Case study: Relational working key in delivering high-quality healthcare in care homes
No common approach to health care in care homes
Care homes provide an essential service for nearly half a million older people in the UK who can no longer care for themselves independently. Most care home residents live with dementia and complex healthcare needs, including depression, pain and mobility problems. Achieving good health outcomes for residents relies on good models of care and effective day to day social care. This requires access to co-ordinated health and care services that promote good health and wellbeing as well as respond to health crises.
Around one third of care homes are registered for nursing but all rely on NHS services for medical, nursing and specialist healthcare. In addition to long-term care, care homes often provide respite and end-of-life care too, as well as caring for people who would otherwise be in hospital. Earlier research showed that NHS service provision to care homes and the ways in which residents accessed different NHS services varied across the country. It was clear that improved coordination between care home staff, NHS practitioners and policy makers was needed to deliver the best service for residents, but the best way to achieve it was uncertain.
The Optimal study, funded by the NIHR Health and Social Care Delivery Research (HSDR) Programme, aimed to explore different health care approaches to see which best supported and improved care home residents’ health and wellbeing. Led by Claire Goodman, Professor of Health Care Research at the University of Hertfordshire, the team comprised researchers from seven universities around the UK. Explaining their research, Professor Goodman said:
“Our study demonstrated the benefits of finding common ground and coordinating those services that visit care homes to provide wraparound care. OPTIMAL’s findings identified ways that can reduce the well-documented inequities in how care homes access health care across the country.”
Professor Claire Goodman, lead researcher for the Optimal study
Recognising the value of care homes
The Optimal study was carried out in two stages. In the first stage, the team surveyed the evidence of how the NHS works with care homes, publishing their results in Primary Health Care Research & Development. Their review of previous research on health care models for working with care homes, and interviews with care home residents, managers, health care professionals and commissioners, was published in BMC Health Services Research and the Journal of the American Medical Directors Association. Using their evidence, the team suggested a theory of how a health care intervention to improve residents’ health may work in some situations but not in others.
This theory in the second stage, focusing on different ways of providing health care to residents. The care received by almost 250 care home residents living in 12 care homes in three regions of England was tracked over one year. Each region provided different types of health care services for their care homes: designated care home teams; ‘paid-for’ extra GP provision to care homes with specialist support; and similar access to services provided by GPs and the primary care team to older people living at home. Their results were published in Age and Ageing.
Their analysis identified key elements of care services that, if addressed, were likely to improve residents’ care regardless of the model of care used. As such, high quality care was possible when a model enabled close working and shared aims between care home staff and health care professionals (relational working). Professor Goodman explained how good working relationships were fostered when health care providers’ time at care homes was protected and funded, saying: “NHS organisations need to value and invest in working with care homes, so that NHS input is seen as legitimate and important work.” Feeling valued and listened to was also important for care home staff.
While the study noted some successful partnerships between the NHS and care homes, health care was often delivered in response to illness or crises, rather than promoting good health. Many NHS staff found visiting and treating care home residents with dementia difficult. As nearly three-quarters of care home residents live with dementia, Optimal found that both NHS and care home staff needed access to specialist dementia services to have the support, skills and confidence to treat residents appropriately.
Overall, the three different care approaches accessed similar levels of NHS service at similar cost. However, the region receiving the least dedicated support from GPs also saw the most residents admitted to hospital. The team noted that GP availability and treatment referrals probably played a role in preventing admissions in the other regions. GPs meeting regularly with staff to plan residents’ care and discuss issues, rather than visiting individual patients, was associated with greater confidence amongst staff that residents’ needs were being met.
Influencing national policy and practice
Optimal clearly showed that relational working between health care professionals and care home staff helped them to identify, plan and implement care plans - this was central to providing high quality health care.
Optimal’s work and earlier NIHR-funded research - the APPROACH study - directly informed NHS England’s flagship project, the Vanguard Programme, which developed new ways of delivering care within the wider health and care system. Known as vanguard sites, selected partnerships in local areas, including care homes and health care providers, were supported to develop new ways of working together.
The NHS England’s National Care Homes Lead at the time of the study’s publication, William Roberts, commented that: “The Optimal study clearly identified the importance of working with care homes to design and develop services for residents. The emerging evidence from Optimal both supported and shaped the work NHS England has done to develop a model of care for Enhanced Health in Care Homes.”
In support of the 2019 NHS Long Term Plan’s commitment to the Ageing Well Programme, it is now national policy to put the Enhanced Health in Care Homes framework into practice in England. The framework built on vanguard sites’ experiences to create a model of good practice for other care home and NHS partnerships. As identified by the Optimal study, the framework promotes provision of wraparound care for care homes by the NHS. It also encourages proactive care, focusing on the needs of individual residents, their families and care home staff and supports the view of care homes being partners with the NHS.
Professor Martin J Vernon is a Consultant Geriatrician at Tameside and Glossop Integrated NHS Foundation Trust, Senior Clinical Advisor in Greater Manchester and London and Chair of the North West Clinical Senate. As the National Clinical Director for Older People at NHS England between 2016 and 2019, he directed the roll-out of the EHCH framework in England. Commenting on Optimal’s impact on health care in care homes, he said:
“It has provided much needed and robust evidence for policy reform that will redress inequalities of access to health care experienced by care home residents.”
Professor Martin J Vernon
As the NIHR Applied Research Collaboration’s (ARC) lead a national network of care home researchers, Professor Goodman continues to identify ways to improve relationships and working practices between care homes and the NHS. A current £2.6 million study funded by the NIHR HSDR Programme, DACHA (Developing research resources And minimum data set for Care Homes’ Adoption and use), is building on Optimal’s work in the sector.
Working with researchers from nine ARCs and home care sector and resident representatives, DACHA addresses the inconsistent approaches to handling residents’ information. Its work will ensure that their information is organised, managed and shared in useful ways for those commissioning, providing and reviewing the care of older people.
Reflecting on their research, Professor Goodman said: “Through our research with the Optimal and DACHA studies we are creating new ways of working and doing research in, and crucially with, care home staff and the people they care for, ensuring that planning for the future needs of residents is based on the best evidence.”
The study was funded by the NIHR Health and Social Care Delivery Research Programme.
More information about the study is available on the NIHR’s Funding & Awards website.
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