Guest Blog written by Professor Steve Iliffe, University College London on Thursday June 29, 2017
The Section of Geriatrics & Gerontology at the Royal Society of Medicine hosted a conference on Care Home Medicine on May 16th 2017. Opened by Victoria Elliot of the Orders of St. John Care Trust, the conference showcased six recent or current projects; OPTIMA (1), PEACH (2), PROVIDE (3), MEDREV (4), PROSPER (5) and Handover (6). The event highlighted the changes that had occurred in care homes research in the five years since the start of ENRICH – the NIHR portal for Enabling Research In Care Homes.
Victoria Elliot reminded participants that the care home sector was experiencing similar recruitment and retention problems as the NHS, and those aspects of regulation unique to the sector reduced research capacity. On the other hand, care homes favoured relational approaches to working, innovation (e.g. Admiral nurses working with homes) and a focus on residents’ wellbeing, making some research attractive for some care homes.
Claire Goodman, speaking on the OPTIMAL project, commented that it is unlikely that there is one way for the NHS to work with care homes. When commissioning and delivering NHS services for care homes the study identified key characteristics that are more likely to lead to better health care for older people. These are, ensuring NHS services and practitioners have protected time to work with care homes, recognising it takes time for NHS and care home staff to learn how to work together and seeing care homes as partners not a problem to the NHS. When the focus of NHS was solely to stop care homes sending fewer residents to A&E– this could have the unintended consequence of creating hostile working relationships and scapegoating care homes for not responding to the NHS and its priorities.
Adam Gordon from the PEACH study described how research interventions (such as Comprehensive Geriatric Assessment, Appreciative Inquiry and Quality Improvement) are used differently by different people in care home settings. Attempts to harmonise interventions, through collaborative meetings could result in difficult dialogues in which NHS staff were more likely to take offense than care home staff. Care homes, in his view, were beginning to show signs of ‘innovation saturation’ and ‘improvement inertia’.
Michael Bowen, reporting on the PROVIDE study, noted that the research team had been unable to recruit care home staff to focus groups despite scheduling them to fit shifts and providing food. At a fundamental level, Ian Maidment from the MEDREV study had struggled to identify all the care homes in a geographical area, and had resorted to time-consuming hand-searching of the Care Quality Commission (CQC) website. Once identified, no more than 50% of Care Homes expressed interest in the study’s topic – medication reviews in care homes. Recruitment of GPs was also problematic, and the research team had to overcome initial reluctance and avoid “raising hackles”, which they were able to do after recruiting a GP from the Clinical Commissioning Group to the study’s management committee.
Debra de Silva described how the PROSPER project in Essex involved 90 care homes working in partnership with the local authority, NHS, academic institutions and independent organisations. A great deal was learnt about how to improve culture, care processes and resident outcomes. There was also learning about how researchers can effectively work alongside care homes including using simple tools, not assuming that tools can be transferred from health to social care without adaptation and focusing on oral traditions, in-person meetings and engaging with all levels of staff to gain buy-in. In this programme all homes provided qualitative data and two thirds provided quantitative data. However there were still challenges: half of the homes said taking part in quality improvement took extra time and one quarter felt the improvement support provided by the local authority could have been more consistent.
Jill Manthorpe from the Handover study argued that it was important to recognise that systems that were familiar to NHS staff, such as shift handovers, could be very different in care homes. This study has both explored the literature on care home handovers – finding that there is very little on the subject despite its ubiquity - and observed shift handovers at night and in early morning. She commented that much care home research relied on people telling researchers about their work rather than observational methods, which could be insightful.
The Handover study found that care home staff are interested in what other care homes do, particularly if they are not part of larger chains. They are ‘research receptive’ in this sense. Talking to staff before collecting data seems key as well as remembering that many staff are not from the UK so may have views of research and researchers that should be considered and taken account when making contact and asking people to sign consent forms.
Finally the presentation by Victoria Elliott was well received and confirmed what many people in the audience knew and what they saw in practice. There seems to be greater familiarity with the social care sector – problems were well-recognised and the differences between health and social care settings appeared to be valued. ENRICH may have helped in the making of changes to healthcare professionals and researchers as much as to care homes.
Steve Iliffe is a Emeritus professor of Primary Care for Older People at University College London, having been a general practitioner in inner London for 30 years. He is the director of the Centre for Ageing Population Studies within the Department of Primary Care and Population Health at UCL with a research programme in health promotion in later life as well as in dementia studies. He has an interest in health services research, evaluating a system of health promotion in an EU-funded trial (the ProAge study) and is co-author of Cochrane systematic reviews on visual function screening in older people.
(1) Gordon AL, Goodman C, Dening T, Davies S, Gladman JRF, Bell BG et al. The Optimal Study: Describing the key components of optimal health care delivery to UK care home residents: A research protocol. Journal of the American Medical Directors Association 2014;15(9)681-686. DOI: 10.1016/j.jamda.2014.06.011.
(1) Goodman C, Dening T, Gordon AL, Davies SL, Meyer J, Martin FC, Gladman JR, Bowman C, Victor C, Handley M, Gage H et al . Effective health care for older people living and dying in care homes: a realist review. BMC Health Services Research. 2016 Jul 16;16(1):269.
(1) OPTIMAL First Look Summary: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/11102102/#/
(2) Gladman JR, Conroy SP, Ranhoff AH, Gordon AL New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap. Age Ageing. 2016 Mar;45(2):194-200.
(5) Marshall M, de Silva D, Cruickshank L, Shand J, Wei L,Anderson J. What we know about designing an effective improvement intervention (but too often fail to put into practice). BMJ Quality and Safety 2016;0:1–5. doi:10.1136/bmjq-2016-00614
(6) Norrie, C., Lipman, V., Moriarty, J., Elaswarapu, R. & Manthorpe, J (2017) ‘How do handovers happen? A study of handover-at-shift changeovers in care homes for older people’, London: Social Care Workforce Research Unit, Policy Institute at King's College London. http://www.kcl.ac.uk/sspp/policy-institute/scwru/pubs/2017/reports/norrie-et-al-2017-Handovers-report.pdf