Quest for Quality: BGS Joint working Party Inquiry into the Quality of Healthcare Support for Older People in Care Homes: A Call for Leadership, Partnership and Quality Improvement Incorporating interviews: The contribution of health professional expertise Hazel Heath Independent Nurse Consultant for Older People, Honorary Senior Research Fellow City University London, Consultant Editor: Journal of Dementia Care, Chair RCN Older People Forum. 16th September 2011

BGS Joint Working Party Report Describes: Current NHS support for care homes Current NHS support for care homes What should and could be done What should and could be doneHighlights: The need to build joint professional leadership from the health, social and care home sectors, statutory regulators and patient advocacy groups for find the solutions that none of these can achieve along. The need to build joint professional leadership from the health, social and care home sectors, statutory regulators and patient advocacy groups for find the solutions that none of these can achieve along. Calls for: National action by government National action by government Local action by NHS commissioners, planners and clinical services Local action by NHS commissioners, planners and clinical services

Methods Working with a range of stakeholders Working with a range of stakeholders In-depth interviews (21 health professionals working into care homes) In-depth interviews (21 health professionals working into care homes) Focus groups (BGS Consultant Nurses, BGS OP Specialist Forum, Care Homes, Commissioners) Focus groups (BGS Consultant Nurses, BGS OP Specialist Forum, Care Homes, Commissioners) Review of contemporary surveys (GPs, Geriatricians) Review of contemporary surveys (GPs, Geriatricians) Collating and evaluating the published evidence and systematic reviews Collating and evaluating the published evidence and systematic reviews Synthesis of guidance on the management of long-term conditions adapted for use in care home settings Synthesis of guidance on the management of long-term conditions adapted for use in care home settings

Focus of the interviews: The expertise and distinct contribution of health professionals. The expertise and distinct contribution of health professionals. How health professionals are working in different localities. How health professionals are working in different localities. Common situations in which health professionals are consulted. Common situations in which health professionals are consulted. The issues that clinical experts want to signpost; ‘pieces of wisdom’ they want to share with others less familiar with healthcare work in care homes. The issues that clinical experts want to signpost; ‘pieces of wisdom’ they want to share with others less familiar with healthcare work in care homes. How can we do things better? How can we do things better?

Twenty one interviews have been undertaken with: Six Geriatricians Six Geriatricians Two Old Age Psychiatrists Two Old Age Psychiatrists Five GPs (two in General Practice, two with Special Interest, two working in Nursing Home Medical Practices) Five GPs (two in General Practice, two with Special Interest, two working in Nursing Home Medical Practices) Two Older People Specialist Nurses Two Older People Specialist Nurses Two OPSN Mental Health Two OPSN Mental Health Two Community Matrons Two Community Matrons Two other (care home manager and researcher). Two other (care home manager and researcher). Eighteen around England, two in Scotland, one in Wales.

Health care: service models Wide variety around the country. Each interviewee working to different model. Services influenced by: Local responses to national priorities Local responses to national priorities Local responses to perceived patient need Local responses to perceived patient need Funding sources and priorities Funding sources and priorities Individual professional priorities, local ‘talents’ and influential leaders Individual professional priorities, local ‘talents’ and influential leaders Commitment and perseverance ! Commitment and perseverance !

Referral patterns: all professionals Schedule visits, meetings and reviews. Schedule visits, meetings and reviews. Individual referrals, requests and consultations. Individual referrals, requests and consultations.

Focus, approach, ways of working: Uniquely individual. Uniquely individual. Focusing on specific problems, clinical issues, patient and family issues, ethical issues. Focusing on specific problems, clinical issues, patient and family issues, ethical issues. Focusing on patients within situations, then ‘stepping back’ and investigating to establish a broader picture. Focusing on patients within situations, then ‘stepping back’ and investigating to establish a broader picture.

HEALTH CARE / CLINICAL EXPERTISE Knowledge: Health Care and Clinical Skills: Clinical; Inter- personal Skills: Teaching; Supporting Others Team workingConfidence Commitment Enthusiasm Stamina Autonomy Authority Power Experience: Clinical and in Care Homes

GPs ‘General medical services’, specific medical interventions, acute interventions, chronic illness, family practice ‘General medical services’, specific medical interventions, acute interventions, chronic illness, family practice Some practices ‘adopt’ care homes Some practices ‘adopt’ care homes Some work alongside other practices into care homes Some work alongside other practices into care homes Some care home residents retain their own GPs. Some care home residents retain their own GPs.

GPs with Special Interest GPs with special interest in older people: additional training and experience. Work in ways similar to geriatricians. GPs with special interest in older people: additional training and experience. Work in ways similar to geriatricians. GPs with special interest in, e.g. medications or palliative care. GPs with special interest in, e.g. medications or palliative care. Some GPSIs ‘adopt’ care homes, others work into care homes. Some GPSIs ‘adopt’ care homes, others work into care homes.

