might be more cost-effective if targeted at nursing home residents.
An interview study of the actors involved in the health care of
care home residents
There is concern about the quality of health care for care home residents, but little evidence to explain or guide the rational development of improvements to services. We therefore aimed to explain the delivery of health care to residents living in care homes in the UK and hence enable rational service development. This study has been published elsewhere.93
Methods
This study was a qualitative interview study using a grounded theory approach. It was set in six UK care homes and included primary care professionals serving the homes. In total, there were 32 participants: seven care home managers, two care home nurses, nine care home assistants, six GPs, three dementia outreach nurses, two district nurses, two advanced nurse practitioners and one occupational therapist.
Results
Five themes were identified:
1. Complex health needs and the unstable and unpredictable nature of residents’ illness trajectories (illustrative quote from GP informant: ‘Because one day, they can be fine, the next day, they stop eating, and then they could linger for months, or the next day, they could die’).
2. A mismatch between health-care requirements and GP time.
3. Reactive or anticipatory health care (illustrative quote from GP informant: ‘In the past, we used to try and do anticipatory things like a little ward round once a week. And I think we just found that it wasn’t making a lot of difference to just letting the staff call us when they needed help. So we were putting more hours in without seeing very much for it’).
4. A dissonance in health-care knowledge and ethos (illustrative quote from GP informant: ‘The average general practitioner isn’t experienced enough . . . and you need a, basically another specialism going in and I think that would deliver better care to the patient’).
5. Tensions in the responsibility for the health care of residents (illustrative quote from a district nurse informant: ‘As a district nurse is a bit of an issue, because there are times when we have to go into a residential home to administer insulin when there are nurses there, trained nurses, and they will not administer the insulin because they’re saying we’re not insured, so that piles even more pressure, even more visits onto the district nurses’).
Care home managers and staff were pivotal to health-care delivery for residents despite their perceived role in social care provision. Formal health care for residents was primarily provided by one or more GPs, often organised to provide a reactive service that did not meet residents’ complex needs. Deficiencies were identified in training required to meet residents’ needs for both care home staff and GPs. Misunderstandings, ambiguities and boundaries around roles and responsibilities of health and social care staff limited the
development of constructive relationships. Discussion
The health care of care home residents was found to be difficult because the residents’ needs were complex and unpredictable. Neither GPs nor care home staff had enough time to meet these needs and many lacked the prerequisite skills and training, irrespective of the model of organisation employed. Anticipatory care was generally held to be preferable to reactive care, but attempts to structure care to make it more anticipatory were dependent on effective relationships between GPs and care home staff and their ability to establish common goals. Roles and responsibilities for many aspects of health care were not made explicit and this risked poor outcomes for residents. These findings help explain the concerns noted about the quality of health care for care home residents in the UK. Missed opportunities for partnership working were described, which should give rise to more rational approaches to service development.
Chapter 5 Synthesis
Introduction
As described in Chapter 1, this synthesis aims to bring together the findings from all three workstreams with the objective of identifying key factors that are likely to influence health-care improvement. To do this we describe the results of the research programme with reference to an established framework for understanding health care, adapted from Brown and Lilford13(Figure 1), which applied the
input–process–outcome chain (described first by Donabedian14) highlighting three essential measurement
points: ‘proximal end points’ to describe content, ‘at the level’ measures to assess fidelity and ‘distal end points’ to assess effect. Each of these points may use qualitative or quantitative data.13
Figure 2 shows how the model shown in Figure 1 was applied to this programme.
Subsequent sections of this synthesis discuss the programme’s findings under headings taken from
Figure 1: context, structure, generic interventions, specific management processes, clinical processes,
intervening variables and fidelity.
Context
Although the programme of work summarised here was developed within a health service perspective, demographic, societal and politicoeconomic factors were important contextual considerations. Growing numbers of people surviving into a longer old age is a cause for celebration, but these people also have increasing expectations of health services as health care and technology afford a growing range of interventions to treat disease and ameliorate age-related disability. The investigators’ prior expectations were of a mismatch between the needs of older people and the services provided for them: increasing numbers of older people were presenting to AMUs but these services did not appear to be tailored to their needs; people with cognitive impairment seemed to be very common in hospital but, again, there seemed
Structure Management processes Latent errors Clinical processes Active errors Patient outcomes Interventing variables (e.g. morale) Fidelity Fidelity Context Generic intervention (e.g. human resource policy)
Specific intervention (e.g. drug interaction
warning system)
Throughput (e.g. no. of patients treated)
FIGURE 1 Causal chain for health care. Reproduced from ‘Evaluating service delivery interventions to enhance patient safety’. Celia Brown, Richard Lilford. BMJ 337, p. 162, 2008, with permission from BMJ Publishing Group Ltd.
to be little evidence that hospitals had taken this on board; care home residents seemed to have complex health problems without a service in place designed to deal with such complexity. This mismatch was confirmed by findings from the programme across all workstreams:
l In the AMU workstream the testimonies of people discharged from AMUs in the AMIGOS study (see Chapter 2) described considerable ongoing and unaddressed health needs and the findings of the AMOS study (see Chapter 2) showed that such people had a measurable decline in their health over time.
l The MMHU workstream (see Chapter 3) was justified and informed by the findings of our parallel Service Delivery and Organisation (SDO) programme-funded Better Mental Health study,9which
identified two root causes of care failures: (1) inadequate staff training and support in the
management of older patients with cognitive impairment and (2) organisational inflexibility, which imposed unrealistic targets on those caring for such patients and detracted from their time and ability to provide appropriate care.
l The interview study of GPs and care home staff (see Chapter 4) again confirmed a mismatch between need and provision.
