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Claire Goodman: 'We need to know how best to provide healthcare in care homes'


There is no consensus on how services should be provided to care home residents, warns Claire Goodman

In England, most long-term care for older people is provided by independent care homes. These older people are often in the last years of life, have a degree of cognitive impairment and live with multiple health and social care needs. They rely on primary care services for medical care and access to nursing, specialist services and secondary care.

Care homes are often the solution for the NHS. In addition to long-term care, they may provide intermediate, respite and end-of-life care. Through continuing care funding, they take responsibility for people who would be in hospital if a care home was not available. Under the new commissioning structures, it is possible that care homes will assume more duties that were based in hospital. For example, one care home organisation is providing in-house care for a hospital’s dialysis patients.

“The Optimal study seeks to understand the key elements of healthcare provision necessary to achieve high-quality healthcare for care home residents and appropriate use of NHS services”

Care homes are important collaborators with the NHS, but it is not a straightforward partnership. NHS service delivery is often determined by local custom and practice. For example, in some areas district nurses visit care homes with nursing provision to provide specialist advice on wound care, or specialist palliative care nurses will support staff to provide end-of-life care.

Elsewhere, these services are unavailable or restricted to homes without nursing provision (residential homes) and provided on a resident-by-resident basis at the discretion of local services. Other homes benefit from NHS-funded nursing specialist teams that offer training and support to staff and resident assessment.

Many clinical commissioning groups are now looking at how they can support care home residents and reduce demand on emergency and hospital services. While there is guidance on commissioning, there is no consensus how services should be provided and it is possible that approaches will become more varied. It is likely that some approaches will be more of a priority and effective than others, for example access to specialist nursing expertise or staff involvement in decision making and whether their expertise is valued.

The Optimal study, funded by the National Institute of Health Research (NIHR), is a collaboration between six universities - the University of Hertfordshire, the University of Nottingham, the University of Surrey, Brunel University, City University and University College London. It seeks to understand the key elements of healthcare provision necessary to achieve high-quality healthcare for care home residents and appropriate use of NHS services.

The three-year study has two stages. The first stage has mapped all the ways in which the NHS works with care homes, interviewed key stakeholders and reviewed the evidence of what works and in what circumstances. The second stage will use the findings from stage one to compare approaches with improving residents’ access to healthcare. To understand what elements are most effective and in what circumstances, we will track the impact of different approaches used by the NHS to provide healthcare to older people in 12 care homes in three areas over a year.

If you would like to know more about this study or share your experiences, please email:

● Optimal is funded by the NIHR Service Delivery Research programme. Department of Health Disclaimer: the views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Health Service Research Delivery Programme, the NIHR, the NHS or the Department of Health

Claire Goodman is professor of Health Care Research at the University of Hertfordshire. The Optimal team are Sue Davies, Adam Gordon, Justine Schneider, Tom Dening, Christina Victor, Julienne Meyer, Finbarr Martin, Brian Bell and Heather Gage



Readers' comments (11)

  • Health workers who provide support to direct payment clients are put at risk of breeching standard code of conducts

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  • Meeting national policys in some direct payment cases causes inner conflict on the workers knowledge and duty.Support worker can be a libality to them selfes in some situations. The employee remains without support to enable clients with a higher standard of care. With the client also being the employer. It is in the employees duty to maintain respect and comply with their employers/ clients wishes. The employee if previously trained is "in the know of national policy guidlines " the employer / client is without knowledge of these standards. It is difficult for any emplyee to create a plan or offer guidance for the clients best intrests, without taking away the clients rights or dicriminating against the clients beliefs. As the work place is the employers home, its unclear who is in the right on making sure care standards are maintained. Is this important factor it in the duty of carer or the individual receiving care .? I'm sure many workers have found them selves in a cross fire situation. Good support workers care and empathise and build relationships with clients. A greviance can be caused by the worker having the clients best intrests at heart and with holding intilectual knowledge on the fear of causing distress or taking away a employers / client basic human right.

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  • Tinkerbell

    in no particular order but firstly

    Employ enough trained staff in dementia.

    Easier access to continuing care funding without having to jump through reams of zombie tickbox paperwork only to have it thrown back at you for some incomprehensible reason, (missed one tick box) whilst the patient still languishes in an in an inappropriate placement not having their needs met and thus deteriorating. Ever tried accessing timely funding, don't hold your breath.

    Placement 'without prejudice' until said funding is approved. Never known it happen but more lip service.

    Less lip service and more timely action please.

    More accountability for homes who can't provide a service but still take the patient anyway into their care and then have them moved out having served 'notice to quit'. Provide them with staff to do the job properly or suggest they take up an alternative 'business' money making venture.

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  • michael stone

    Just a comment - I sent an e-mail to Claire and found a (sensible) reply waiting the next day, when I read the piece above. Perhaps Tink should consider e-mailing Claire ?

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  • Tinkerbell

    michael stone | 31-Jan-2014 2:53 pm

    Mike, I was hoping she might be reading the responses to this article.

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  • michael stone

    tinkerbell | 31-Jan-2014 5:32 pm

    I do have something else to point out to Claire - I'll ask her if she is reading the responses to this article or not, and I'll probably incude your post in my e-mail.

    Despite some negativity on these pages, it often turns out that senior clinicians and clinical academics do understand the problems and issues (but not always - some issues get ignored/overlooked, because they are nobody's specific area of interest). But they also have the same problem, of how do you actually change things for the better in practice.

    You seem to have academics 'arguing things out between themselves' somewhere up in the clouds, and quite different things happening on the front line (the ground, in that analogy).

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  • Tinkerbell

    Hopefully they can use their 'imagination' if they haven't got the 'experience' as discussed in the article on supporting mental health in nurses who have a vast experience in seeing what is actually is 'happening' in their workplace rather than thinking they know, or don't know as is the case and reason they are saying 'we need to know'.

    Then combine theory will reality et voila!

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  • michael stone

    tinkerbell | 1-Feb-2014 5:32 pm

    Actually, I think they say 'we need to know' because of a fundamental issue within the NHS: unless there is some 'formal research' to back up what everyone actually does know from observation/experience, the people who could change things (usually goverments and purse-string controllers) say 'we need proof before we act'. Of course, if you come up with 'proof' they don't like, they dredge up some 'opposing proof' that supports their own desires, anyway.

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  • Tinkerbell

    what a game is being played when peoples lives are at stake. Unfortunately now the Condem Clowns have had their wicked way it's all pretty much a done deal.

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  • Trained staffing levels in care homes must be increased. At present many homes have HCA in charge of units. They have not had the training nor do they understand interactions of drugs. In one case a HCA was giving a new resident digoxin because he had bought it in with im. It was his wifes digoxin and he had a pacer!!! There was 1 RN to 71 residents This is not enough to give even basic care. The care providers dont care, they would cut it back further.

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