Ambitions for change: Improving healthcare in care homes
This document describes the care home sector across the UK as it currently stands and recent initiatives taken to improve healthcare for care home residents, including specific initiatives during the COVID-19 pandemic. It describes how health and wellbeing has traditionally been supported in care homes and sets out what good healthcare provision in a care home environment should look like.
The COVID-19 pandemic hit the whole of society in an unprecedented way, resulting in the deaths of more than 130,000 people in the UK.1 Care home residents were particularly affected by the pandemic, accounting for 35.6% of these deaths.†
The pandemic exposed both the diversity of the social care and care home sector and how little governments and the public understand about provision of care in care homes. Care homes and those who live and work in them were initially neglected by governments and many have paid the ultimate price for this. While experts predicted that care homes would be particularly badly affected by the pandemic, these warnings were not initially heeded.
†We have estimated this figure from official data published by the four nations.
In England and Wales, there have been 41,552 COVID deaths among care home residents aged over 65: https://tinyurl.com/ONSCOVID19.
In Scotland, there have been 3761 COVID deaths among people living in care homes for older people (with no age specified): https://tinyurl.com/CIScotCareHomes.
In Northern Ireland, there have been 1014 COVID deaths among care home residents (with no age specified): https://tinyurl.com/NISRACareHomes.
2. Summary of recommendations
This document sets out how healthcare delivered in care homes can be improved. Throughout the text we make the following 11 recommendations for local and national Governments and decision-makers to consider:
- The NHS across the UK should work with care homes to roll out and fund programmes to enable enhanced healthcare services to be provided in all care homes. This support should include investment in IT infrastructure that enables relevant data to be accessed by all professionals involved in care delivery. Additional support should be provided to care homes which are struggling to implement the changes.
- Governments across the UK should dedicate appropriate funding for the development of care home staff to ensure that they have the knowledge, skills and competencies to support residents with frailty and complex needs.
- Comprehensive Geriatric Assessment (CGA) should be routine for older people entering care homes to ensure that their needs are met. This enables proactive assessment with a focus on quality of life rather than depending on reactive crisis-driven care. Care plans produced as part of CGA should be recorded in residents’ care home and primary care records.
- A definition of a care home multidisciplinary team (MDT) should be developed and standardised across the UK, as part of Enhanced Health in Care Homes (EHCH) in England and through similar initiatives in the other nations, with the overall aim of allowing CGA to be conducted as described.
- All members of a care home MDT, including those employed by both the NHS and care homes, should undergo specific training in the care of older people. This should include nurses employed by care homes, so that they are enabled to play an active role in the care home MDT.
- Regardless of where they live, care home residents should be able to access NHS-funded rehabilitation, equipment and other services according to their needs, in the same way that an individual living in their own home would.
- Education providers should develop and define specific core competencies for each of the professional groups regularly participating in the care home MDT and consider the development of accreditation for these individuals.
- UK Governments should commit funding to ensure that all care homes have access to support allowing care home residents to receive care in situ that would otherwise have been provided in a hospital setting. This includes extensivist care provided by registered nurses employed by care homes as well as that provided by visiting healthcare professionals. Care home staff should be involved in the design of all new initiatives to support healthcare in care homes.
- Healthcare systems should be set up to ensure that providing healthcare within a care home environment is the default option if at all possible, unless the resident prefers other alternatives. We know that there will be exceptions to this and in some cases, hospital treatment will be the best option for a resident. Care home residents should never be denied hospital treatment where there is a clear health benefit to be achieved that outweighs the burden and risk of harm associated with hospitalisation.
- UK Governments should commit to ensuring that linkable datasets for long-term care are developed with the aim of improving the quality of care received by residents. This may include implementing the recommendations of the DACHA (Developing resources And minimum dataset for Care Homes’ Adoption) study if shown to be relevant to all four nations. We acknowledge that data collection has implications in terms of resource and staff time; the benefit of collecting the data must justifythe burden placed on staff.
