While new investment in community healthcare teams is welcome, Adam Steventon, director of data analytics at The Health Foundation, encourages the NHS to build on past evaluations.
As a preview to the much-anticipated NHS long-term plan, the government recently announced a national initiative to reduce avoidable admissions to hospital by providing enhanced community healthcare, including rapid response teams, to support people in their own homes. Significantly, this support is also going to be available to people living in care homes.
The initiative builds on work of the enhanced health in care homes vanguards which were announced as part of the Five Year Forward View for the NHS in England. The vanguards have been widely evaluated, meaning that there is a rich evidence base available for those implementing the new initiative.
Improving healthcare in care homes
The importance of providing good support for people living in care homes is a key theme emerging through the work of the Improvement Analytics Unit (IAU), a partnership between NHS England and The Health Foundation, that evaluates complex change in the NHS. The IAU has evaluated two vanguard initiatives related to care homes (Principia in Rushcliffe and Sutton Homes of Care) and two more evaluations are due to be published in spring 2019.
The IAU focused on how often people are admitted to hospital from care homes, and found that around 40 per cent of these emergency admissions were potentially avoidable. Although emergency hospital admissions are often essential for delivering care, they can expose a patient to stress, loss of independence and risk of infection, reducing their health and wellbeing after leaving hospital. Residents of care homes might be particularly affected by a hospital admission as they can be more susceptible to infection or rapid loss of muscle strength from being confined to a hospital bed.
Emergency care is a costly element of the healthcare system, with three-quarters of acute hospital beds being occupied by emergency patients. Reducing avoidable emergency admissions for care home residents could have a significant impact on acute care. The critical question is – how can care for care home residents be improved to promote their wellbeing as well as reduce admissions? Examples from the IAU show that identifying the active ingredients is not straightforward.
Principia’s enhanced support initiative included aligning care homes with general practices, regular visits from a named GP, improved support from community nurses, independent advocacy and support from the third sector. It also involved a programme of work to engage and support care home managers. Our analysis found that care home residents who received this enhanced support attended A&E 29 per cent less frequently than similar care home residents in other parts of the country and were admitted to hospital as an emergency 23 per cent less often.
The Sutton Homes of Care vanguard has been working to improve the quality of care offered to care home residents through a range of initiatives. Initiatives included measures to improve integrated care, such as the hospital transfer pathway (the ‘red bag’ scheme) and weekly health and wellbeing reviews for residents. The vanguard has also been supporting ongoing education and development for care home staff and promoting quality assurance and safety. Overall, though, the IAU found no strong evidence that people moving to a Sutton Care Home between January 2016 and April 2017 used hospitals more or less frequently than a matched control group.
More work is needed to understand why we saw these different results from the two studies. One answer might be that the Sutton study examined the impact of the intervention over 15 months, compared with 23 months for the Principia study. We know that complex initiatives such as these are not always effective immediately and need time to be embedded and adapted.
The government is pursuing an initiative that includes healthcare professionals being assigned to care homes, where they can get to know residents’ needs and provide tailored treatment and support. It is therefore more important than ever to consider what contributed to the success at Principia and learn from it.
According to the IAU’s evaluation, a key success criterion might be the extent to which a genuine partnership, based on shared objectives and approaches, is fostered between health and social care providers. The Principia vanguard had a long-standing programme of work to build relationships across organisational boundaries, engaging care home teams as well as the NHS. Did this lead to greater mutual understanding of the problems that needed to be addressed and, therefore, more effective interventions?
Shifting care from hospitals into primary and community health services has long been a goal of policy. But turning that ambition into a reality on the front line has been elusive, which is why it is so encouraging that initiatives such as Principia’s are linked with concrete reductions in emergency admissions.
A recurring lesson from our experience of improvement is that there is no one-size-fits-all solution. Those implementing the new initiative to improve care in care homes should learn from what has happened before, rigorously evaluate change and be prepared to tailor their approach to local context.
Adam Steventon is Director of Data Analytics at The Health Foundation. Follow Adam on Twitter @ASteventonTHF and The Health Foundation @healthfdn