The latest report from the QualityWatch programme makes a valuable contribution to our understanding of admissions to hospitals from care homes. It suggests that care home residents are almost 50% more likely to experience an emergency admission to hospital than other older people. These rates are driven, in part, because care home residents appear more likely to be admitted several times in a single year. The findings underline how little we know about how older people use health and social care services.
Hospitals and care homes: a complex relationship
Experience within my own family hints at some of the complex ways in which hospitals and care homes interact. An elderly relative – let’s call him Alan – is a care home resident in his late eighties. Although alert and in good mental health, he is physically very frail; he cannot walk, or stand unless supported. Three weekends ago he was described as ‘having a funny turn’ at breakfast. The care home staff suspected a stroke and an ambulance was called.
On arriving at A&E, Alan was found to have a urinary infection due to a blocked catheter, which was treated. He was given a brain scan, but no conclusive evidence of a stroke was found. Alan was then moved to the A&E ‘overspill ward’ where he remained until Tuesday morning, when he was returned – on a stretcher, in an ambulance – to the care home. Neither the care home staff nor the GP felt Alan was ready to leave hospital: they were all convinced that Alan had suffered a stroke. An ambulance was called and he was taken back to hospital.
At the hospital, Alan was admitted to the Acute Elderly ward. By this time he had lost almost all feeling in his left arm and left leg. His speech and his face showed no sign of a stroke, but tests revealed he was anaemic, possibly caused by a bleed on the brain. He still had a urinary infection, which was not responding to antibiotics. Yet again the weekend intervened, so it was Monday before he was visited by the hospital’s stroke team: this time a diagnosis of stroke was definitive.
Finding the best place of care
Now the problem becomes where best to care for Alan. He should be on the stroke ward, but it is a week before a bed there is available. When he is ready to leave, hospital staff want him to continue his rehabilitation in a community hospital. The nearest one for stroke patients is over 20 miles away, meaning significantly fewer visits from family and friends.
After staying at the community hospital, it is unlikely that he will be able to return to the care home. People requiring nursing as well as residential care can apply to be admitted to their local nursing home: yet a local authority assessment is required before applying, and there is often a waiting list for places. (All the while Alan is still officially a resident of the care home, for which he is paying £750 a week.)
A better understanding of how to care for older people
The experiences of individual patients like Alan remind us that research is fundamentally about how we can improve care for people.
Leading geriatricians such as David Oliver have described what can go wrong in acute care of the elderly, not through poor treatment by clinicians, but by system failures. In Alan’s case there are questions – not about individual clinical decisions, but about the context in which such decisions are made, whether within individual care settings or across the wider system. In talking to staff at the hospital and care home about Alan, we found we were not alone in speculating about some of these difficult questions.
As Nuffield Trust researcher Paul Smith explains in his blog, this latest QualityWatch report and other research shed valuable light on how care home residents use hospital services. These studies can point the way to a better understanding of how to care for elderly people, within both care homes and hospitals. We also need to look at how the health and care systems are aligned, to ensure that patients are always cared for in the most appropriate setting and neither become ‘stuck’, nor are moved too quickly from one care environment to another.
Both of which are important. People like Alan need to know that as their medical or care needs change as they grow older, they will be offered the right care, in the right place, and at the right time.
Matthew Batchelor is a publishing consultant for the Nuffield Trust. He writes here in a personal capacity.