, so we need to ensure that the lives of older people, and the care homes they live in are properly supported to deliver effective care in collaboration with the NHS.”

The three-year study, funded by NIHR, involved seven UK partner universities – the University of Hertfordshire (lead), University of Nottingham, University of Surrey, Brunel University, City, University of London, Kings College London and University College London.

The full report: Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings can be accessed here.