David Oliver: Reducing emergency admissions from care homesBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6149 (Published 30 October 2019) Cite this as: BMJ 2019;367:l6149
- David Oliver, consultant in geriatrics and acute general medicine
Follow David on Twitter: @mancunianmedic
The Health Foundation recently published a report on emergency hospital admissions from care homes.1 The analysis, coproduced with NHS England, found that 41% were for “potentially avoidable conditions,” such as respiratory infections, pressure sores, and urinary tract infections. It estimated that one in every 12 patients admitted to emergency wards is a care home resident—around 192 000 a year.
Care home residents are often in the final phase of life: median survival from entry is around two years (less in nursing homes than residential homes), with a 55% chance of surviving the first year.2 Advance care planning and support at the end of life should surely be mainstream and universally offered.34 More people die in care homes than in hospices.5 And around one in three residents admitted acutely to hospital dies.6
Local initiatives that focus on responsive end-of-life care can help residents die in place and avoid potentially distressing, disorienting ambulance transport and (often futile) admission to hospital. With around 340 000 care home places in England7 and only 102 000 overnight general and acute beds,8 local hospital activity is inevitably affected by care provided in the local care home sector for residents already in beds in supervised, supported environments.
The NHS long term plan now includes a pledge for “guaranteed NHS support” for care home residents.9 This includes a new component in the GP contract; however, primary and end-of-life care alone are insufficient. Residents also need parity of access with the rest of the population to the full range of community services, including allied health professionals, specialist community nursing practitioners, mental health services, and community pharmacy. The Health Foundation report alludes to this and to the British Geriatrics Society’s care home commissioning guide,4 which heavily influenced NHS England’s work in meeting residents’ healthcare needs.
Ideally, our offer should also include more access to rapid response teams providing short term interventions—IV antibiotics, fluids, or transfusions or early supported discharge. And residents should ideally not be denied rehabilitation in a care home after acute illness or injury—especially in residential care, where it might prevent the need to move to a nursing home.
We can do all of this, but we mustn’t forget that the care home sector faces funding and staffing gaps that often threaten viability.1011 Individual care homes, chains, or provider groups have a substantial stake in developing and supporting their own staff and processes. They also have expertise and deep knowledge of residents that we in the NHS should respect and learn from. After all, they’re with the residents every day.
We know from research programmes such as the PEACH programme (Proactive Health Care of Older people in Care Homes)12 that care homes don’t appreciate a disempowering narrative or service models predicated on what the NHS can do for them by “reaching in” or “upskilling”—nor the implication that their residents are a drain on the local NHS.
NHS acute care staff and those in the care home sector need to work in partnership but also to have mutual respect for each other’s skills and the pressures everyone faces.
Competing interests: See www.bmj.com/about-bmj/freelance-contributors.
Provenance and peer review: Commissioned; not externally peer reviewed.