Long-term relationships and joint working between community health practitioners and care homes are the keys to improving appropriate hospital admissions and access to medications. Additional payments for GPs, jointly agreed protocols, clear role specifications and structured systems have impact only if they trigger and sustain collaborative working.
This realist evaluation in 12 English care homes for older people explored contexts for ‘relational working’ in three service delivery models alongside the theoretical mechanisms by which this type of working achieves better outcomes for residents.
The researchers report that care home residents use a wide range of external NHS services including GPs. They point out that before their research primary care provision in care homes was thought to be inadequate compared with that received by older people in the community. This could potentially worsen the impacts of multiple health conditions on residents’ quality of life.
The findings support efforts at integration set out in the NHS Framework for enhanced health in care homes in England. Training is needed for care home staff and NHS practitioners in the areas of dementia and medicines management, and can be applied to the design of services elsewhere.
Why was this study needed?
More than 400,000 older people live in 19,000 independently owned UK care homes, with the majority aged over 85 years. Care home residents’ multiple long-term health conditions often include dementia and mobility problems.
Yet care home residents’ receipt of health services does not match this level of need. Only around 45% of 81 care homes inspected by the Care Quality Commission reported scheduled GP visits. An analysis of 2011-12 hospital administrative data estimated that residents experienced half as many outpatient appointments as did their age group as a whole.
The NIHR-funded OPTIMAL study aimed to understand which NHS and care home activities in three service delivery models improved healthcare outcomes for older residents, and how improvement occurred, for whom and in which contexts. This methodological approach is in contrast to evaluations assessing the overall effectiveness of delivery models.
What did this study do?
This realist evaluation used evidence reviews and 58 stakeholder interviews to identify and refine theories of change for how activities affect patient outcomes (use of community and out-of-hours services, medication use and review, hospitalisations and resident satisfaction).
Longitudinal case studies took place in three geographic areas to test the theories. One area had multidisciplinary care home-specific teams. Another area gave incentivising payments to GPs designated to individual care homes. The third area delivered training to care home managers.
Researchers collected quantitative outcomes and costs data over a year in four care homes in each locality. They conducted 181 in-depth interviews with residents, care home staff, external healthcare practitioners and family members. Findings are general observations arising from careful review of the data and are based on emerging theories about why certain ways of working might have more or less success.
Findings are based on small numbers of homes in England, so will need further consideration if they are applied in other health systems such as those in Wales or Scotland.
What did it find?
- Healthcare provision for care home residents is reactive and patchy. This includes unnecessary hospitalisations; inadequate out of hours/emergency care including psychiatric; and a lack of dentists and speech and language therapists.
- Established respectful relationships between NHS practitioners and care homes enable ‘relational working’ in the co-design of services and in shared healthcare planning for individual residents. Over-emphasising NHS agendas such as hospital admissions as a rationale for joint working can lead to short-termism and distrust.
- Commissioners and managers support relational working by formally endorsing, incentivising and paying for the protected time of GPs, other NHS practitioners and care home staff. This results in practitioners prioritising this joint work against the backdrop of routine professional work and their wider caseload.
- GPs’ regular presence in care homes is important, even where nurses and other NHS practitioners provide input such as care plans and service development. GPs find their input sustainable when supported by dedicated NHS care home-specific services, not just services aimed at individual residents.
- Care home staff appreciate a range of clinical input relevant to older people: for example, from nurses and others skilled in the care of dementia. When supported with this expertise, staff are more confident in dealing with challenging behaviours. This reduces distress for residents and can lead to less antipsychotic prescribing.
- Regular, GP-held clinics in care homes facilitated access to medicines and more frequent medication reviews. Nurses prescribed and reviewed medication, but this did not substitute for GP involvement. Pharmacists were rarely involved in reviews across these three sites.
What does current guidance say on this issue?
The NHS Five Year Forward View (2014) stated that the NHS would develop shared healthcare models with care homes and local authorities. Based on learning from six pioneer Vanguards, the enhanced health in care homes framework (2016) emphasised co-production and enhanced primary care.
The NICE Quality Standard on medicines management in care homes (2015) states that multidisciplinary health and social care teams should carry out medication reviews. The Quality Standard on mental wellbeing in care homes (2013) and the NICE guideline on oral health in care homes (2017) recommend that residents receive mental health, oral health and dental services at their homes. Wales has separate regulations and standards for care in homes.
What are the implications?
There is no ‘magic service model’ for NHS delivery to care homes. The study found that the costs of each service delivery model were broadly the same. Care homes and the NHS need to work together on an equal footing to achieve tailored local solutions.
The research findings are consistent with the NHS England enhanced health in care homes framework stating the importance of aligning budgets and incentives, joined up commissioning, multidisciplinary teams, and high-quality dementia care. The Vanguards have reported lower growth in emergency hospital admissions than in the rest of England, and cost savings from reducing inappropriate medications.
Citation and Funding
Goodman C, Davies SL, Gordon AL, et al. Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings. Health Serv Deliv Res. 2017;5(29).
This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 11/1021/02).
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NHS England. Next Steps on the NHS Five Year Forward View. Leeds: NHS England; 2017.
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NICE. Medicines management in care homes. QS85. London: National Institute for Health and Care Excellence; 2015.
NICE. Mental wellbeing of older people in care homes. QS50. London: National Institute for Health and Care Excellence; 2013.
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NIHR Dissemination Centre. Advancing care - research with care homes. NIHR Dissemination Centre Themed Review. Southampton: NIHR Dissemination Centre; 2017.
Welsh Assembly Government. National minimum standards for care homes for older people. Cardiff: Welsh Assembly Government; revised 2004.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre