Commissioners are looking at placing frail patients in care homes - with a full care package. By Alison Moore

One of the greatest challenges for the NHS is caring for patients who are too ill or frail to remain at home but don’t need to be in an acute hospital bed.

Specialist input can help these patients regain independence or avoid an acute admission. But shortfalls in care which do not meet their needs can result in them remaining in a hospital bed for too long - and not being able to manage at home afterwards, potentially ending up in residential care permanently.

Community hospitals have provided care for such patients for many years. But they have limited capacity and some are no longer fit for purpose with buildings in a poor state of repair. And sometimes staff and financial pressures have meant there has been insufficient focus on getting patients out of hospital and back to normal life.

‘We are, in many cases more cost effective than a hospital bed: in these times of austerity the NHS is becoming more aware of that’

So PCTs and now CCGs have started to look towards more innovative solutions. And some are commissioning beds and services in private care homes. While using beds in nursing homes has been commonplace for some time, there is now an additional focus on ensuring care is focused on helping patients recover rather than just providing them with a bed.

In 2010, for example, NHS Hertfordshire produced an intermediate care strategy which looked at providing beds in more locations through local nursing homes, allowing patients to remain closer to home but with input from nurses and therapists. It also opened the way to redevelop an existing hospital site and to close an ageing community hospital.

Seizing the baton

And with an ageing population and people who are admitted to hospital often sicker and frailer than in the past, there is increasing demand for intermediate care to help those who are unlikely to be able to move back home immediately after treatment.

Many care home operators are seizing the baton and see an opportunity to both provide quality care for vulnerable patients and provide cost efficiencies for the NHS, and in some cases they are pushing on an open door.

Pauline Lawrance, managing director of Four Seasons Health Care England West, says that over the last year or two there has been a change with more PCTs and CCGs interested in buying not just a bed but also therapeutic input for patients on an ongoing basis.

“In the past they used to contract beds and provide sessional rehabilitation teams from the community,” she says. “But now they are getting more confident and commissioning a full service.”

For example, one home the company runs operates a unit where all care - including physiotherapy and occupational therapy - is provided by inhouse staff (including some medical input commissioned by the home).

NHS commissioners are effectively commissioning a full package of care, rather than just a bed.

“It is about health and social care integration,” says Ms Lawrance. “It has been a case of never the twain shall meet. But now it is about working with both health and social care and seeing the opportunities for both them and us.”

Ms Lawrance suggests this has many benefits. “We are, in many cases more cost effective than a hospital bed: in these times of austerity the NHS is becoming more aware of that. We can provide a more homely environment.

“It is more conducive for rehabilitation, assessment and enabling for the patients than if they were in a big hospital ward. They have their own room and access to kitchen areas as well as a continuous enabling philosophy on the units.”

No pressure

Perhaps most importantly, good targeted care in such units can produce good outcomes with many patients able to return to their own homes, perhaps with a package of care. This can often be achieved within a relatively short length of stay with homes working to key performance indicators agreed with commissioners.

And with community teams often being hard-pressed to care for those already on their books, this can ensure that they are not put under extra pressure.

Ms Lawrance believes that CCGs, with their increased medical leadership, are likely to be interested in what the sector has to offer. GPs obviously have frequent contact with care homes already and an awareness of the sector’s strengths.

This can include “admission avoidance” - by diverting patients who otherwise would end up in A&E and would probably be admitted - but also providing extra options when patients no longer need an acute hospital bed but can’t simply be discharged. This sort of “step up” and “step down” care is beginning to feature in many CCGs thinking - especially given the pressure the acute sector was under last winter.

The vast majority of people referred to intermediate or ‘step up, step down’ units run by Four Seasons are older persons but in principle there is no reason why younger people should not benefit as well, if they need the sort of care on offer, says Ms Lawrance.

But what is holding CCGs back? She suggests that sometimes it is a matter of getting in front of the right person to explain what is on offer - and that this can be more than just “bed and board” in a nursing home, with input from visiting NHS staff such as community-based physiotherapists.

“For the majority of people we are not their first thought,” she says. “There are some commissioners who have a vision of what can be provided and others we need to get in front of and say, this is what we can do.”

Another barrier is length of agreements. While nursing home beds are usually spot purchased, providers need some form of guaranteed income stream before they will make investments in additional staff and facilities. This is particularly relevant if they are going to offer a full package of care and start to employ physiotherapists and other staff.

But private providers are often willing - and able - to make this investment if they know they will get adequate referrals. Four Seasons invested heavily in its flagship project in Stoke-on-Trent, says Ms Lawrance, and has also looked at issues such as governance and data protection at other units to ensure it fully meets NHS requirements.

“We are willing to invest, but we do need some sort of long term agreement. In Stoke-on-Trent, for example, we have a two year contract with the option to extend for another year. After that it has to be tendered again,” she says.

See the care home case studies

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Pauline Lawrance on stepping up and down

After making the case, over a number of years, for a more joined up approach to health and social care funding, Four Seasons Health Care has welcomed recent statements by the Commons Health Select Committee and Audit Commission regarding the need for a rethink of the way care is delivered.

The independent sector can play an increasingly important role in health and social care provision, particularly for the elderly, that is complementary to the NHS. Larger operators have developed capabilities and have capacity in specialised areas of care such as nursing for frail elderly, step-up and step-down care, dementia care and palliative care.

A number of operators, including Four Seasons, have already contracted specialist care services with both health and social care commissioners for high dependency patients at a fraction of the cost to the NHS and taxpayer, (between 35 and 50 per cent less than NHS tariff rates for hospital care).

‘We believe people should be helped to remain at home for as long as it is their wish and in their best interests but there should be informed choice’

This approach to commissioning helps the Department of Health meet spending targets without a drop in quality and arguably provides a better all-round experience for patients. It also helps free up hospital beds and alleviate the situation where between a quarter and a third of beds in acute medical wards are occupied by people, mostly elderly, who don’t need to be there.

They are there because of widely held misconceptions amongst some commissioners that there is no suitable alternative and in some cases an ideological resistance to the private sector’s role in health and social care provision.

We believe people should be helped to remain at home for as long as it is their wish and in their best interests but there should be informed choice. There is no one size fits all solution. Whilst some people may benefit from additional input in care provision in their own home, others may benefit from a short stay in a residential setting either following hospitalisation or to avoid an admission in the first place.

These short stays are far different to the old concept of convalescence but are forward thinking enabling services, such as those described in the case studies, that have appropriate discharge at the forefront of care planning designed to rehabilitate and enable people to return home safely and maintain their independence for longer.

That’s why we have developed a range of bespoke models of care to support local health economies in meeting this need.

Pauline Lawrance is managing director of Four Seasons Health Care England West.