A note on health and social care systems
This study refers to services in England, which has a purchaser–provider split in the planning and funding of services on the one hand, and their provision.
Primary care organisations (previously called Primary Care Trusts and now called Clinical Commissioning Groups) allocate resources to providers organised as community or hospital Trusts. These providers manage community nursing, rehabilitation and pharmacy services. Clinical commissioners are mostly general practitioners.
Places in care homes (with or without nursing) may be self-financed by the resident or funded by local government.
The quality of care homes is assessed by the Care Quality Commission (CQC), a government regulatory body.
In England, long-term care for older people not living in their own homes is mostly provided by independently owned (for-profit and not-for-profit) care homes, which include 90% of the 10 331 care homes that accommodate 376 250 people, making a sector that in terms of bed numbers is three times the size of the National Health Service (NHS) hospital bed complement. Care homes is a generic term for long-term care providers and encompasses care homes that have on-site nursing and those that do not. The typical care home resident is female, 85 or more years old, in the last phase of her life, living with cognitive impairment and in receipt of seven or more medications. A substantial proportion live with depression, impaired mobility and persistent pain [British Geriatric Society (BGS), 2011; Goodman and Davies, Reference Goodman and Davies2011; Gordon et al., Reference Gordon, Franklin, Bradshaw, Logan, Elliott and Gladman2014)]. Care home residents rely on general practice for both their medical care and for access to specialist services.
The care home sector is diverse, varying in size, ownership, funding sources, focus, organisational culture and presence or absence of nursing on site (Davies et al., Reference Davies, Goodman, Bunn, Victor, Dickinson, Iliffe, Gage, Martin and Froggatt2011; Goodman et al., Reference Goodman, Mathie, Cowe, Mendoza, Westwood, Munday, Wilson, Crang, Froggatt, Iliffe, Manthorpe, Gage and Barclay2011). Across the NHS there are numerous approaches to provision of health care for residents, including: general medical care provided by general practices, community services linked to homes, outreach clinics, care home specialist nurses or support teams, pharmacist-led services, designated NHS hospital beds and enhanced payment schemes for general practitioners (GPs) to undertake additional work (Hayes and Martin, Reference Hayes and Martin2004; Donald et al., Reference Donald, Gladman, Conroy, Vernon, Kendrick and Burns2008; ECCA, 2008; Joseph Rowntree Foundation, 2008; Gage et al., Reference Gage, Goodman, Davies, Norton, Fader, Wells, Morris and Williams2010; Gladman, Reference Gladman2010; Lawrence and Banerjee, Reference Lawrence and Banerjee2010; Thompsell, Reference Thompsell2011). As a result of this diversity, some care home residents may have unequal access to NHS resources, particularly those that offer specialist expertise in dementia, rehabilitation and end of life care (Jacobs et al., Reference Jacobs, Alborz, Glendinning and Hann2001; Glendinning et al., Reference Glendinning, Jacobs, Alborz and Hann2002; Goodman et al., Reference Goodman, Woolley and Knight2003; Goodman et al., Reference Goodman, Robb, Drennan and Woolley2005; Alzheimer’s Society, 2007; Steve et al., Reference Steves, Schiff and Martin2009; Robbins et al., Reference Robbins, Gordon, Dyas, Logan and Gladman2013).
A recurring policy concern is that the ways in which problems are defined and services organised by the NHS do not always reflect the needs and wants of older people and their relatives, nor those of care home staff (Goodman et al., Reference Goodman, Davies, Dickinson, Froggatt, Gage, Iliffe, Martin and Victor2013). Szczepura et al. (Reference Szczepura, Nelson and Wild2008) summarised the evidence on best ways to improve medical care in care homes without on-site nursing, and concluded that the provider needed to be more proactive with a focus on prevention of health crises, complications or worsening disability, and that primary care should work strategically with care homes to achieve these goals. There is evidence, for example, that targeted support by local NHS services in end of life care and in medication management can improve outcomes for care home residents (Szczepura et al., Reference Szczepura, Wild and Nelson2011). However, despite this evidence base and our understanding of the barriers and facilitators to collaborative working, there is uncertainty about how to sustain effective joint working between the NHS and care homes functioning as independent providers of care for the oldest old.
The 2010 CQC survey (Carter, Reference Carter2011) of Primary Care Trusts found that patterns of NHS services for care homes were disparate and lacked coherence, with limited ability to support reviews of care or audits of quality or of cost-effectiveness. At the time of the CQC survey, 40% of Primary Care Trusts in England were using Local Enhanced Services payments to incentivise GP practices to provide services to care homes. However, the survey could not establish how many care homes benefitted from this extra investment, nor in what ways. For example, the same payments could have been used to develop and expand work in care homes or to close a gap in GP provision. The survey found no evidence of governance or outcome targets that were care-home specific.
