Published: 12/12/2001, Volume II2, No. 5835 Page 28 29
Primary care trusts will be responsible for commissioning care from nursing homes from next April, but they will find the sector beset with problems. Naomi Chambers and Jane Tyrer examine the results of a study
With over 140,000 beds in the registered nursing home sector, vulnerable sick and older people in England are more likely to be looked after in a privately run nursing home than in an NHS hospital.
1But debate about quality of care has mainly focused on hospitals and primary and community care.
Nursing homes feature mainly when hospitals become concerned about delayed discharges, particularly in areas where property prices and the new national standards have triggered significant numbers of home closures. The health select committee report published in July 2002 estimated the net loss in long-term care home places exceeded 34,000 over the past four years.
2The priorities and planning guidance from the Department of Health called for an increase of 6,000 in the number of places in care homes supported by councils over the next three years.
3Our research suggests that attention urgently needs to be paid to secure capacity and ensure the wellbeing of residents, and to sustain improvements across the health and social care system.
4Forty-six interviews were carried out between July and October 2001, with residents, relatives, home owners, home managers and social service managers in Blackpool and Stockport, and with 12 registration and inspection managers across north west England.
The research found that wellmanaged homes had a manager (often called 'matron') with good leadership skills, a realistic business plan, an owner with a keen interest in the home, high bed occupancy and enthusiastic staff with low turnover. These homes also had an ethos of choice, respect and kindness for residents and relatives.
Residents attached a particular importance to food and its presentation. As one relative described it: 'As soon as we came here we knew... we could hear people talking and laughing. It seemed as if the place was alive... everyone was caring about everyone else.'
Poorly managed homes were characterised by an impoverished physical environment, chaotic atmosphere, poor handling of visitors, bad smells and difficulties in relationships with other agencies.
Other disturbing examples experienced by respondents included incorrect and late medication, residents returned to the wrong room after a hospital stay, lost clothing and lateness in daily routines. The impression of abandonment where respondents had experience of homes in trouble was telling. One inspector described this as 'where everyone is staring at nothing'.
The research looked at different types of homes to find out whether these corresponded to different management styles. Single, independent homes were more likely to be 'homely' but often lacked resources and robust business management processes.Homes owned by small groups provided some internal peer support and cover for local managers but were sometimes over-stretched. The larger 'chains' benefited from economies of scale, tended to have the larger homes and focused strongly on cost containment. There was evidence to suggest homes that exclusively took residents needing nursing care (not those who required only residential care) had higher staffing levels and a clearer view of what the home could offer.
There was no association found between the type of home and quality of care.
We found examples of innovation such as forums and professional networks with NHS colleagues, inter-agency development of clinical care pathways and guidelines, professional development opportunities and clinical audits. But there were also major barriers, including a fear of staff being poached and mixed views of the value of professional development.
There were positive views across the spectrum that the nursing home sector could be used more fully by the NHS, and worries about effects on existing residents and other concerns about capacity, competence and technical commissioning challenges to resolve.
There was empathy among commissioners and inspectors about the perceived poor levels of funding for nursing home care.Acute funding problems for homes have resulted in unpaid staff, closures and insecurity for residents, relatives and staff.
Funding problems have resulted in shabby environments, low pay, poor training and high staff turnover. Concern was also expressed about differential charges for self-funding residents: fees paid by privately funded residents are sometimes higher than for residents who are funded by the local authority.
There was a cautious welcome for the National Care Standards Commission, established in April.
There were concerns that the standards were too focused on what was easy to measure rather than on what would be useful catalysts for change, and also about the standards' affordability for nursing homes. The government has heeded this concern with changes announced in August. National and local quality assurance mechanisms like Investors in People and the Blackpool star-rating scheme (an independent scheme which assesses the standard of care homes in the Blackpool area) were found to be useful to meet local circumstances, but needed to be better tied in with NCSC approaches.
Relatives and residents suggested more focus on staff attitudes and quality of care. As one relative put it: 'They could look at the one-to-one personal care and the wellbeing of the patient, but when they come round they are looking at whether the doors lock.'
Cost pressures were an underlying theme in this research and in some areas the shortage of nursing home places is already so severe that respondents talk of the system 'imploding'.
Additional monies are expected to flow into the system from April 2003. The difficulty lies in identifying (whether or not it can be nationally or locally politically afforded) what the appropriate fee levels should be. Fees paid by different local authorities for supported residents in residential and nursing care vary from over£300 to£500 per week.
5The cost of running a nursing home varies not only according to geography but also in relation to a range of individual factors, including the level of debt of home owners.
Nursing homes could be better supported by health and social care partners. Payment could take the form of a block booking for an annualised volume of activity rather than payment for individual residents.
This would provide enhanced financial security for homes in return for which commissioners could expect improved arrangements in areas including staffing and training.This would make it easier for the NHS to use nursing homes for intermediate care.
Primary care trusts are charged with assessing the health needs and securing services for local populations.A few are working closely with the nursing home sector, but most have not yet begun to map the capacity or identify the strengths and weaknesses of their local homes.They need to move swiftly on this in partnership with local authorities and local hospitals and GPs to boost capacity and encourage the local market.Commissioners also need to look beyond local boundaries to the availability of nursing home beds elsewhere.
A few nursing homes are learning to benchmark clinical care and developing care pathways.This work should be supported and extended across the sector and used, together with the national service framework for older people, to connect to the wider health and social care community.As the purchasers of nursing care in homes from April 2003, PCTs will want to be satisfied about the quality and value for money of care bought with public funds in the private sector.
They need to work with local authorities to monitor services and ensure that homes have systems of clinical supervision and networks of professional support.
Inspection needs to balance issues relating to the physical environment and residents' and relatives' experience.
The inspection process could be enhanced by adopting a variant of the models developed by the Commission for Health Improvement and Ofsted.
This approach would complement the existing inspections with an occasional in-depth examination of the way a home operates with a focus on the views of residents, relatives and staff (for example, every four to six years or when a home gives cause for concern).The review would include confidential feedback to the home and support in developing an action plan arising from the findings.
The research suggests the need for a national development programme for nursing home managers and greater access to NHS nursing expertise.
A small study of nursing home owners, managers, residents and relatives found effective management depended on strong leadership skills, high bed occupancy, enthusiastic staff and low staff turnover.
Funding problems were a key issue for homes, creating massive insecurity for residents, relatives and staff.
There was a feeling that nursing homes could be used more effectively by the NHS, but there were concerns about capacity and competence.
The viability of homes would be improved by annual block booking by the NHS.This would also facilitate the development of intermediate care.
A national development programme for nursing home managers is needed.
1Community care statistics, Department of Health, 2002.
2Delayed discharges.House of Commons health select committee. The Stationery Office, 2002.
3Improvement, expansion and reform: the next three years. Priorities and Planning Framework 200306. Department of Health.
4Policy issues and management challenges in the English nursing home sector.Manchester University centre for healthcare management, 2002.
5Personal social services performance assessment framework www. doh. gov. uk/paf
Dr Naomi Chambers is senior fellow, and Jane Tyrer is fellow, Manchester University centre for healthcare management.