Thursday, 10 October 2013

Why aren’t care homes higher on the agenda in the health debate?

Why aren’t care homes higher on the agenda in the health debate? Much has been said in recent weeks about the role of the GP. The political mantra seems to be that GPs are not accessible and are not providing continuity of care, and that this causes unnecessary and unscheduled hospital admissions for some of the most vulnerable adults in our society – the elderly.
But why has there been little mention of the quality of services in care homes?
This is despite the fact that 20 per cent of over 85 year olds in the UK are in permanent care home residence, and that reports by the Care Quality Commission consistently demonstrate lower quality of care in nursing and residential homes compared to hospitals.
With multiple co-morbidities and multiple medication use, patients in care homes are the most medically complex group of patients in the community. So much so that in the Netherlands, nursing home medicine has been a recognised specialty since 1990, distinct from general practice or traditional elderly care medicine. Yet in the UK, NHS beds have been closed and support for the resulting increased care home population withdrawn, shifting the responsibility of caring for this group from NHS geriatricians to…well that is the issue, to whom? Only 1 per cent of total UK consultant geriatrician time is contractually allocated to care homes, and the needs of residents go well beyond what is covered by the General Medical Services contract.
Nevertheless, GPs have been expected to fill the void, but less than 40 per cent have had specialist training in the care of older people. In a 2010 survey by Pulse, 68 per cent of GPs reported that care home work was a ‘major source of stress’, and 61 per cent felt existing arrangements were unsatisfactory. Formal support is also limited: only 14 per cent of elderly care departments hold regular forums where GPs can discuss more complex cases with hospital colleagues.
Given all of this, and with care homes neatly straddling the health and social care divide, it is perhaps no surprise that, according to figures from the British Geriatrics Society, nationally 68 per cent of care home residents have no regular medical review, 44 per cent have no regular review of medications and just 3 per cent have occupational therapy – a critical service to promote independence
More than 50 years after Peter Townsend concluded that UK care homes were a poorly resourced ‘Last Refuge’ which should be replaced by enhanced community support, it appears their basic remit is unchanged. They remain a place of last resort, and the 29-fold national variation in rates of transition (going from home, to hospital, to care home residence) reflects the ongoing disparity in access to the community services that would enable independent living.
So what is the way forward? The key seems to be recognising the need for dedicated, multidisciplinary teams to provide services within care homes. Creating a national policy to set out the standards required would be a crucial first step, and the forthcoming GP contract negotiationsmay prove to be both an opportunity and a barrier to this process.
GPs are increasingly using local enhanced services contracts, to enable them to establish committed care home services, in which they can conduct care home visits at the same time and on the same days each week.
Under this model, care becomes more pro-active, with residents having a comprehensive individualised assessment on arrival at the care home to identify issues and ease the distress of transition, with a scheduled review every six months. The regular GP contact ensures referrals are made to specialist NHS services as needed, and having a single team facilitates co-ordination of care. Carers are less inclined to call out-of-hours services for patients with acute problems, since they know a doctor will be attending at a set time. The result is a significant reduction in emergency department attendances, increased confidence amongst care staff and improved quality of life for patients.
The benefits are also financial - in the pilot study reported by Briggs and Bright, medication reviews combined with reduced admission rates saved £18,000 per care home, more than covering the £15,000 annual cost of the service.
There are many similar examples of good practice across the country, including North East London Foundation Trust’s dementia outreach programme that has reduced hospital bed use by 33 per cent, saving an estimated £400,000. The Royal College of General Practitioners has also established a ‘GP with a Special Interest’ training framework around elderly care and care homes, and the British Geriatric Society has already published advice on commissioning services for care homes. Our forthcoming conference will be exploring a range of examples of service re-designs in health and social care services that are successfully meeting the needs of an ageing population.
With all this in mind, care homes could become the ‘house of care’ for integrated ‘community medicine’ services that could involve the voluntary sector and encompass the vulnerable elderly living at home.
So much of our effort is spent trying to extend life that our ageing society should be a success story, a cause for celebration. Why then aren’t care homes firmly on the agenda in political debates on the NHS? It’s time we established them as a positive option, not the only one. The King's Fund

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