A BGS report on the quality of health care support for older people in care homes, published in 2011, concluded that there was a need to clarify NHS obligations to care home residents (BGS, 2011).There is no definitive evidence, which dictates whether these activities will be better provided by enhanced primary care or specialist services but subsequent guidance for commissioners (BGS, 2013) sets out a range of outcomes for residents, the NHS and care homes, how these outcomes may be achieved, and suggests how they may be monitored and evaluated
This paper explores the complex relationship between the NHS and care homes. It reports the findings of a survey of published and unpublished studies of the range, frequency and type of NHS service provision for care home residents. The study was carried out to establish a benchmark for further research into collaborative working between the two sectors. This study (OPTIMAL) is funded by the NIHR (HS&DR Project code11/1021/02).
To obtain a comprehensive overview of the range, frequency and type of NHS service delivery and build on an earlier review of NHS involvement in care homes (Gage et al., Reference Gage, Dickinson, Victor, Williams, Cheynel, Davies, Iliffe, Froggatt, Martin and Goodman2012), we reviewed surveys of how NHS services in England were provided to care homes completed since 2008. Document retrieval, review and scrutiny of papers and reports, information retrieval and preliminary analysis were carried out by two researchers. To be eligible for inclusion the surveys had to focus on health care delivery to care homes in the United Kingdom and had to be completed since 2008. This review updated the findings from the APPROACH national survey that focused on care homes without on-site nursing (Davies et al., Reference Davies, Goodman, Bunn, Victor, Dickinson, Iliffe, Gage, Martin and Froggatt2011).
We searched the following electronic databases; Medline (PubMed), CINAHL, BNI, EMBASE, PsycInfo, DH Data, Kings Fund. In addition, we contacted care home-related interest groups and used lateral search techniques, such as checking reference lists of relevant papers, and using the ‘Cited by’ option on Web of Science (WoS), Google Scholar and Scopus, and the ‘Related articles’ option on PubMed and WoS.
The search terms used were: ‘Care homes health care survey’, ‘residential care health care survey’, ‘nursing homes health care survey’, ‘older people health care homes survey’, ‘older people health residential care survey’, ‘older people health nursing homes survey’, ‘health service provision care homes survey’, ‘health service provision nursing homes survey’, ‘health service provision residential care homes survey’, ‘long term care health care survey’, ‘long term care health care survey’, ‘long term care health care survey’, ‘long term care health service provision survey’.
Online searches were conducted on the websites of care home researchers known to the OPTIMAL team, voluntary sector providers of care homes, other care home organisations and their representative and professional organisations. Where possible the websites of NHS regional management structures (strategic health authorities) were searched to identify care home initiatives referred to in their annual reports (up to March 2013). However, as these were in a state of flux due to reorganisation not all websites were available. We also requested information through primary care and care home e-networks (eg, My Home Life Network, National Care Home Research and Development Forum, the Primary Care Research Network (PCRN), clinical study groups of the Dementias & Neurodegenerative Diseases Research Network (DeNDRoN) and the Age and Ageing network).
Electronic search results were downloaded into EndNote bibliographic software. Two reviewers independently (S.D., C.G.) screened all titles and abstracts of citations identified by the electronic search, and extracted data from included studies using a standardised form. Data extraction was structured to capture forms of NHS service provision for care homes in England in terms of frequency, location, focus and purpose and, where possible, funding.
Due to substantial heterogeneity in study design, interventions, participants and outcomes we did not pool studies in a meta-analysis. Instead a narrative summary of findings is provided. Since the paper is about a review of published literature, no approval was needed from an ethics committee.
The searches identified 15 surveys, of which five focused on general practitioner service provision to care homes, while also collecting data on specialist services. The other 10 focused on specialist services to care homes, or were topic-specific; for example, concerned with dementia or with end of life care. In the five surveys that concentrated on generalist provision data were collected from care home managers, with the exception of the CQC study analysed by the BGS (Carter, Reference Carter2011). Insight about how wider NHS provision was organised was limited in this subset of studies, although some information on geriatrician services was reported in the survey by Steves et al. (Reference Steves, Schiff and Martin2009), and on dental care by the British Dental Association’s survey (BDA, 2012). Table 1 summarises these studies.
Most surveys focused on care homes, relied on care home managers to provide most of the information on service provision, together with input from other health and social care professionals, including GPs, geriatricians, primary care lead nurses, registered nurses working in care homes, other care home staff and dentists. Studies of specialist services for care home residents are shown in Table 2.
Only two surveys included residents as participants, one of which also included relatives of residents who were unable to participate due to cognitive impairment. The main method of data collection was postal or online questionnaires, although some used face-to-face interviews with care home residents and telephone interviews with GPs.
