Residential care commissioning leaves room for improvement

More than 350,000 older people in England live in care homes. Many who have conditions such as stroke, Parkinsonism and dementia live with confusion, continence or mobility problems, some with all three. Despite their complex needs, however, few have access to specialist care.

Specialism weaknesses

The journal Clinical Medicine reported last autumn on complementary surveys of geriatric medicine departments and primary care trusts. Responses were sought to questions designed to reflect recommendations made in the 2000 document The Health and Care of Older People in Care Homes, published by the Royal College of Physicians and a subsequent British Geriatrics Society position statement.

Among the results the surveys found that only 16 per cent of geriatric medicine departments allocated session time for care home work (1 per cent of the total consultant time available), less than 40 per cent of GPs had specialist training in the care of older people and only 18 per cent of primary care trusts funded the involvement of a specialist geriatrician.

Support initiatives

A significant majority of the departments favoured greater care home involvement with nearly half reporting local PCT care home support initiatives designed and delivered without their input.

It also appears that despite evidence showing the benefits, many older people are being admitted to residential care without prior specialist assessment.

“It has been established continuing care guidance for a decade at least that there would be consultant involvement in those assessments. But there also an additional issue of ongoing review, especially for that smaller group of residents receiving NHS continuing care funding,” says Finbarr Martin, consultant physician and geriatrician at Guy’s and St Thomas’ Foundation Trust in London and a joint author of the article. “It is inconceivable that these people, with complex and intensive needs, are not in need of a level of care over and above primary care. In fact their funding makes it entirely implicit.”

Consensus lacking

So where, Dr Martin and others want to know, is the NHS when it comes to these vulnerable older people’s care? Routine general practice is clearly not the answer.

There is yet to be any national agreement, consensus or commissioning guidance on how their needs should be met.

As a result there are no thoroughly researched models of care that could deliver a better patient experience, reduced need for acute hospital care, better long term disease management and end of life care.

In other words - a policy and evidence gap for ways of doing things better for less.

That is not to say nothing is being done. Examples of models of health provision that have emerged in spite of the lack of evidence can certainly be found. Lambeth, Southwark and Lewisham in south London share one (see case study). Leeds alone has at least three.

“That is partly a legacy from the days when the city had five PCTs,” says Eileen Burns, clinical director for older people at Leeds Teaching Hospitals Trust.

“Some parts of Leeds have a GP practice with an enhanced service agreement to provide proactive input into care homes.

They call on their community geriatrician on an ad hoc basis and their interventions have shown a demonstrable reduction on unscheduled calls for GP visits.

“Another model combines a GP enhanced service with regular geriatrician visits every six to eight weeks to support complex and intense care.

“A third model is built around community matron visits with geriatrician support and has no proactive GP input.”

Dr Burns continues: “All the models show reductions on acute admissions.

“One of the most effective components of the proactive input has been thinking about appropriate advance care planning with families for those frail patients with little to gain from further hospital visits.”

Organisations reviewing provision in their own area will want to consider the local mix and concentration of homes and residents, numbers of health funded patients, rates of emergency admissions from specific homes, GP practices with an interest in working with community geriatricians and matrons to develop services and the opportunity to improve quality while reducing cost.

While they do that, and the Care Quality Commission continues a review of healthcare for people in care homes, the challenge is for policy makers to improve access to this vulnerable group.