Failing the Frail
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.
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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.
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.
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.