Structure
In this analysis, ‘structure’ refers to strategic policy objectives and systems influencing the delivery of health care. In 2010 health expenditure consumed nearly 10% of UK gross domestic product. Despite a
consistent trend in England towards reducing state involvement in the provision of health care since 1979, the state continues to fund 80% of health care and the NHS continues to provide most of it, with central commissioning, policy-making and research funding. Preventing the high costs of hospital admissions, through the development of alternatives to inpatient treatment (such as hospital-at-home schemes, day surgery), was a major objective. When admission is inevitable, efforts have focused on minimising the
Structure Management processes Latent errors Clinical processes Active errors Patient outcomes Interventing variables (e.g. morale) Fidelity Fidelity Context Generic intervention (e.g.
Specific intervention Throughput (e.g. no. of patients treated) CGA ISAR DRS-98-R This is Me Poor fit between acute care provision and ageing population’s needs Reduce admissions Reduce costs Increase quality Benchmarks for patient outcome metrics can be based on MCOP findings
Not measured Some reliability testing AMIGOS approach Interface geriatrician Medical Mental Health Unit Bed pressures Regulatory body’s prioritoies
FIGURE 2 How the model in Figure 1 was applied to this programme. Adapted from ‘Evaluating service delivery interventions to enhance patient safety’. Celia Brown, Richard Lilford. BMJ 337, p. 162, 2008, with permission from BMJ Publishing Group Ltd. DRS-98-R, Delerium Rating Scale–Revised 98; MCOP, Medical Crises in Older People.
length of stay and increasing bed occupancy rates, to maximise throughput and gain efficiencies of scale. However, this has led to a pressured system:
l In the AMU workstream the rising number of people attending emergency units was a matter of
concern because it was associated with a rising number of admissions. Another central policy factor affecting this workstream was the requirement for patients to spend no longer than 4 hours in an emergency department, with financial penalties for hospital trusts if this target was not met. To ensure that those patients whose assessment and initial treatment would take > 4 hours did not spend >4 hours in the emergency department, many patients were moved into AMUs and when these became full (as they usually were) there was intense pressure to discharge patients from AMUs. This led, potentially, to under-assessment and this was one of the deficits that the intervention in the AMIGOS trial aimed to overcome. It also made it difficult to carry out the AMIGOS study because patients were often sent home before they could be recruited.
l In the MMHU workstream the pressure was most obvious in terms of the constant ‘bed crisis’ – when
bed usage is close to 100% the system is unable to accommodate natural fluctuations in demand and so there is inevitably a shortage of beds. Such a shortage of beds can threaten the ability to run a trial of a bed-based unit. It can also threaten the running of such units: if bed crises are severe, patients who should not or who do not need to go to a ward may be sent there anyway if there is nowhere else. Confused patients might therefore be sent to units with little or no expertise in their management and patients without cognitive impairment might find themselves on wards mainly for such people and may find this unacceptable. Patients may also be discharged prematurely; carers thought that 22% of standard care patients were discharged too soon and 30% said that they were unprepared for discharge. The extent of this pressure was illustrated by the considerable accommodation required to the TEAM trial design (see Chapter 3), including Zelen-type randomisation (in which random allocation is carried out before recruitment rather than the more usual recruitment before allocation), the complex algorithm to deal with varying numbers of beds and the requirement for 24/7 senior investigator cover to ensure compliance with the algorithm.
Another key strategic and policy objective was care quality. Respect for the individual, dignity in care and person-centred care are stated to be of paramount importance in the planning, delivery and evaluation of health-care interventions. Nevertheless, the evidence suggests that the reality falls short of aspirations. In 2012 the Care Quality Commission review of services found that hospitals were ‘struggling in areas such as dignity and respect, nutrition, care and welfare’94and the Patients Association published 13 cases
of care failures.95The unsatisfactory situation was acknowledged by the Prime Minister’s prioritisation
of ‘improving care standards’ in 2013.94While this programme was being undertaken, in 2011 a
collaboration of health-care groups led by the British Geriatrics Society went so far as to describe existing arrangements for health care in care homes as ‘a betrayal of older people, an infringement of their human rights and unacceptable in a civilised society’.96We were able to offer some of the findings of this
programme for the British Geriatrics Society report.