We summarise the survey findings under the two headings used to present the surveys themselves: ‘primary care’ and ‘specialist services’.
Primary care was seen, in most studies, as key to the provision of good quality health care for care home residents, including end-of-life care, but there was no consensus about how GP and other primary care services should be organised in relation to the care homes. There was variability in services provided to care homes with, for example, some GPs providing regular medication reviews (six monthly or yearly), while some did post-admission assessments. The majority of care homes surveyed worked with multiple practices and multiple GPs. The largest number of practices visiting one care home was 30 – although some had a single, designated general practitioner. Consultation arrangements were variable. Some GPs did weekly clinics, while others visited only on request. This variability was mirrored in family and residents’ views; one survey found that only 56% reported good access to and support from GPs, with 55% of staff also reporting that residents got enough support from general practitioners (CQC, 2012).
The numbers of different types of nurses involved in working with care homes was striking. It was not possible to determine if there was a duplication of provision in some care homes and limited access to specialist nursing support for others. Eight types of nurses were identified as visiting care homes. District nurses were most frequently mentioned. Nursing services could be organised as a service for the care home (community psychiatric nurse, nurse practitioner, nurse consultant, falls prevention nurse, nurse-led care home team) or provided on a resident by resident basis (district nurse, continence specialist, tissue viability, palliative care, Parkinson’s disease nurse).
A common theme mentioned by care home managers was the difficulty experienced in accessing some specialist services, especially palliative care teams, geriatricians and old age psychiatrists. Accessing dental care was also reported as problematic in some places, and this was reflected in the CQC survey (Carter, Reference Carter2011) in which large numbers of relatives and residents reported that they were unsure how to access dental services. This was corroborated in the dentistry-specific surveys with Monaghan and Morgan finding that residents with their own teeth were much less likely to report regular dental check-ups (19%) than older people living at home (Monaghan and Morgan, Reference Monaghan and Morgan2010). However, in some surveys, care homes reported good access to specialist services. Although surveys were able to measure the frequency of contact, very few addressed the quality and range of provision.
Despite the multiple services identified as having contact with care homes, one survey suggested that moving into a care home did not increase residents’ access to NHS services (Darton, Reference Darton2011). However, there was some evidence that care homes with nursing staff had greater access to geriatricians than did residential care homes.
We found 15 recent surveys of working arrangements between the NHS and care homes, of which five were primarily focussed on primary care, whereas 10 focussed on specialist services. Different patterns of GP working were noted, including the use of payments above and beyond those in the standard GP contract. Access to a large variety of health professionals and services was found (eg, with eight different types of nurse) but access seemed to vary markedly. Access to dentistry was poor.
The wide variation in organisation, provision and funding of both enhanced generalist and specialist services to care homes is likely to persist as clinical commissioning groups develop and seek solutions that address local needs. Localism may actually be to the advantage of the care home sector given that it too varies between regions. There is the possibility that GP commissioners can now respond more strategically to their local needs. For example, care homes in Nottinghamshire were reported as having more access to community pharmacists than found in other surveys. Nevertheless, commissioners have first to recognise that the sector requires special consideration. Although there was some evidence from the surveys of the development of care home-specific services, these were the minority and it was impossible to establish how many residents they supported. Similarly, geriatric medicine departments input to care homes was predominantly in response to referrals and requests rather than proactive with dedicated staff time for care home work. The surveys we found did not explore access to mental health services in detail, but an earlier study by Purandare and colleagues of 1689 home managers who responded to a Postal survey sent to a random sample of care homes in the United Kingdom suggests that around a half had input from social workers and psychologists, and two-thirds were supported by old age psychiatrists and community psychiatric nurses (Purandare et al., Reference Purandare, Burns, Challis and Morris2004).
Care homes that are members of corporate chains may benefit from the company’s managerial depth to both influence access to NHS generalist and specialist services, and supplement gaps by residents’ payments for in-house provision (eg, podiatry). In Bowman’s study of 204 Nursing and dual registered homes (Bowman, Reference Bowman2005), the homes were well supported by NHS services with more than 80% receiving most services, including palliative care, and over 90% receiving input from dieticians, physiotherapy, dentistry, continence advisors, CPNs, opticians, pharmacists, podiatrist and speech and language therapists (SALTs). In another survey, access to community NHS services and the quality of service received were reported to be better after relocation to a care home (Seymour et al., Reference Seymour, Kumar and Froggatt2011).
