Caring for older people in care homes is one of the most important priorities for the health and care system in England. The ‘average’ care home resident is an 85-year‑old woman, with a life expectancy of 12–30 months. Her care needs are likely to be extremely complex, with six or more diagnosed conditions, seven or more prescribed medicines, and a combination of physical frailty, disability and mental health conditions. Older people are the fastest-growing section of the community: the number of people over 85 is expected to double within two decades. The number of older people living in care homes in England (currently 329,000) is already more than three times the number of hospital beds, and is set to increase further (Care Quality Commission 2017; National Institute for Health Research 2017; Wittenberg and Hu 2015).
A string of studies and reports have consistently shown that care home residents – most of whom are already in vulnerable circumstances and have complex needs – often have poor access to health services and especially a full range of quality services that meet their needs (see, for example, Healthwatch 2017; Smith et al 2015; Care Quality Commission 2012; British Geriatrics Society 2011). This is one of the most striking inequalities of the English health and care system.
Historically, care home residents have been under-represented in dementia and other research, and care home services have often been considered separately to health care. But this is now starting to change (National Institute for Health Research 2017). NHS England’s programme to develop new care models is a practical embodiment of the recognition that good health, health care and social care are mutually dependent and need to be approached together (NHS England, undated b). One of the new care models specifically promotes enhanced health in care homes, while others that are focused on urgent care or community services include care homes as key partners.
Hospitals, GPs, community health and social care services working together as one local care system, rather than fragmented or competing services, is also increasingly deemed essential if levels of quality and access to health and care services are to be sustained (Ham and Alderwick 2015; NHS England et al 2014). The NHS and local authorities face significant pressures around capacity and demand (Robertson et al
2017; Baird et al 2016; Maybin et al 2016). The environment for care homes is also extremely challenging, with concerns about the fundamental viability of the way the market operates, and day-to-day difficulties such as a 28 per cent staff turnover rate across social care services (Care Quality Commission 2017; Competition and Markets Authority 2017).
Working together more closely will involve practical changes, such as more integrated care processes and better communication. It will also involve changing cultures, mindsets and power relationships – not least the relationships between large health organisations with highly professionalised staff, and care homes, which are usually small enterprises with staff who often do not have formal qualifications.
For several years, The King’s Fund has helped to develop and promote improvements in practice, understanding and leadership skills to support these changes (The King’s Fund 2016). In partnership with My Home Life, we have also run a learning network for housing, health and social care services working with care homes (see The King’s Fund, undated). This report builds on that experience and is part of a growing focus within The King’s Fund on care homes and social care.
The report will be of interest to people working in care homes, health services, local authorities and clinical commissioning groups (CCGs). Its purpose is to share learning from diverse areas about how staff in these organisations experienced the process of working together more closely. It focuses on what they have actually done to put the high-level aim of closer partnership working into practice.
In some areas, teams of health staff have provided intensive support to care homes facing challenges such as high rates of hospital admission or regulatory concerns. In others, health staff have started working routinely with care homes to ensure regular ‘ward rounds’ so that all residents’ care is reviewed regularly. Other areas used an approach of continuous quality improvement, with providers supporting each other to develop a series of projects to improve care processes. Our interviewees said that common threads running through these different approaches included regular assessment and close working together on care processes, training staff from different organisations together, and a cultural change leading to shared ownership of responsibility for care and greater mutual understanding.
Various studies and reports have shown that when care homes and health services work closely together in these ways, they can achieve impressive results, such
as reductions of 30 per cent or more in urgent admissions to hospital (Baker et al 2016). However, for every study showing achievements, there are others showing
limited results, or that an approach that was effective in one area did not replicate the results when introduced in another. This is because the types of partnerships
that are needed are highly dependent on relationships and on the local context of services, organisations and practices.
When developing projects to enhance health in care homes, a set of partner organisations is identified to define the area that the projects will cover. They then work out for themselves how to adapt and tailor NHS England’s framework guidance (NHS England 2016b) and approaches such as those described in this report to their unique circumstances. The improvements that this enables can be significant, but there are no shortcuts: simply importing approaches developed elsewhere, without adaptation and without involving all stakeholders, is likely to fail. By synthesising and sharing experiences, and reflecting on their implications, this report should help local areas going through the process of developing partnerships and practices that will enable them to maximise the health, quality of care and quality of life for older people living in care homes.