Failing the Frail: A Chaotic Approach to Commissioning Healthcare Services for Care Homes
Analysis of data collected by CQC about PCT support for the healthcare of older people living within nursing and residential care homes
Executive Summary
In March 2010 the Care Quality Commission (CQC) conducted an on-line survey of PCTs about their services people living in care homes. CQC gave the data to the British Geriatric Society and the Society commissioned a secondary analysis of the data to further inform its campaign about the quality of care in care homes.
There are concerns about the standard of and access to healthcare of the 375,000 older people in England who live in care homes, who typically have greater and more complex health needs than their peers who live in the community. Improvements in their access to healthcare will benefit this population and reduce unplanned and costly demands on the NHS.
CQC’s survey was the first part of a two stage review of healthcare in care homes and with the exception of the data on whether response standard were met, the data refers to the position on 31 December 2009. CQC used a basket of nine exemplar services that older people were likely to use to test the specialist primary care PCTs provided to people in care homes and to their counterparts in the community. One of CQC’s concerns was unequal provision and differential access to services between those living at home and those of equivalent age living in care homes. They also considered whether PCTs provided enhanced GP services as they could not consider mainstream GP services due to the lack of data. As befits a regulator CQC treated “don’t knows” as negative answers.
Main conclusions
1. There is no consensus across PCTs as commissioners about what services older people in care homes need, how care should be provided and what services can do. This follows a decade of research and professional debate that has repeatedly highlighted the healthcare needs of care home residents.
2. PCT interest in their services for care homes is limited. Many PCTs had difficulties in answering CQC’s questions, just 51% had enhanced service agreements with GPs for work in care homes and only 12% of specialist community services involved a care home specific provider.
3. CQC’s data does shows that with 52 different combinations across 152 PCTs there are significant variations in the specialist services available to older people and only in 43% of PCTs are older people likely to have access to all the services they need.
4. PCTs largely ignore the differences between and nursing and residential care homes and with people living in the community as for most services the same provider covered both sectors and where there were different providers they worked to the same response standard. CQC’s data however is about commissioning intentions rather than the service received.
5. Response standards vary greatly between services and areas and many of the longer standards seem inappropriate given the limited life expectancy of care home residents. Further nearly half of services for which there was data did not meet their response standards.
6. Only 60% of PCTs provided a geriatrician service to all older people in contrast to 86-97% for the other exemplar services.
7. These conclusions can be applied to older people living in the community.
Author: Chris Carter is an associate of the Primary Care Foundation (http://www.primarycarefoundation.co.uk/). Previously he worked for the Healthcare Commission and the Care Quality Commission as part of their Reviews and Studies Team, where he was responsible for the design and management of the CQC review into Healthcare in Care Homes.
Main findings
Section 2 - The provision of specialist primary healthcare services
a) Only 65 (43%) PCTs provided all the services CQC considered to be appropriate for all older people. 44 (29%) provided seven or fewer and one PCT provided just three services to all older people.
b) Only 91 (60%) of PCTs provided a geriatrician service to all older people and 44 (29%) either did not provide one or did not know if they did. This compares to 86-97% and 1-12% for the other services surveyed.
c) 95% of specialist services covered all both nursing and residential care homes and in 88% of services the same provider served people wherever they lived.
Section 3 – Response standards for specialist primary healthcare services
d) PCTs had set a standard and provided data for just 39% of care home specific services and 58% of those supplied by a community based provider. 40% of all services lacked a response standard.
e) While 87 (63%) PCTs monitored all the response standards they had set, 50 (36%) only monitored some.
f) 59% of community based services met their response standard, but only in 12 PCTs did all services meet their response standard.
g) Response standards ranged from less than two weeks to 18 weeks for all services, and length did not affect whether they were met.
Section 4 – Activities undertaken by specialist services within care homes
h) While a small number of services did not visit care homes most did, most of which were made on request.
i) 36% of services undertook scheduled visits, which usually supplemented request visits. For all services the frequency set for these visits ranged between fortnightly (and under) to quarterly or less frequently.
j) Almost all services that visit care homes provide individual consultations and advise staff about how to care for these individuals, however about one service in seven will not provide care homes with general advice.
Section 5 – Referral arrangements
k) Only 24% of services have a specific pathway for care home residents and apart from acknowledging the presence of clinically trained staff in nursing homes, referral arrangements for older people are essentially the same wherever people live.
l) With the exception of geriatrician and psychiatry services community nurses can refer patients to at least 90% of services. Their counterparts in nursing homes have slightly more restricted referral rights.
m) For geriatrician and psychiatry services a sizeable minority of services restrict referrals to GPs (40% and 17%).
n) Services do not treat referrals from people without a clinical training consistently: many services that will accept self-referrals will not accept them from care home staff (and vice-versa).
Section 6 – GP services for care homes
o) All but 35 (23%) PCTs provided at least one activity considered by CQC as an enhanced service, or as part of their GMS service. Only 12 (8%) thought that care home residents needed all seven of CQC’s activities.
p) 77 (51%) PCTs provided an enhanced service and 75 (49%) included at least one activity in their GMS service. 35 (23%) PCTs used both approaches.
q) PCTs were divided about whether the activities listed by CQC should be an enhanced service, or even whether the activity was needed.
r) 67% of PCTs did not think care home residents needed additional medication reviews.
s) About a quarter of the limited number of enhanced services covered all care homes.
