More reasons to develop a National Care Service? Clive E Bowman honorary visiting professor1, 2 Oliver1 andGordon andDhesi2 discuss delayeddischarge fromhospital causedby lack of social care capacity and the inadequacy of rehabilitation resources and raise legitimate concerns about deconditioning through simply moving older people from hospital beds to care homes. Their concerns might be related to the lack of continuity of care throughout the “system.” It is wrong that healthcare is undermined by long ambulance and emergency department waits; it is also wrong for people waiting to regain health after an illness to convalesce in an expensive acute bed. In this context, the use of care home beds makes good sense, with important caveats. Firstly, every person transferred should have a named case manager linked to the discharging hospital team. Patients and their families or representatives should have a clear understanding of the transfer and, crucially, its expected outcome. Secondly, although there are some excellent examples of care home beds being used for multidisciplinary reablement, these are typically in carefully commissioned units, with NHS therapists and doctors “owning” the patient’s journey. Similar approaches can be seen in care homes providing specialist led end-of-life care. Care homes that provide convalescence—enabling patients weakened by an acute illness to regain their strength and return home—need better commissioning. This is health driven personal care, not social care. This implies casemanagement by a specialist team. It also requires block contractingwith carehomeoperators to ensure that skillsets and processes (not least the rapid admission and discharge cycles) are not confused with the cost base and ethos of long term care. The pressures on primary care, acute care, hospital care, and social care cannot be remedied by simply doing more of the same, but the development of a national care service could provide a route to resolving many of the current difficulties.

David Oliver, 27 March David Oliver usefully highlights problems with do not attempt cardiopulmonary resuscitation (DNACPR) processes. Nursing and residential home residents should have a “clear emergency and treatment escalation plan,” and the current lack of such individual plans is at the heart of much of the present difficulties in care home emergencies and …

Manthorpe and Iliffe go some way to identifying the risk of failure in the care home market, but their suggestion of an NHS franchise model (like that which underpins general practice) is a reflex solution based on their frustration with the current impasse around funding and access.1 Starting with a clear understanding of the role of care homes now and in the future might be …

Manthorpe and Iliffe go some way to identifying the risk of failure in the care home market, but their suggestion of an NHS franchise model (like that which underpins general practice) is a reflex solution based on their frustration with the current impasse around funding and access.1 Starting with a clear understanding of the role of care homes now and in the future might be …

Background Many care home residents cannot self-report their own health status. Previous studies have shown differences between staff and resident ratings. In 2012, we collected 10 168 pairs of health status ratings using the howRu health status measure. This paper examines differences between staff and resident ratings.Method HowRu is a short generic person-reported outcome measure with four items: pain or discomfort (discomfort), feeling low or worried (distress), limited in what you can do (disability) and require help from others (dependence). A summary score (howRu score) is also calculated. Mean scores are shown on a 0–100 scale. High scores are better than low scores. Differences between resident and staff reports (bias) were analysed at the item and summary level by comparing distributions, analysing correlations and a modification of the Bland-Altman method.Results and conclusions Distributions are similar superficially but differ statistically. Spearman correlations are between 0.55 and 0.67. For items, more than 92.9% of paired responses are within one class; for the howRu summary score, 66% are within one class. Mean differences (resident score minus staff score) on 0–100 scale are pain and discomfort (−1.11), distress (0.67), discomfort (1.56), dependence (3.92) and howRu summary score (1.26). The variation is not the same for different severities. At higher levels of pain and discomfort, staff rated their discomfort and distress as better than residents. On the other hand, staff rated disability and dependence as worse than did residents. This probably reflects differences in perspectives. Red amber green (RAG) thresholds of 10 and 5 points are suggested for monitoring changes in care home mean scores.

Oliver rightly reports that care homes are in trouble.1 Covid-19 has laid bare weaknesses of support from the NHS, public health, regulators, and local government, showing once more that care homes and their residents don’t fit traditional healthcare or social care paradigms.\n\nThe public perception of care has shifted with the recent appalling covid-19 related mortality to the commitment, passion, and anxieties of staff for residents and …

Thank you for your interest in spreading the word about The BMJ.NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Username * Your Email * Send To * You are going to email the following Care homes after covid-19: we need a wide ranging inquiry and reform Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Oliver rightly identifies a challenge in the health and care landscape—the pressure on care homes.1 Many people are waiting for the green paper as a new messianic totem, but it is likely to disappoint because care homes fit the paradigms of neither the NHS nor social care. Talk of medical complexity is at odds with the …

Background and methodIn care homes, staff well-being, job confidence and opinion of the care provided to residents are central to morale and care quality. In this study, care home staff in the East Midlands region of England completed self-reported outcome and experience surveys in two rounds. Mean scores for each home are shown using a scale from 0 (all chose lowest option) to 100 (all chose highest option). High scores are good.ResultsIn round 1, 332 staff in 15 homes submitted responses; in round 2, 207 staff in 9 homes. Mean scores in round 1 and round 2 were similar, although those of some homes scores differed significantly, cancelling each other out. Overall, Work Wellbeing mean score was 83 (care home range 48–97), with worthwhileness (92) the highest ranked item and anxiety at work (78) the lowest. Job Confidence mean score was 84 (range 59–94), with able to manage the work (86) highest and involvement in decisions that affect staff (79) lowest. Care Provided mean score was 86 (range 59–97), with treat people kindly (91) highest and well organised (80) lowest. Homes rated as outstanding by the Care Quality Commission had higher scores on average than those rated good, which were higher than those rated as needing improvement.ConclusionsThis study has demonstrated the practicality of measuring staff views of their Work Wellbeing, Job Confidence and Care Provided in care homes. Rather than wait for adverse quality outcomes to be detected, this approach offers a way to track staff morale and declared capability over time.

