In the United Kingdom, there are approximately 416,000 people whose home is a nursing or residential care home – roughly the same size as the population of Bristol.
These individuals have a wide range of needs, and require care and support from different health and social care practitioners. Those practitioners face numerous challenges driven, in part, by funding and workforce issues. And in recent years, quality issues in care homes have been highly publicised, featuring in national press and television.
In July this year, my uncle, who lived in a care home, passed away. I found it profoundly moving that staff from his home asked to speak at his funeral - painting a picture of him that was absolutely recognisable to me. While the home was somewhere my uncle received care, it was also his home. He was a resident as well as a patient, and this was reflected in the relationships he had developed with the people that worked there.
This experience showed me that within a challenging context, with the right support, practitioners can deliver excellent care.
National support for local improvement
In the Five Year Forward View, national health leaders in England made a commitment to improve the provision of health and rehabilitation support for care home residents. Shortly afterwards, the New Care Models programme backed up this commitment with transformation funding and support for some areas that had already begun to tackle the issues locally.
One such area is Principia, a multi-speciality community provider in Rushcliffe. In 2014, they began a programme of work to improve care homes, with a specific aim to improve residents’ access to health care.
One initiative the team in Principia has put in place is to align care homes with general practices. This has enabled GPs to visit the care homes more frequently, making weekly rounds to review the health care needs of residents. As a result, health issues can be identified and responded to sooner, potentially improving outcomes. Age UK staff supported residents to share their concerns about their care, for example by developing a ‘worry catcher’ questionnaire that can be completed during a short conversation. As a result, although some residents were nervous about changing their GP to aligned practice, 90% have now chosen to do so.
This change didn’t happen overnight, and a key ingredient seems to be relationships. These were built over time as a result of sustained engagement between the care home managers, GPs, residents, families, Age UK and others from the multidisciplinary care team. Only after these relationships were established were practitioners able to come together from across health and social care to develop a shared view of the underlying issues with residents.
This focus on relationship building and collaboration appears to have had benefits. At an event I attended, I heard a care home manager from Rushcliffe describe how involvement in the programme reduced her feelings of professional isolation and as a result, increased her own job satisfaction. Perhaps the proliferation of such an approach could provide part of the solution to the recruitment and retention issues we see in the sector.
At the Health Foundation, we will be evaluating whether the programme has had an impact on hospital admissions through our Improvement Analytics Unit – a joint initiative with NHS England.
Sharing what works
While we don’t yet know the evaluation results for Principia, it is encouraging that so many ideas are emerging in this sector. The challenge is to identify the ingredients that contribute towards high quality care, so that they can be spread.
I was particularly interested to see the enhanced health in care home framework that was published last month by NHS England. This builds on the experience from the New Care Models programme, setting out seven core care elements that could be adopted more widely by care homes.
It was positive to see that the value of co-production with residents and the importance of building inter-professional relationships described within these elements. The document goes as far to say that such work ‘has the potential to spur a different relationship between health and social care (both providers and commissioners), and a new culture of improvement’ across services within the area.
My concern going forward is that the value of relationships, which came through so clearly at both the Principia workshop and with my uncle, are not lost as new care models are rolled out nationally. The temptation for national policy makers may be to mandate adherence to the identified care elements. While these may have a rationale, they may not have the desired impact, unless space is created for health and social care practitioners to come together with residents and their families to develop a common understanding of the issues faced in care homes within their local area.
Providing space for people to come together
Recent research has provided some relevant lessons. First was an evaluation of a Health Foundation safer clinical systems project to uncover why that project had not been as successful as anticipated in improving care transitions for residents between hospitals and care homes. This not only provided valuable learning but also emphasised the need for practitioners, residents and their families to build trust and a common understanding of the problems before embarking on solutions.
A second example comes from our in-house analytics team, and their evaluation of a national requirement that all patients in England aged 75 or over should have a named GP, and that this GP should be recorded within the electronic medical record. The findings showed that this approach did not achieve its intended aim of greater continuity of care for these patients – demonstrating that meaningful continuity of care is more than ticking a box.
National policy makers must therefore take action to foster a culture of openness and support that allows local areas to co-create solutions – and determine what will work for them locally. This is by no means easy, but perhaps the approach taken by the new care models programme provides some answers.
Anna Starling (@annastarling) is a Policy Fellow at the Health Foundation