Key points

  • In January 2019, the NHS published its 10-year Long Term Plan, including a commitment to improve NHS support in care homes, rolling out the Enhanced Health in Care Homes (EHCH) framework across England. One of the aims of the framework is to reduce emergency admissions from care homes which, although essential for delivering medical care, can expose residents to stress, loss of independence and risk of infection. Care home residents often prefer to be treated in the care home or avoid the need to seek urgent treatment in the first place. Therefore reducing emergency admissions could be good for residents, as well as help reduce pressure on the NHS.
  • In this briefing, we firstly present our analysis of a national linked dataset identifying permanent care home residents aged 65 and older and their hospital use in the year 2016/17. In the second part of the briefing we synthesise learning from four evaluations of the impact of initiatives to improve health and care in care homes carried out by the Improvement Analytics Unit (IAU).
  • Our analysis, using a new data linkage method that allows us to identify permanent care home residents aged 65 and older in NHS datasets, found that during 2016/17 care home residents went to A&E on average 0.98 times and were on average admitted as an emergency 0.70 times. The overall number of emergency admissions from care homes in 2016/17 was an estimated 192,000, comprising 7.9% of the total number of emergency admission for England for people aged 65 years or older. The overall number of A&E attendances from care homes was 269,000, comprising 6.5% of the total number of attendances for people aged 65 years and older. Reducing emergency hospital use from care homes therefore has the potential to reduce pressure on hospitals.
  • A large number of these emergency admissions may be avoidable, with 41% of emergency admissions from care homes being for conditions that are potentially manageable, treatable or preventable outside of a hospital setting, or that could have been caused by poor care or neglect.
  • Surprisingly, emergency admissions are particularly high in residential care homes (0.77 admissions per resident per year) compared with nursing care homes (0.63 admissions per resident per year). This is the case even though residential care homes provide 24-hour personal care, while nursing homes also provide nursing care and therefore one would expect residential care home residents to be less seriously ill than nursing home residents. People in residential care homes attended A&E on average 1.12 times in the year 2016/7, compared with 0.85 times in nursing care homes. One possible explanation is that staff in residential care homes may have less support in managing health needs within the home, and therefore rely more on emergency services. Also, health needs may not be detected as early in residential homes as in nursing homes.
  • The IAU has evaluated four initiatives to improve health and care in care homes that were associated with the NHS’s New Care Models programme. For several of these we concluded there were reductions in at least some measures of emergency hospital use for residents who received enhanced support: in Rushcliffe we found care home residents were admitted to hospital as an emergency 23% less often than a comparison group, and had 29% fewer A&E attendances; Nottingham City care home residents had 18% fewer emergency admissions and 27% fewer potentially avoidable admissions than a comparison group; and Wakefield residents had 27% fewer potentially avoidable admissions. In Sutton, however, the results were inconclusive.
  • These initiatives included elements of the EHCH framework, which will be rolled out as part of the NHS Long Term Plan. Therefore, the work of the IAU shows that there is potential for the EHCH framework to reduce demand for emergency care from care homes, but it also points to some implementation challenges that need to be taken into consideration when rolling out the framework.
  • Given the policy focus on improving care in care homes, both over the past few years and moving forward with the NHS Long Term Plan, understanding and monitoring the quality of health care provided to care home residents will be important, both to gauge the impact of national programmes and to help pinpoint areas of improvement, identify ‘active ingredients’ for a successful intervention and spread good practice.
  • In this briefing, we synthesise learnings from our evaluations of the initiatives in Rushcliffe, Sutton, Wakefield and Nottingham City to pull out what seem to be key lessons for implementing the framework in care homes. These key lessons are that (i) there is greater potential to reduce emergency admissions and A&E attendance in residential care homes compared with nursing homes, (ii) co-production between health care professionals and care homes is key to developing effective interventions, (iii) access to additional clinical input by named GPs and primary care services and/or multidisciplinary teams (MDTs) may be a key element in reducing emergency hospital use, and finally (iv) our studies show that it is likely to take more than a year for changes to take effect – meaning it is important not to judge success too quickly.
  • Finally, this briefing shows the importance of having access to linked administrative datasets to provide evidence to support policy making. It is important that these sorts of data are routinely and consistently collected and are easily accessible to both care providers and research teams if we are to understand residents’ health care needs and produce robust evaluations – and ultimately improve care for this vulnerable group.