- Governments in the UK should set out plans to support care homes to harness digital technology to help them improve the care they provide to their residents. This support should include financial assistance to enable care homes to purchase the equipment they need as well as training for care home staff to ensure that they have the skills to use the technology to its potential.
3.1. The care home sector
Care homes are home to some 400,000 older people in the UK4 with the care home population projected to rise by 127% over the next 20 years.5
The care home sector provides a particular challenge when trying to generalise because there is no ‘standard’ care home – they can range in size from fewer than 10 residents to more than 100 residents. The sector is also diverse in terms of business models, with some care homes owned by independent ‘for-profit’ companies or individuals, some operated by local authorities and others owned by charitable organisations, particularly for specific faith groups. The sector has a large number of small operators - the National Audit Office reported that in England 75% of care home providers own just one home and that these homes account for 38% of care home beds.6 This statistic is similar in Scotland with the Care Inspectorate estimating 36% of care home beds are provided by small operators.7 Care homes are also diverse in the care provided – some are nursing homes and have registered nursing staff available 24 hours a day, while others are residential homes, staffed by people with a range of job titles and qualifications. Some care homes also provide a combination of nursing and residential care. Across the UK, 42% of care homes provide nursing care. Registration of professionals working in care homes varies depending on nation. In Scotland, care home staff are all required to be registered whereas this is not the case in England.
3.2. The wider social care context
3.3. COVID-19 in care homes
- Closer alignment of General Practice with care homes in England, led by Primary Care Networks as part of the Enhanced Health in Care Homes (EHCH) programme.
- Introduction of Clinical and Professional Oversight Groups to support care homes in Scotland, although it has been suggested that this provides additional bureaucracy with limited improvement in outcomes.11
- Advances in IT integration, including access to NHS mail for care homes, increased IT hardware in care homes, and support for broadband installation in care homes. This allowed the use of the NHS Near Me tool for GP consultations in NHS Scotland, although in some places this is limited by the availability of broadband and IT systems.
- Publication of a digital action plan for care homes in Scotland to ensure residents in care homes have equal online access to those not in care homes.
- Remote monitoring to inform escalation of care through numerous regional roll-outs of the RESTORE-2 model,12 the national COVID Oximetry at home programme,13 and the Tameside and Glossop Safe Steps initiative.14
- Point-of-care testing through the national Lateral Flow Testing programme,15 with further NIHR-funded evaluations of Point of Care Testing technologies including Point-of-Care Polymerase Chain Reaction16 and Automated Antigen Testing.17
- In parts of the country, introduction of augmented approaches to healthcare delivery in care homes, including oxygen administration, and use of intravenous fluids.18 In Northern Ireland, existing Hospital at Home teams developed to provide this enhanced care to care home residents.
- Increased focus on routine data in care homes, with collation of mortality data by the Care Quality Commission (CQC), COVID case rates by Public Health England (PHE), care home organisational data through the Capacity Tracker, routine compilation of care home data as part of “the Foundry”19 and the Turas Care Management Safety Huddle Tool in Scotland.20
- Unprecedented levels of expenditure on care home research, including the multi-million pound PROTECT-CH study,21 which aims to establish a care home randomised controlled trial (RCT) platform that will inform COVID-prophylaxis initially but extend beyond the pandemic as a national resource.
3.4. How has care traditionally been perceived in care homes?
†With exceptions for prescription charges, eye care and dentistry.
Responsibility for these costs for care home residents is another cause of confusion.
4. Specific health concerns for care home residents
Older people in care homes usually have several long-term conditions and are almost universally living with frailty.25 As such, they have a range of health needs. This section sets out a few of the more common conditions which staff are required to support their residents to manage on a daily basis.
4.1. Cognitive impairment and mental health
4.2. End of life care in care homes
4.4. Nutrition and hydration
4.5. Continence care and assessment
4.6. Medicine optimisation
5. What does good look like?
Having outlined the diversity in care homes and the specific challenges that care home staff and management face in caring for their residents, we now turn to outlining what good care in care homes looks like and what all older people living in a care home should expect from the staff looking after them, regardless of where in the UK they live.