Oliver rightly identifies a challenge in the health and care landscape—the pressure on care homes.1 Many people are waiting for the green paper as a new messianic totem, but it is likely to disappoint because care homes fit the paradigms of neither the NHS nor social care.Talk of medical complexity is at odds with the …

Background Medical diagnoses and assessed need for care are the prerequisites for planning and delivery of care to residents of care homes. Assessing the effectiveness of care is difficult. The aim of this study was to test the practicality and construct validity of the howRu health status measure using secondary analysis of a large data set.Method The data came from a Bupa Care Homes Census in 2012, which covered 24 506 residents in 395 homes internationally (UK, Australia and New Zealand). Staff completed optical mark readable forms about each resident using a short generic health status measure, howRu. Response rates were used to assess practicality and expected relationships between health status and independent variables were used to assess the construct validity.Results and discussion 19,438 forms were returned (79.3%) in 360 care homes (91.1%); complete health status data were recorded for 18 617 residents (95.8% of those returned). Missing values for any health status items mostly came from a small number of homes. The relationships between howRu and independent variables support construct validity. Factor analysis suggests three latent variables (discomfort, distress and disability/dependence).Conclusions HowRu proved easy to use and practical at scale. The howRu health status measure shows good construct validity.

Financial and Competing Interests: CB is a NED to a care home provider and is Chair of a technology company engaged in medicines management software

Hospital admissions from care homes1 are often due to a clinician being unable or unavailable to “do something,” such as make the difficult decision that admission would be futile. The PEACH study joins an increasing litany of well crafted studies identifying the potential for supportive interventions.2 These generally ignore the realities of staff availability. Care home residents do not fit the …

IntroductionPatients need to feel confident about looking after their own health. This is needed to improve patient outcomes and clinical support. With few suitable tools available to measure self-care health confidence, we developed and validated a short, generic survey instrument for use in evaluation and quality improvement.MethodsThe Health Confidence Score (HCS) was developed through literature review, patient and expert focus groups and discussions. This paper reports an initial survey (n = 1031, study 1) which identified some issues and a further face-to-face survey (n = 378, study 2) to test the construct and concurrent validity of the final version. Scores were correlated against the My Health Confidence (MHC) rating scale, howRu (health status measure) and relevant demographics.ResultsThe HCS is short (50 words) with good readability (reading age 8). It has four items covering health knowledge, capability to self-manage, access to help and shared decision-making; each has four response options (strongly agree, agree, neutral disagree). Items are reported independently and as a summary score.The mean summary score was 76.7 (SD 20.4) on 0–100 scale. Cronbach’s alpha = 0.82. Exploratory factor analysis suggested that the four items relate to a single dimension. Correlation of the HCS summary score with MHC was high (Spearman r = 0.76). It was also associated with health status (Spearman r = 0.49), negatively with number of medications taken (r=–0.29) and age (r=–0.22) and not with ethnicity, having children or education level.ConclusionsThe HCS is short, easy to use, with good psychometric properties and construct validity. Each item is meaningful independently and the summary score gives an overall picture of health confidence.

Introduction: care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use. Methods: a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners. Results: context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which 'wraps around' care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites. Conclusion: activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.

Introduction This protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation. Methods and analysis The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes. Ethics and dissemination The study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video.

