Around 10,500 or so care homes in the UK care for around 400,000 older people, of whom some 20 per cent are over the age of 85. Future demand for care homes is expected to rise by around 150 per cent over the next 50 years. Furthermore, in Scotland, if age specific rates of care home provision remain the same as now, the requirement for placements is expected to increase by 72 per cent by 2028, from 33,000 to over 57,000.
Over the past decade the average life expectancy of an older person entering a care home has changed dramatically and is now between one and two years. A high percentage of residents are also in their last year of life and likely to be in need of compassionate end of life care. Regardless of whether they are in the last year of life, most residents have quite complex health care needs, both physical and mental; with high prevalence of late stage neurodegenerative conditions such as Parkinson's disease, dementia, and severe stroke. Many residents will also suffer from depression and loneliness. As a result, and in the absence of effective healthcare, care home residents will have higher rates of both necessary and avoidable hospital admissions.
Providing good quality health care for older people living in care homes raises a number of significant challenges for the NHS and care home providers. While the social care model is central to residents' needs, research shows that the health services currently on offer are failing to meet their complex care needs. Finding a cost-effective way of delivering such services is clearly an imperative, given the increasing costs of caring for the elderly. While healthcare for residents, in theory, remains free at the point of need; accessing good quality care seems increasingly difficult.
Care home staff rarely have the skills or training to handle the complex healthcare requirements that many residents increasingly suffer from and require support from specialist health care staff. This includes support in relation to nutrition and hydration; preserving residents' skin integrity; and preventing pressure sores. Medical treatment remains an important part of the response but requires attention to detail, which many GPs find difficult to deliver given their existing time and resource constraints. Some may need specialist support from geriatricians. Furthermore, single condition based protocols don't work for people with co-existing late stage diseases and what is needed is an approach in which shorter term goals aimed at alleviating symptoms, outweigh the longer term value of disease control.
Frailty and age can often mean a more complex drug regime which can increase the risk of adverse drug events and requires input from community pharmacists and specialist nurses. Access to GP surgeries and outpatient clinics can often be very difficult for residents due to frailty and mobility issues and is likely to be less effective than assessment and care planning delivered in the care home. Urgent responses out of hours rarely meet individual needs and lead to overuse of A&E attendance and emergency admissions. There is also wide variation in access to community-based therapies with long waiting times. Patient-centred health care and support plans are therefore essential for all residents, including advance care planning and needs to be based on a co-ordinated input from multi-disciplinary healthcare teams working in partnership with social care professionals and care home staff.
A report from the British Geriatric Society in 2012, based on a review by the Care Quality Commission (CQC) into health support to care homes, found that over half (57 per cent) of older people resident in care homes did not have access to all the NHS services they required. With considerable variation in the extent to which their healthcare needs were being met, limited access for care home residents to specialist geriatric care and significant variations in access to mental health teams, dietetics, occupational therapy, physiotherapy, podiatry, continence, falls and tissue viability nurses. The report recommended that commissioners should ensure that clear and specific service specifications are agreed with local NHS providers to meet the needs of older care home residents. It called for a new co-ordinated healthcare model to meet these needs considering that 'traditional' general practice in many areas is not equipped, supported or motivated to fill this void.
These "gaps" in healthcare provision are experienced by older people more generally but are simply more obvious in care homes. Despite healthcare services being free at the point of need, there are examples of GPs charging retainers to care homes, even though they should have the same responsibility to patients in care homes as they do for those in their own homes. While NHS policy makers, commissioners and managers acknowledge that there are problems, they have little consensus on their obligations to address this.
On 14 October 2013 the British Geriatric Society published a two page guide for health service commissioners and planners which sets out what local services should be in place to meet the health needs of older care home residents. Its aim is to reduce the distress caused by the residents' condition, avoid unnecessary deterioration and reduce the risk of falls, fractures and other injuries. It also aims to enhance autonomy and involvement in decisions about care and reduce the fear of dying.
Given the above challenges it's interesting to reflect how the proposed changes to the GP contract announced last week, that every person aged 75 and over will be assigned a named, accountable GP to ensure they receive coordinated care, might work for people in care homes. In theory it should be exactly the same as for someone living in their own home, but in reality I would suggest that a much more efficient and effective approach would be to ensure that every care home is partnered with a named GP practice and given access to advice, support and, when needed, treatment 24/7.
Proper access to effective healthcare for care home residents is a human right. Regular input from multi-disciplinary teams should help identify and tackle avoidable deterioration in patients' conditions and reduce the need for emergency or even planned hospital care. Healthcare for care home residents should no longer be a "Cinderella" service of the NHS. Tackling this issue now could have a fundamental and life enhancing impact on what is a very challenging area of care. Providing more, high quality care closer to home is after all part of NHS Policy and is highlighted in the NHS Mandate, the only difference is that in these cases, the home is a care home.
The Centre for Health Solutions will be publishing a report on care for the frail and elderly early in the New Year. The Centre is also working on a point of view piece discussing end of life care. If you would like to receive these reports, please register your interest by contacting me at centreforhealthsolutions@deloitte.co.uk or registering for this blog.
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