The BGS has a multidisciplinary membership with doctors, nurses and allied health professionals working across a range of acute, primary and community settings in all four countries of the UK. Our members care for care home residents in situ in care homes both as care home staff and as visiting clinicians to care homes and when they are admitted to hospital. They are thus ideally placed to advise on what good practice in providing medical care in care homes looks like.
5.1. Person-centred care for care home residents
5.2. Development of a skilled care home clinical workforce
5.3. Providing hospital-style care in care homes
- Intravenous or subcutaneous fluids could be used to provide hydration support whilst residents receive treatment to reverse reduced intake associated with hypoactive delirium. While some care homes already provide subcutaneous fluids, it is much less common to have intravenous fluids administered in care homes.
- Oxygen therapy could be used in situ, or to facilitate early discharge from hospital, in the context of acute respiratory tract infections.
- Remote monitoring could be used as an adjunct to soft clinical signs to enable care home staff to seek earlier advice for residents at risk of deterioration, or even to trigger proactive assessment by care home MDTs.
- Point-of-care testing could be used in the context of winter respiratory or gastrointestinal infection outbreaks to identify causative pathogens and guide treatment prophylaxis in a timely way.
5.4. Joined-up approach to data collection and sharing
5.5. Embracing digital technology
As more people make care homes their home in later life, it will be important for healthcare professionals and systems to adapt to providing healthcare within care homes rather than requiring care home residents to go to hospital or other locations to receive healthcare.
While the COVID-19 pandemic has been devastating for care homes, innovations have emerged that must not be lost and an opportunity exists now to build back better for care home residents and staff. The BGS is a strong advocate of the provision of more personalised and integrated care for older people, including the growing number who will be living in care homes. Older people must have access to the same high-quality care, regardless of their living situation.
We implore governments and health and care systems across the country to implement our recommendations to ensure that older people living in care homes are supported to live well for longer. As noted throughout this document, the care home sector is diverse and our recommendations aim to elevate all care provided in care homes to a similar high standard. However, care homes do not exist in a vacuum and the recommendations made in this document must go hand in hand with reform to the wider social care system.
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- Prof Adam Gordon, Professor of Care of Older People, University of Nottingham; Consultant Geriatrician, University Hospitals of Derby and Burton NHS Foundation Trust; BGS President Elect
- Dr Firdaus Adenwalla, Consultant Geriatrician, Abertawe Bro Morgannwg Health Board
- Anita Astle MBE, Managing Director, Wren Hall Nursing Home
- Dr David Attwood, GP Partner, Pathfields Medical Group, Plymouth, Clinical Lead for the Integrated Care of Older People in Devon; BGS Honorary Secretary
- Derek T Barron, Director of Care, Erskine
- Dr Eileen Burns, Consultant Geriatrician, Leeds Teaching Hospitals NHS Foundation Trust
- Dr Jenni Burton, Clinical Lecturer, University of Glasgow
- Dr Jane Douglas QN, Chief Nurse, Care Inspectorate
- Dr Sara Gerrie, Consultant Physician, Betsi Cadwaladr University Health Board
- Prof Claire Goodman, Professor of Health Care Research, University of Hertfordshire
- Ros Heath, Owner Manager, Landermeads Nursing Home
- Prof Anne Hendry, Honorary Professor, University of the West of Scotland; Honorary Clinical Associate Professor, University of Glasgow; BGS Deputy Honorary Secretary
- Liz Jones, Policy Director, National Care Forum
- Dr Maggie Keeble, Care home GP and Clinical Lead for Integrated Care Systems, Worcestershire Health and Care Trust; BGS Co-Chair GeriGP Group
- Ann McKay MBE, Director of Policy, Care England
- Jeremy Richardson, Chief Executive, Four Seasons Health Care Group
- Dr Jan Ritchie, Consultant Geriatrician, Belfast Health and Social Care Trust
- Dr Richard Tristham, GP Partner, Cwmtawe Medical Group
- Sally Greenbrook, Policy Manager, BGS