Introduction This protocol describes a study of a Quality Improvement Collaborative (QIC) to support implementation and delivery of Comprehensive Geriatric Assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement, and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching, and assistance with project evaluation. Methods and analysis The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in 4 local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom, and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test, or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations (CMOs) describing what needs to be in place to use QICs to implement service improvements in care homes. Ethics and dissemination The study protocol was reviewed by the NHS Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham ethics committee (reference: LT07092016). Both determined that the PEACH study was as a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphic illustration, and a dissemination video. Summary box: strengths and limitations 1. A realist evaluation approach will enable an in-depth study of how a QIC intervention works (or not), for whom, and also in what ways when used to implement and deliver CGA in care homes. 2. Two researchers will analyse the data, and the whole study team of multidisciplinary academics will be involved in interpreting the data during the programme theory generation, testing, and consolidation to improve validity of the findings. 3. The study team will act as both intervention facilitators and evaluators, and thus will have firsthand experience of how a QIC approach works in this setting, for whom, and in what ways. 4. This dual role for the study team may introduce bias due to socially desirable responding, which will be mitigated through self-reflective techniques and member checking. 5. This is a study of one QIC used to implement and deliver CGA in care homes in one region of the UK, and therefore generalisability will pivot upon establishing mid-range theory applicable in other settings. Introduction A large and growing number of older people with frailty live in care homes. The total care home population is approximately 433,0001, of whom approximately 170,000 have high dependency needs (needing 24 hour nursing care)2. The number with high dependency needs is forecast to increase to approximately 310,000 by 20352. This forecast presents challenges for health and social care providers. Current healthcare services do not adequately meet the needs of care home residents, let alone being prepared for future growth. Iliffe et al3 reported working relationships between the NHS and care homes lack structure and purpose, with wide variation in the provision of both general and specialist healthcare services to care homes. The current challenge is to develop existing services to meet peoples’ care needs4. Comprehensive Geriatric Assessment (CGA) is the accepted standard process of caring for older people with frailty. The process starts with a holistic assessment of an older person, which is then used to develop a comprehensive care plan that is then delivered using multidisciplinary, and coordinated specialist care. CGA has a strong evidence base showing improved outcomes5, however there is evidence that CGA is not currently taking place in care homes6. One possible approach to facilitate the practice change necessary to implement CGA is a Quality Improvement Collaborative (QIC) intervention7. The QIC approach focuses on implementing evidence into practice by facilitating shared learning using ‘Plan, Do, Study, Act’ cycles to reflect and build upon changes made in practice in an iterative way. In a QIC, clinical and quality improvement experts provide teams with guidance, improvement ideas, structured activities, and encouragement to improve the quality of healthcare service, usually for a limited period of time (approximately 1-2 years). The way QICs are delivered vary8, but they generally comprise five essential features: (1) focus is on a specified topic; (2) provision of ideas and support for improvement by clinical and quality improvement experts; (3) participation by multi-professional teams from multiple sites; (4) utilisation of a model for improvement (setting targets, collecting data and testing changes); and (5) the requirement for collaborative participants to engage in a series of structured activities9. Recently, Wells et al10 systematically reviewed the evidence around QICs, and found that 83% of the 64 included studies reported an improvement in one or more of the study’s primary effect measures. Four of the included studies were conducted in a care home setting and used the QIC intervention to improve care. The specific aims in these studies were to reduce falls11,12, reduce pressure ulcers13, and improve painmanagement processes of care and outcomes14. Three of these reported improved outcomes after the QIC, namely reduced pain prevalence14, reduced falls incidence11, and improved pressure ulcer prevention and care13. Systematic reviews, like the one conducted by Wells, are useful in describing the effectiveness of an intervention but cast less light on the mechanisms by which it operates. QICs are complex, multifaceted, context-sensitive, social and behavioural interventions. The intervention recruits collaborative teams of people employed across different organisations, environments, and seniority levels. Effects of QIC interventions are likely to be a consequence of social interactions, and team dynamics which are influenced by organisational structures, cultures, and social norms. It is important to understand these interactions, and the different factors that influence the extent to which interventions are effective9,15. Research literature describes how QIC interventions are generally thought to work, and describes barriers and enablers of using QIC interventions in care home settings11-14. These insights are outlined in box 1, and comprise our initial programme theory. Insights from quality improvement literature describing how QICs are thought to work By collaborating and comparing practice, teams will be motivated to do things differently and make changes to practice that improve patient outcomes16. QICs are a learning organisation which empower teams to address quality problems through providing motivation, knowledge, skills and support17. The QIC intervention creates a collaborative environment which provides an opportunity for diverse participants to come together, reflect and learn. New learning and insights are then shared across the collaborative and taken back to employing organisations18. Barriers and enablers of using QIC interventions in care home settings Barriers: • Fear of potential side effects when changing medication14. • Problems occurring at the care home at the same time of the QI project (e.g. staff shortages) resulted in the QI project being seen as a low priority14. • Difficulties applying quality improvement methodology14. • High turnover of key members of staff involved in the QIC14. • Complexity of the intervention and complexity of applying the change12. Facilitators: • One-on-one mentors kept quality improvement work as priority, and simplified project tasks14. • Providing simplified and incremental project steps to nursing home staff14. • Effective communication (both inside and outside of formal meetings) to facilitate sharing and receiving new ideas, and passing on learning from pilot testing11. • Allowing time for buy-in decision11. • Engage wider range of care home staff in the process of quality improvement as multiple levels of staffing will affect the decision to adopt new care practices12. • QIC project depended on self-selected, motivated and diligent nursing homes13. Box 1 Initial programme theory insights from the literature describing generally how QICs are thought to work, and evidence describing barriers and enablers of using QIC interventions in the care home setting This study will address a gap in the body of knowledge. The existing literature on care home QICs comes from outside the UK. It is possible that QICs will be challenged in this context in the UK because of the complex arrangement of health and social care provision in this setting, meaning that responsibilities can either be unclear or disputed19. In addition, CGA is a particularly complex intervention, such that it may be less amenable to introduction by QIC than more straightforward approaches. Box 1 presents insights around how QICs are thought to work generally, and a description of barriers and enablers of the QIC approach used in care home setting. The current study will build on this and use a realist approach to develop a detailed programme theory presenting context-mechanism-outcome configurations which answer the questions what works, for whom, and in what ways when a QIC is used