Jef Smith considers the often controversial issue of healthcare in care homes, paying particular attention two separate reports on the matter and their ongoing place in discussions on the quality and availability of primary care within care homes.
No care home manager or practitioner needs reminding of the difficulty of keeping up with publications about social care. Reports, policy statements and papers from learned societies, professional associations and pressure groups appear with such frequency that it would be difficult merely to keep track of everything published, let alone to fully absorb all of the content.
The shift from hard to electronic copy may have limited the pile of paper mounting in the in-tray, but some guilt may linger as a result of the mass of potentially useful material produced each year that goes unstudied owing to the sheer number of publications flooding the industry.
It may not be very tactful, therefore, to remind you of a document you may have read, learned and inwardly digested when it first appeared in 2011.
The Quest for Quality in Care Homes report of a Joint Working Party Inquiry hosted by the British Geriatrics Society (BGS) examined the quality of healthcare support for older people in care homes. It generated significant attention at the time, though it is rarely referenced in current literature and discussion on the area.
Four years is a long time in a field as fast-moving as health and social care, but when so much energy and thought has gone into such an important topic, it seems remiss to simply allow the end product to slip from our memories. The working party described their endeavour as “a call for leadership, partnership and quality improvement”, but has this call been answered?
The topic, after all, remains as important as ever. In its 2012 Health in care homes report, the Care Quality Commission (CQC) found that as many as 10% of homes were paying for GPs to visit, and in the intervening period little seems to have changed. As recently as 13 August this year, Care England — whose Chief Executive, Professor Martin Green, was a member of the BGS working party — called for an end to the practice of care homes paying retainers in order to ensure NHS care for residents. In support of this stance, Professor Green quoted NHS Chief Executive Simon Stevens, who in his Five Year Forward View, published in late 2014, had emphasised “the importance of care home residents having the access to the healthcare they would if they were living in their own homes”.
Charging for GP services
One of the eye-catching features of Professor Green’s statement in criticism of the practice was the claim that one of Care England’s member organisations pays £70,000 per month to ensure GP services for its residents. He did not say whether this amount was paid to cover one home or several homes, or how many residents were involved in the deal, but the figures themselves are not critical to this issue. The principle at stake is that NHS primary care should be free at the point of delivery; Care England holds that any deviation from this fundamental value is at the very least unethical, or even, though no case has yet come to court, illegal.
Care England accepts that it is reasonable for GPs to charge for “enhanced” services, but maintains that there is no clear explanation of the difference between “enhanced” and “basic” in this field, and that the definition of what constitutes a “basic” service provided within the GPs contract is far from explicit. It is the responsibility of the Department of Health (DH) to address this confusion, but the GPs contract is such a historically sensitive area that Care England’s appeal is likely to go unheard.
Simply looking after the day-to-day health needs of residents in care and nursing homes can be seriously demanding on GPs. This is the case even when laying aside such obvious extras as carrying out medical examinations of new staff, formally advising on health and medication procedures, and auditing a home’s practice in relation to, say, end-of-life care or communicable diseases – services for which any reasonable home manager would expect to negotiate a specific fee. GP visits to older people living in their own homes are now rare, but many people in residential homes are often so poorly much of the time that expecting them to make the journey to a surgery is quite unrealistic. Then again, the fact that so many patients are grouped in one place makes visiting them at the care home much more economical than it would be for a similar number of visits in the wider community.
Perhaps predictably, the BGS report was silent on the highly controversial matter of money. It recommends that “the UK nations’ health departments should clarify NHS obligations for NHS care to care home residents”, but goes no further. It is possible that its authors deliberately side-stepped an issue they realised might alienate their primary care colleagues, but it is actually typical of the report’s tone that it declines to offer that level of detail. This is not necessarily a criticism, since the principles it sets out, which form the bulk of the report, are valuable as they provide a sound framework for the complex relationships on which effective interdisciplinary practice depends.
