The NHS plan gives a new prominence to the nursing and residential care sector. In response to the current shortfall in NHS capacity, the government plans to expand intermediate care provision, both in the NHS and in the mainly private residential and nursing home sector.
Although there are currently some 600,000 residents in nursing and residential care homes, little is known about their needs, the levels of services provided, or the outcomes of care.
Essentially, government surveillance of this area has been missing, largely because care is regarded as the responsibility of individuals until they are too poor to pay.
Among the changes proposed in the NHS plan is that health and social care should be jointly commissioned by the new primary care trusts.
It will be crucially important for these trusts to put in place explicit guidelines on eligibility for NHS-funded care, criteria for admission to homes, and methods of linking reimbursement to highquality service provision.
For this to happen, the NHS and social services must first establish baselines for the funding and provision of healthcare services, and for healthcare needs, in the long-stay institutions.
Barking and Havering health authority has begun this process. In 1996 it commissioned research into the way older people enter institutional care, and their access to community and primary healthcare services.
The authority's findings provide a valuable insight into the sector, and the challenges now facing the new PCTs under the NHS plan.
Barking and Havering health authority serves a population of 373,000, of whom 16.5 per cent are aged over 65 (16.3 per cent in Barking & Dagenham and 16.7 per cent in Havering). It has responsibility for the registration and inspection of 16 nursing homes and five dual-registered homes, with sizes ranging from eight to 120 beds (average 45). There are two local authorities within its boundaries.
Barking & Dagenham has eight local authority and four private residential homes. Havering has six local authority residential homes, and 38 private homes. Ninety-three per cent of residential home admissions in Barking & Dagenham and 45 per cent in Havering are publicly funded. Barking & Dagenham has six nursing homes, including two which are dual registered, and Havering has 15, of which three are dual-registered. All the nursing homes are private.
Results There were 131 publicly funded admissions, of which 70 were to nursing homes. Only 10 people (8 per cent of the sample) were even part-funded by the NHS; none was fully NHS-funded.
Nearly two-thirds of the admissions (83 people) came directly from hospital. Almost all had entered hospital via accident and emergency and about half had been admitted to hospital at least once in the previous 12 months. Most people were discharged to residential and nursing homes directly from geriatric wards. It was not possible to determine how much rehabilitation had taken place in this setting.
Medical input to the assessment process was surprisingly low. Of the patients admitted from hospital, in only 56 per cent of admissions to nursing home care and 50 per cent of admissions to residential care was there direct medical input to the care plan by a GP, geriatrician, psychogeriatrician, or other hospital physician. Medical input to assessments of the 48 people entering care from the community was evident in less than 50 per cent of cases.
Dependency, health and social needs
Previous research has shown that there is no simple relationship between dependency levels and the decision to stay at home, and that motivation and emotional factors - particularly fear - may be powerful influences.
1 Our research showed that mental and physical health problems, combined with professionals' and relatives' perceptions of risk and/or carer stress, were the predominant reasons given for entering care. Lack of motivation and clients' fears about coping were mentioned in a third of cases, and loneliness and isolation in one-fifth.
The dependency levels of residents in the study - as measured by the Barthel score - showed that of the people admitted to nursing homes 51 per cent had bladder incontinence and 24 per cent bowel incontinence. The corresponding figures for residential homes were 10 per cent and 5 per cent respectively.
2 The most striking finding was the high prevalence of mental health disorders. Seventy per cent of the sample were suffering from one or more mental health condition - 60 per cent from dementia and 32 per cent from depression and/or psychiatric disorder. The high incidence of social needs such as 'lack of motivation' (48 per cent), 'loneliness/isolation' (40 per cent) and 'self-neglect' (38 per cent) implied that the number of patients suffering from some degree of depression could be even higher.
Cognitive impairment was measured using the MDS cognitive performance scale.
3 Between 55 and 75 per cent of nursing home admissions in both authorities had moderate to severe cognitive impairment. Similar proportions applied to residential admissions in Barking & Dagenham, while in Havering around half of the residential admissions had moderate to severe cognitive impairment.Most people admitted to residential or nursing homes have a high degree of cognitive impairment (figure 1).
Care planning for healthcare need Despite the high levels of physical and mental health conditions, specific nursing and primary healthcare needs were rarely identified in the core assessment, and even less frequently in the care plan Continued from page 27 (figure 2). For instance, for the nursing home admissions, only 20 per cent had the need for tissue viability care (pressure sore risk) identified in the core assessment, and for only two-thirds of these (14 per cent of total) was it specified in the care plan; the corresponding figures for residential admissions were 10 per cent and 5 per cent. A need for community psychiatric nurse services was identified in only 11 per cent of nursing home admissions, and none of the residential home admissions.
