The Nuffield Trust has evaluated many new models of care, and for a number of reasons the results are often rather lacklustre against the expectations of the designers. Our evaluation of an intervention in care homes in Outer North East London has been a welcome exception. The scheme, called Health 1000, offers nursing homes access to GP support from 8am until 8pm, seven days a week, as well as training and advice for care home workers and help from a geriatrician.
We have seen reductions in the use of emergency inpatient services, especially in the last three months of life, and the care homes and their residents also benefited significantly from better and more organised care. Other evaluations of this type of model have found similarly impressive results.
So what works?
There are some important lessons to be learnt from such successful interventions.
First, those with the best results have generally targeted the care homes with the highest utilisation rates and which are keen to participate. Nonetheless, developing relationships between care homes and the NHS requires hard work. One of the features that struck me about other schemes of this nature has been the type of people driving them – interpersonally skilled, and able to develop and manage a range of relationships across the system. This is even more complex as care homes vary in their management approach, with some part of a corporate chain.
I have heard NHS people say that care homes are happy to get residents into hospital, as it makes their work easier. But the impact of being in hospital for even a short period, in terms of muscle loss, decompensation and other problems, is so significant that it has the opposite effect. Once this point is understood, it turns out that the interests of the NHS and the care homes are much more aligned than is often assumed.
One other interesting oddity that these models sometimes uncover is a presumption that, because people are in a care home, they do not need – or sometimes should not have – NHS care. In fact providing support to care homes, from specialist nurses, help with IV therapy and a number of other interventions, goes beyond what a care home can reasonably provide and has big benefits for the residents and the NHS.
A further lesson is that the interventions that deliver change are a bundle of different practices, and it is not possible to isolate one. This again is a common feature of many new models and is often their undoing. The bundle of interventions are often interconnected and letting one fail can undermine the results.
An important point that applies to many of the models is around how savings are calculated. Economic evaluation tends to look at the full cost, or even the tariff, to estimate savings. The danger that bed days not used by care home residents are taken up by others is a well-known problem that can fully consume any savings.
The real saving is probably at the margin, and even with very significant scaling up it may be difficult to release fixed or even semi-variable costs. This remains a major challenge, as there is no agreed method for really working out how costs fall out when services change.
Whatever the fine print, these models really do show the impact of well-designed, relatively simple but skilfully executed projects driven by bottom-up effort. We need more like this.
Edwards N (2018) "Success story: learning from interventions that work", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/success-story-learning-from-interventions-that-work