This post is from The King's Fund Blog
Today is national care home open day. This has prompted me to reflect on how some areas have been successful in joining up health care and residential care to better meet the complex needs of people living in care homes. The best-known examples are perhaps the six vanguards for enhanced health care in care homes, but other areas outside NHS England’s vanguard programme have adopted a similar approach.
In these schemes health professionals work closely with care homes and deliver care on site to address issues around access to and quality of health care. The schemes involve greater input from and regular patient reviews by health professionals – GPs, district nurses, consultants and others – who are matched with specific care homes. Care home staff within these schemes may have additional training and undertake new roles, and many schemes include initiatives such as streamlining information flows at admission and discharge from hospital or greater use of telehealth. The aim is to prevent health concerns or detect them early, enabling people to be treated without admission to hospital, and to provide both continuity and comprehensiveness of care.
I’m especially interested in efforts to join up commissioning. When we reported on the future of HIV services in England, we found that three years after a reorganisation of commissioning responsibilities, many services were still adjusting to change. HIV services are not slow: building up new relationships and processes just takes time, especially when people’s needs, financial pressures and other services that are interdependent are all changing at the same time. Until commissioners agree on a strategy, services can easily fall into planning limbo.
The enhanced health care in care homes model involves ‘collaborative commissioning’ across NHS services and residential care. For example, some areas are working towards common service specifications, based on co-production with service users and an ongoing forum with care homes.
It is likely that the key to getting this collaboration right, has been a shared vision of what good looks like. To create this vision areas have evidence to draw on, for example around using comprehensive geriatric assessment (CGA) to keep people well rather than reacting to ill-health, and guidance from the British Geriatrics Society and schemes such as My Home Life.
Enhanced health care in care homes projects are not as large-scale or high-profile as sustainability and transformation partnerships (STPs) or primary and acute care system vanguards. Nonetheless, they can make a significant difference to people’s lives and shouldn’t be overshadowed. Presentations from our conference in 2016 demonstrated how significant reductions in unplanned admissions can be achieved. Our learning network is sharing experience around work such as falls prevention through pharmacists reviewing medicines within care homes in Leicester and introducing Schwartz rounds to support care home staff in providing compassionate care in Hammersmith.
My impression is that the schemes’ benefits have so far been measured mostly in terms of reducing hospital activity, rather than more direct improvements in the quality of care and quality of life of people living in care homes. It may still be too early to expect evidence of benefit to wellbeing and life expectancy, but that definitely needs to be the direction of travel. In the meantime, measures such as preventing avoidable admissions or delayed transfers may serve as indicators of progress, and are likely to help make the case for spreading good practice. It’s quite possible that many commissioners do not appreciate the scale of avoidable hospital stays and the potential financial savings involved in reducing them.
The role of national bodies in supporting the roll-out of new models of care is critical. At the start of this year, expectations were high that NHS England would act to accelerate the spread of good practice between the NHS and care homes in every area of the country. What happened to that? It was not mentioned in NHS England’s Next steps on the NHS five year forward view and the grapevine has gone quiet. Hopefully now that the restrictions on policy announcements during the election period have ended, this will make its way back on to the agenda.
Evidence is growing that investing in joined-up working between care homes and the community-based health care workforce, such as district nurses and GPs, can save money and reduce pressures in other parts of the health care system. Fully recognising achievements so far, I would lay down a challenge for commissioners in local authorities, CCGs and area teams: how will this growing evidence be acted on? What will enhanced health care in care homes schemes tell us about the will and the ability to invest in out-of-hospital services, as envisaged in so many STPs?
We will be holding another conference on enhanced health care in care homes later this year. My hope is that speakers and delegates will provide some answers to these questions, and demonstrate progress in spreading good practice from pioneering projects, to the mainstream.