Access to GP services
Most nursing homes had a special arrangement with a particular GP practice for GP cover. This generally included the practice running regular clinic sessions at the home, with the home paying the practice a standard fee.
Only about half of residential homes had any such arrangement.
All the homes were happy for residents to register with the GP practice of their choice. But 26 per cent of homes recorded difficulties for some or all of their residents in doing so.
There were also problems obtaining GP cover for periods of short-term respite care; this presented difficulties for homes that specifically offered a respite service. Regular preventive checks, initiated either by the associated practice or the home itself, were carried out in most homes to some degree.
However, only just over half of the homes were able to confirm that every resident over 75 received an annual health check, and four homes carried out no such checks, either themselves or via a GP practice.
The district nursing service was generally regarded as providing excellent support. However, variable use was made of the available advisory services, with take-up among homes ranging from 13 per cent for stoma care to 83 per cent for continence advice. It was not evident whether under-used services were not wanted, not known about, difficult to access, or not understood.
Community psychiatric nursing services had been accessed in the previous 12 months by 73 per cent of the homes for an average of around 11 per cent of their residents: overall access of around 8 per cent.
This contrasts strongly with the 70 per cent of new admissions identified as suffering from a severe mental health condition in the admissions survey, and underlines again the worrying shortage of appropriate mental health facilities in the institutional care of older people.
Rehabilitation and support
NHS rehabilitation and support services were used to a variable degree by both residential and nursing homes, but were generally regarded as difficult to access. Some homes redressed the perceived shortfall by bringing in private services.
In general, residents wishing to access these services paid for them on a private basis. While several homes supported the potential preventive and health maintenance role of certain services - especially chiropody and physiotherapy - these were not, in general, accessible from the NHS on this basis.
The provision of health and activity programmes, and voluntary sector involvement in advocacy for the provision of transport, were extremely variable.
While some homes provided excellent facilities, a small number did none of these things. This lack of a consistent focus on a holistic approach to care reflects the findings of the 1998 Counsel and Care study on access to health support in care homes, Bringing Health to Homes.
General patterns could be identified in the provision of specialised equipment - for example, a tendency for feeding apparatus to be supplied on prescription, and pressure-relieving beds and mattresses for residential homes to be provided by the NHS. But there were no guidelines governing what constituted specialist equipment and who should supply it.
This was also the case for wheelchairs. In addition, there was also a lost opportunity to address individual specialist requirements as part of the admissions procedure.
The decision to expand NHS intermediate care into nursing and residential care homes presents a serious challenge to civil servants and policymakers.
Our research shows the extraordinarily high levels of healthcare need among residents of nursing and residential homes. In particular it reveals high prevalence of mental health disorders, incontinence, physical disability and cognitive impairment. There is a serious mismatch between the needs of people admitted to institutional care and the support available. Most homes did not have units for elderly mentally infirm people. Nor, on the whole, did care staff have specific training in caring for people with dementia. Despite the high levels of cognitive and mental health impairment, uptake and provision of NHS support services was low.
Also, there is evidence that residents and homes are currently being charged for a range of NHS services including GP clinics, and for community health services such as chiropody and therapy.
The effect of making long-term care the responsibility of individuals has been to render this group largely invisible to providers of NHS care. It has also blurred the boundaries between NHS and privately funded care, with a high proportion of homes and residents paying for healthcare at the point of use in order to obtain services.
Although the NHS plan now states that all NHS care should be free, the real challenge will be to identify the health and social care needs of this frail and vulnerable group, undoing current inequities.
The Care Standards Act has put in place the legislation to establish a Commission for Care Standards. Clear criteria are now needed to stipulate what is covered by NHS funding and what is personal care, and how NHS reimbursement will be linked to packages of care and high-quality staffing input.
There is little evidence of health authorities having put in place measures to guarantee highquality, appropriate NHS care, rehabilitation or health-promotion services. The risk is that, unless this group is made a priority under the plans for intermediate care, increasing numbers of frail, elderly and vulnerable long-term sick and disabled people will continue to lie outside the jurisdiction of the NHS.
1 Warburton R. The F Factor: Reasons why some older people choose residential care. Department of Health, 1994.
2 Collin C, Wade DT, Davies S, Horne V. The Barthel ADL index: A Reliability Study. International Disability Studies: 1998; 10, No 2, 61-63.
3 Morris JN et al (1994).MDS Cognitive Performance Scale, J of Gerontology: Medical Sciences 49, No 4 M174-M182.
4 Bebbington A, Brown P, Arton R, Netten A. Survey of Admissions to Residential and Nursing Homes for Elderly People, Discussion Paper 1222, PSSRU, 1996.
5 O'Dea G, Kerrsion SH, Pollock AM. Access to Health Care in Nursing Homes: a survey in one English Health Authority, Health and Social Care in the Community, 2000; 88 (3), 180-185.