Care home residents arguably represent a large, underserved population with extensive unmet needs. By bringing these diverse studies together, we have identified that the issues are not localised or limited but generalised and replicated across the country, regardless of whether surveys are conducted by the NHS, voluntary sector, care home. There appears to be uncertainty about where roles and responsibilities are shared. Where shared, the lines of demarcation are subject to local negotiation and where such negotiation is not explicitly conducted, gaps, rather than overlaps, characteristically appear in service provision (Gordon et al., Reference Gordon, Franklin, Bradshaw, Logan, Elliott and Gladman2014). It is also likely that, historical differences in local funding of NHS services, different patterns of innovation within the NHS, and variable levels of organisation inside the care home sector have shaped patterns of service delivery. While this review of surveys cannot differentiate between these factors, it does highlight the need for commissioners to be aware of, and respond to them in specifying an appropriate service for care homes looks like.
Strengths and limitations of the study
This is the most comprehensive review to date of what is known about the working relationships between the NHS and the care home sector. The details of its findings should be interpreted with caution, given the variable survey methods, wide range of recruitment methods, different sample sizes and different depths of detail in the 16 studies. The methods were suitable for finding survey material not in electronic databases, but there is a possibility that there are other surveys that have been conducted that we were unable to locate. However, in our view it is likely that they would only increase the evidence in support of our main findings about variety and diversity. Our deductions from the surveys are limited by the quality of the surveys themselves, and being in the grey literature implies that they were not conducted with the rigour of research. For example, it is not clear whether ‘regular visits from a community geriatrician’ means exactly that or simply access to one. Similarly, surveys did not distinguish between NHS-provided physiotherapy and private physiotherapy, or between ‘group’ and ‘individual’ physiotherapy. Care homes may report that they organise a ‘private physiotherapist’ for their residents when they are, in fact, purchasing chair-based exercises that take place regularly in the day-room. Local surveys may refer to local services whose functions are uncertain, as there is no common and accepted terminology or taxonomy for community health services. This, and the diversity in provision, makes it hard to provide precise figures about levels of provision or meaningful averages.
Implications for commissioning
Care homes provide a crucial role supporting a vulnerable, frail population. Services commissioned for care are insufficiently comprehensive (eg, they miss podiatry, dentistry, physiotherapy), co-ordinated (predominantly reactive rather than pro-active) or expert (limited access to specialist expertise in old age psychiatry and geriatric medicine). Commissioners need to ensure that older people in care homes currently receive age appropriate timely and equitable care as required by the Equality Act (2010), and to make explicit how services can be accessed and the criteria against which performance is measured. There is a strong case to establish what is and what is not covered by the General Medical Service contract for general practice, to consider means of assuring compliance with the contract, as well as considering the adequacy of the contractual obligations. If more GP input is required, there should be a mechanism for this to occur ubiquitously rather than fortuitously.
Implications for research
Given the heterogeneity of services delivered to care homes, the lack of evidence-based explanations for this variation, the lack of comparative outcome or resident experience data, and the instability of the current configurations, several research questions emerge:
∙ What organisational characteristics (of the NHS and of care homes) are associated with better outcomes?
∙ What clinical processes facilitate the achievement of best outcomes (identification of at risk patients, use of care pathways, etc.)?
∙ What commissioning arrangements best secure and sustain the optimal service pattern (eg, incentive payments, integrated clinical governance)?
∙ How do local circumstances such as size of home and case-mix of residents affect these factors?
To date evaluation has focused on single initiatives or new models of service delivery. There is a need for a comparative analysis that can explore the associations of service delivery patterns with contextual care homes factors and different ways of working in order to clarify the optimal commissioning decisions to provide equitable care for residents. There is a question about the utility of conducting further surveys for academic purposes, or even for local service development purposes. Researchers should try to develop and consistently use a taxonomy for health care services for care homes and their residents.
The number of surveys identified and the consistent nature of their findings, despite their methodological diversity, indicates that there is no need for further, descriptive surveys of the inadequacies of existing provision. However, there is a need to know what is achieved by NHS input to care homes (GPs, community nursing, AHP and specialist services) and which models of service delivery are most effective. The absence of a national minimum data set on the health-related characteristics of residents in care homes (as is available in the United States) makes it difficult to judge the relationship between service provided and needs observed. Nevertheless, over the decade since the first national survey of health care provision to care homes (Jacobs et al., Reference Jacobs, Alborz, Glendinning and Hann2001), the findings summarised in this paper demonstrate the need to move beyond surveying or auditing the status quo. We suggest that this calls for a robust and testable framework for understanding the relationship between the NHS and care homes. This is required before we can specify different ‘models of care’, in order to compare their effectiveness in relation to outcomes and costs.
This research was funded by NIHR Health Service Delivery and organisation (HSDR 11/021/02). The views and opinions expressed therein are those of the authors and not necessarily reflect those of the NIHR HSDR or the Department of Health.