Section 7 – Influences on the level of healthcare services provided
t) There is no correlation between need as measured by the proportion of older people in a population or the provision of care home places and service provision as measured by the number of services.
u) There are statistically significant associations between PCTs that regarded all CQC’s list of possible enhanced services as being unnecessary and the number of specialist services.
v) Only 69% of PCTs had a multi-agency group that considered care home issues and most groups omitted at least one key interest, such as GPs, care home providers and care home residents.
Introduction
This paper summarises data from a Care Quality Commission (CQC) survey of primary care trusts (PCTs) and councils with responsibility of adult social services on their contribution to the healthcare provided to people living in care homes. It focuses on how far PCTs have responded to the generally higher healthcare needs of people living in care homes through access to specialist community healthcare and GP services.
This paper was commissioned by the British Geriatrics Society (BGS) as a resource paper to inform their work on improving the quality of care in care homes. Therefore it introduces CQC’s review and examines the data collected systematically to identify matters that BGS may wish to pursue, for example through press releases, briefings for selected audiences and journal articles. The following areas are considered:
§ Section 1 – CQC’s Special Review of Healthcare for People living in Care Homes
§ Section 2 – Specialist community healthcare services provided by PCTs
§ Section 3 – Response standards
§ Section 4 – Activities undertaken within care homes
§ Section 5 – Referral arrangements
§ Section 6 – GP services for care homes
§ Section 7 – Influences on the level of service provided
§ Section 8 – Conclusions
1 CQC’s Special Review of Healthcare for People Living in Care Homes
Before outlining the CQC special review that collected the data summarised in this paper, it is helpful to consider the policy context.
1.1 The policy setting
Health care for older people and for those older people who live in care homes in particular poses the NHS a number of challenges, including the rising number of older people who have complex needs, limited life expectancy, comorbidities and cognitive impairment. At the same time costs are increasing and politically contentious questions about how to pay for care remain resolutely hard to solve, as demonstrated by responses to the Dilnot report.[1] Additionally we are more alert to poor standards of care and use matters such as end of life care and “dignity” to gauge overall standards care. Lastly we acknowledge that poor care can breach human rights where it leads to inhuman treatment and a deprivation of liberty.[2] Therefore there are strong and cogent reasons for being interested in the healthcare provided for older people and these reasons are reinforced by the end of real-terms growth in NHS spending.
In March 2010 about 375,000 older people lived in care homes in England and they comprised about 4% of the UK population aged 65 and over and nearly 20% of those aged 85 and over.[3] The 10,300 care homes in which these people live have seen significant changes since the 1970s .An 80% reduction in the number of NHS long-stay hospital beds has meant that the independent sector has replaced the public sector as the main provider of care homes.[4] The care home population is one that is frail and it is estimated that about 70% of residents have dementia.[5] Additionally most residents have mobility problems and many have multiple needs that require on-going care and often medical supervision.[6] These changes have increased the significance of care homes to the NHS, with most places being provided by independent contractors where a command and control relationship is inappropriate. This shift in care provision has made GPs responsible for people who in previous decades would have been in-patients managed by hospital specialists. On a practical level GPs and others caring for care homes residents must take account of the fact that most residents are homebound.
Medication management is a key issue for care homes and how they work with NHS providers as care home residents often need to take a lot of medicines. There are multiple challenges. The Care Homes Use of Medicines Study (CHUMS), part of the Department of Health’s safety programme, identified issues with medicines not being administered safely as seven out of ten care home residents were exposed to at least one medication error. Another Department of Health report “The use of antipsychotic medication for people with dementia: Time for action”, shows definitively that antipsychotic medication often causes harm, while the interaction between medications can produce a sedative effect. And as noted above the majority of care home residents have dementia. [7] In response to the CHUMS report the Department is supporting a project being undertaken by the National Care Forum, five royal colleges, [8] the Health Foundation and Age UK on “An Integrated Approach to Medications in Care Homes”.
Alongside these changes there have been successive reforms in how the NHS is organised. Despite the rhetoric many reforms have been evolutionary and the Health and Social Care Bill 2011, which will make clinical commissioning groups responsible for most healthcare services, is the latest iteration of the provider/purchaser split that was introduced in the early 1990s. This split has made contracts the keys in determining which healthcare services are provided.
In the light of the matters summarised above the “gaps” in the healthcare provided to older people in care homes are unsurprising. Literature reviews for the My Home Life project document problems across GP, nursing and allied health services.[9] Many of these affect older people generally and are simply more acute in care homes, however there are concerns that care home residents have poorer (or differential) access to services. Despite the NHS’ ethos of providing services free at the point of access to all on the basis of clinical need[10] there is evidence of GPs charging retainers to care homes even though they have the same responsibility to patients in care homes and the community. ECCA (English Community Care Association) commented that this illustrated the uncertainty about what standard general medical services covered in practice.[11] This uncertainty affects other primary care services, especially in regard to what healthcare activities are paid for by fees for nursing care, though the BGS gives examples that cover all care homes.[12] These matters, which are essentially ones of equity, will become more pressing when legislation about age discrimination comes into force in 2012.