Geriatricians Complex medical problems in older people; multiple co- morbidities; frailty; geriatric syndromes; ‘textbook geriatric medicine’. Complex medical problems in older people; multiple co- morbidities; frailty; geriatric syndromes; ‘textbook geriatric medicine’. Complex conditions combining physical, psychological, psychiatric, social etc dimensions in older age. Complex conditions combining physical, psychological, psychiatric, social etc dimensions in older age. Medication use in older people and people with frailty; multiple medication use and interactions; optimum medication use. Medication use in older people and people with frailty; multiple medication use and interactions; optimum medication use. Rehabilitative and reablement approaches. Rehabilitative and reablement approaches. End of life care; decisions on timing end of life care; palliative care; end stage condition management; advanced care planning; ethical dilemmas around end of life. End of life care; decisions on timing end of life care; palliative care; end stage condition management; advanced care planning; ethical dilemmas around end of life. Working with older individuals and families. Working with older individuals and families. Multi-professional team working. Multi-professional team working.

Old Age Psychiatrists Mental health in later life in all its complexities, for example: Depression, any psychotic illness, bipolar disorder, someone trying to self harm. Depression, any psychotic illness, bipolar disorder, someone trying to self harm. Non-pharmacological issues related to mental health Non-pharmacological issues related to mental health Complicated behavioural issues, someone with dementia hitting out or hypersexual. Complicated behavioural issues, someone with dementia hitting out or hypersexual. Issues of capacity which are not straightforward, e.g. with family dynamics Issues of capacity which are not straightforward, e.g. with family dynamics Anything to do with antipsychotics Anything to do with antipsychotics Terminal agitation Terminal agitation

Nurses: Types of intervention District Nurses – specific interventions District Nurses – specific interventions Community Matrons – some have remit for specific interventions, others for specific types of support including individual referral Community Matrons – some have remit for specific interventions, others for specific types of support including individual referral Older People Specialist Nurses – scheduled intervention and individual referral Older People Specialist Nurses – scheduled intervention and individual referral

Nursing expertise Working holistically with individuals and families. Working holistically with individuals and families. Working alongside individuals and families. Working alongside individuals and families. Seeing the broad picture and person’s ‘journey’. Seeing the broad picture and person’s ‘journey’. Older people’s care; complexities (multiple co-morbidities etc) transitions, looking beyond the obvious and unpicking complex situations. Older people’s care; complexities (multiple co-morbidities etc) transitions, looking beyond the obvious and unpicking complex situations. Working in multi-professional teams. Working in multi-professional teams. Rehabilitative and reablement approaches. Rehabilitative and reablement approaches. Individual expertise. Individual expertise. Broad range of knowledge, skill and experience. Broad range of knowledge, skill and experience. ‘Reading situations’; instinct and intuition; anticipation and being able to predict. ‘Reading situations’; instinct and intuition; anticipation and being able to predict. The concept of ‘real’ nurses and ‘real’ geriatricians The concept of ‘real’ nurses and ‘real’ geriatricians

FINDINGS

The problems Residents have complex healthcare needs, long-term conditions, significant disability, frailty Residents have complex healthcare needs, long-term conditions, significant disability, frailty The social care model is central but insufficient to meet healthcare needs The social care model is central but insufficient to meet healthcare needs The NHS has gradually withdrawn its expertise and support. Most geriatricians and Old Age Psychiatrists play no part. The NHS has gradually withdrawn its expertise and support. Most geriatricians and Old Age Psychiatrists play no part. Regulation can highlight problems and promote improvement but providers cannot achieve this without necessary support. Regulation can highlight problems and promote improvement but providers cannot achieve this without necessary support. No model of co-ordinated healthcare to meet needs of care home residents. Traditional GP in many areas ill equipped. No model of co-ordinated healthcare to meet needs of care home residents. Traditional GP in many areas ill equipped. Many residents are denied equitable access to suitable NHS primary and secondary healthcare. Low priority  inappropriate hospital admissions. Many residents are denied equitable access to suitable NHS primary and secondary healthcare. Low priority  inappropriate hospital admissions. Care homes will continue to be an important component of care for frail older people but healthcare remains a Cinderella service in the NHS. Care homes will continue to be an important component of care for frail older people but healthcare remains a Cinderella service in the NHS.

What is needed A health service suitable for the specific needs of this population A health service suitable for the specific needs of this population The residents and their relatives must be at the centre of decisions about care The residents and their relatives must be at the centre of decisions about care A multi-disciplinary approach A multi-disciplinary approach A partnership approach with care homes and social care professionals. A partnership approach with care homes and social care professionals.

RECOMMENDATIONS 1. Local NHS planners/commissioners should ensure that clear and specific service specifications are agreed with local NHS providers. 2. Care home residents should be at the centre of decisions about their care. An integrated social and clinical approach should support anticipatory care planning, encompassing preferred place of care and end of life plans. 3. Service specification for providing healthcare support to care homes should guarantee a holistic review for any individual within a set period from their move into a care home, leading to healthcare plans with clear goals. This will guide medication reviews, modifications and clinical interventions both in and out of hours. 4. Healthcare services to support the achievement of 3 should be integrated, combine enhanced primary medical and nursing care with dedicated input from departments of old age medicine, MH and other specialisms – palliative care, rehab medicine. 5. UK nations health departments should clarify NHS obligations for NHS care to care home residents. 6. Statutory regulators should include in their scrutiny the provision of NHS support to care homes and the achievement of quality standards. 7. Multi-agency and multi=professional national leadership should be promoted to support development and dissemination of good healthcare practice in care homes, supported by clinical guidance and quality standards.

The report marks the start of a process of partnership to develop impetus, resources and clinical guidance that will support the NHS to play its part in improving the experience and the quality of life of residents in care homes.

Hazel Heath