Models of working
Having considered the best arrangement for a care home to have with its local primary care authorities, the BGS report admits that there can be “no clear support for a specific model of care”. This is surprising as the authors had at that point already stated that older people in homes have “high levels of clinical and personal needs due to their physical and mental health” and that “there are many examples of good practice in care homes which demonstrate that care and support can be delivered effectively”. Quite why that good practice could not be described in a manner which would allow it to be replicated is not clear. In truth, the authors do themselves something of a disservice, as in their final conclusion they do in fact come up with a list of the key elements in “the likely features and principles of an effective NHS service to care homes”.
The first of these is described as “Primary Care Plus”. This may take the form of GPs working exclusively with homes, but in any case it requires “specification over and above the contractual obligations of conventional general practice”. Although it does not directly address the issue of who would pay for such an enhanced service, the report does quote a couple of useful statistics relating to the issue of funding; a study undertaken by the Sheffield Primary Care Trust showed that 25% of hospital admissions from care homes are avoidable, while other research indicates that the cost of each admission is between £2000 and £3000. Even allowing for margins of error and argument over definitions, this evidence suggests that an impressive amount of money could potentially be saved.
The other suggested features of an NHS service to care homes included in the BGS report are more predictable. The need for better care planning, more consistently shared records, improved community pharmacy, closer links with community mental health teams, and more readily available sessional commitments from specialists such as geriatricians, rehabilitation physicians and palliative care teams are all familiar to homes, though they bear restating.
The basis for planning a newly admitted resident’s healthcare, the report repeatedly stresses, is a thorough post-admission health assessment. Whatever other checks have been made or reports written prior to admission, the GP who is now going to have the lead responsibility for those residents’ primary care should surely take the opportunity to establish a relationship and familiarise themselves with the problems likely to occur. Yet, two years later, CQC found that this basic procedure was not available to a third of homes and another 7% had to pay for it.
Several of those interviewed for the BSG report claimed that policies in some care homes actually frustrate good healthcare practice. A community matron, for example, complained that homes did not have supplies of antibiotics and steroids to use in emergencies, though the authors explain that regulation does not allow homes to hold stock drugs. This seems to relate to the CQC’s later finding that over a third of homes reported that they sometimes have problems getting medicines to residents on time. If residents who urgently need medicines are not getting them, there is surely a gap in the present system which requires addressing, but who should take the initiative?
Staff training and skills
One further area tackled by both between the BGS and CQC reports is staff skill and training. The BSG researchers identified a lack of confidence which led staff to seek immediate medical advice or hospital admission in situations which may not warrant either, and which also inhibited them from challenging inappropriate medical decisions. Though the authors caution that “greater knowledge itself may not be the most important requirement”, this failure to play a role in crucial decision making failed to make use of care workers’ “insight and better knowledge of residents’ feelings and priorities”.
The CQC found that while 75% of staff felt “confident in understanding residents’ healthcare needs”, the lack of confidence of the remaining quarter is a cause for concern. The explanation lies perhaps in the fact that while the vast majority (93%) of homes provided training in dementia, barely a half (52%) gave staff any training in coping with strokes and not much more than a third (36%) had attended training in continence care in the previous six months. Added to the fact that a majority of staff in homes still lack even a basic qualification, this reflects poorly on staff capacity to tackle some of the quite basic healthcare demands of their residents, let alone to contest what may prove to be wrong decisions by GPs who may not be fully informed of all of the details of the patient’s condition and needs.
Relatively fit older people these days sometimes warn each other — only half-jokingly — of the dangers to their health of being admitted to hospital. The evidence of both the BSG and CQC reports is that in at least some respects going into a home also runs the risk of damaging your health. What is certain is that the extremely vulnerable groups of people who find their way into residential care are not getting the guaranteed high quality healthcare their frailty cries out for. The BSG and CQC studies were carried out four and three years ago respectively, so is it time for another enquiry? What would be rather better would be some action to tackle what we already know to be wrong with the provision of primary care in care home settings.