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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Promoting integration between care home staff and visiting healthcare professionals was the common success ingredient behind diverse efforts to improve residents’ health.

Collectively called “relational working”, it involved things like staff jointly identifying, planning and implementing care procedures. Other approaches, like paying doctors to do more in care homes, and or investing in training of care home staff, were not linked to better outcomes on their own.

People in care homes have complex care needs requiring input from many different professionals, from podiatrists to continence nurses. There are many different approaches but no clear direction on how best to organise or coordinate these inputs.

This NIHR-funded review of literature and interviews with care home staff and service organisers aimed to understand why some approaches worked better than others.

The resulting emphasis on relational working supports the British Geriatric Society’s 2011 report “A quest for quality in care homes” which calls for a partnership approach with care homes and social care professionals.

Why was this study needed?

Around 450,000 people live in care homes in the UK. These residents often have multiple physical and or mental health disabilities such as dementia, resulting in complex healthcare needs that need special planning and implementation. In a research project on their views, older people themselves wanted better care, to meet their individual circumstances. But there is no single national strategy on how to organise healthcare services to meet these needs.

As a result, different areas have tried different things. Some created specialist care home teams, while others tried using incentives or targets to improve existing service providers.

Scaling up of locally successful projects has proved difficult.

This review addresses the need to establish two things. First, how different health service models are attempting to improve health outcomes for care home residents. Second, understand the factors behind successful approaches so they can be cultivated in other places.

What did this study do?

This realist review used literature searching and interviews to find out how and why different care service models were impacting the health and wellbeing of residents in care homes.

The review was informed by 64 reviews, surveys, interview transcripts, book chapters or professional opinion reports referring to one of five health outcomes of interest to health commissioners and residents. These five outcomes were: medication use; use of out-of-hours services; hospital admissions including emergency department attendances; length of hospital stay; and user satisfaction.

Searching published literature and interviewing NHS and local authority commissioners, care home providers, regulators, managers, residents and their families gave the researchers their first insights and preliminary theories.

These were challenged by another search of the published literature before scrutiny by a nine member advisory panel with expertise in providing or receiving care home services.

What did it find?

  • Strategies that supported relationship building, integration and collaboration between care home staff and visiting healthcare professionals explained differences in how successful interventions were accepted and embedded into care homes. Collectively this was called “relational working”.
  • Encouraging visiting healthcare and care home staff to jointly identify, plan, and implement care procedures, when supported and facilitated by visiting doctors, was seen as important to achieve good care home outcomes.
  • Other factors like financial incentives or sanctions, agreed protocols, clinical expertise and structural approaches to assessment and care planning could support improvement through relational working, but could not achieve successful outcomes on their own.

What does current guidance say on this issue?

The British Geriatrics Society website says that standard healthcare provision meets the needs of care home residents poorly, but well-tailored services can make a significant difference.

The conclusions of the realist review are in line with the 2011 British Geriatrics Society report “A quest for quality in care homes” which calls fora partnership approach with care homes and social care professionals. Meaning shared information, assessments, policies, training and learning to support quality improvements.

Care home commissioning guidance and resources are available on the British Geriatrics Society website. NICE advice from 2015 provides guidance for developing an action plan for care home residents’ health.

What are the implications?

The findings reinforce and strengthen the idea that relationship building, integration and collaboration between care home staff and visiting healthcare professionals are essential for successful care home services.

Other approaches, like incentives or boosting clinical expertise, only worked if they were supporting relational working, not on their own.

Commissioners and providers can use this information to assess whether their current activities are supporting relational working in the best way possible, and reconfigure services if necessary. The long term goal must be to determine better what older people in care homes want and need. By doing this closer working relationships can hopefully ensure a 'better life' for older people in residential and nursing care homes.

Citation and Funding

Goodman C, Dening T, Gordon AL, et al. Effective health care for older people living and dying in care homes: a realist review. 2016;16(1):269.

This research was funded by National Institute of Health Research Health Service Delivery and Research programme (HSDR 11/021/02).


Bowers H, Clark A, Crosby G, et al. Older people’s vision for long-term care. York: Joseph Rowntree Foundation; 2009.

NICE. Older people in care homes. NICE advice LGB25. London: National Institute for Health and Care Excellence; 2015.

NIHR Dissemination Centre. Better endings. Right care, right place, right time: themed review. Southampton: National Institute for Health Research Dissemination Centre; 2016.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

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Relational working has many definitions, but in the context of this review it means establishing approaches that promote integrated working between visiting healthcare and care home staff.

The theory is that staff will become less risk averse, trust each other’s opinions and be willing to engage with activities that promote residents’ health and support them to stay in the care home.

On a practical level this means co-designing and joint priority setting of services and outcomes. Means to achieve this include shared learning, education and training, continuity of contact with particular clinical experts, and feedback on achievements between health and care home staff.


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