Nursing home rehabilitation
In March 2020 (pre-Covid lockdown), NHS England and NHS Improvement published a policy document, “The Framework for Enhanced Health in Care Homes” (Version 2, March 2020). This proposes that all nursing and care homes introduce expert medical and rehabilitation services, including mental health and palliative care. This post reviews the proposal, showing how it could be simplified and used to provide accessible, expert rehabilitation services not only in care homes but also to people in the broader community. With the recent Community Rehabilitation Best Practice Standards (October 2022), this could be a vital element of a Rehabilitation Network.
[NOTE. The first version of this post was published on February 11th 2021; this version was published on June 19th 2023.]
Table of Contents
“People living in care homes should expect the same level of support as if they were living in their own home.” This statement is the opening sentence in the report from NHS-E (NHS England). It acknowledges another longstanding healthcare inequity—the plan from NHS-E aimed to improve all healthcare for care home residents. Most patients in nursing homes have complex long-term medical problems and often untreated rehabilitation needs. In addition to inequity, this may lead to avoidable admission of patients to hospital and avoidable prolonged care in a nursing home when rehabilitation might have enabled them to return home.
The report is based on seven elements that should apply to healthcare support for nursing home residents:
- Enhanced primary care support
- Multi-disciplinary team (MDT) support, including coordinated health and social care
- Falls prevention, Reablement, and rehabilitation, including strength and balance
- High quality palliative and end-of-life care, Mental health, and dementia care
- Joined-up commissioning and collaboration between health and social care
- Workforce development
- Data, IT and technology
The first four elements recognise the need for adequate general practitioner medical input (number 1) and specialist healthcare input (second, third, and fourth elements) into care homes. The last three apply to the whole NHS. Ironically, the fifth element refers to collaboration and the overriding of artificial distinctions made within healthcare, yet the first four elements specifically perpetuate artificial differences between healthcare services!
Nevertheless, this framework could transform rehabilitation (and healthcare in general) within the UK if implemented as written. This initiative is a brilliant opportunity to provide a holistic, whole-person service to patients with complex problems. To do this requires NHS England and the Department of Health and Social Care to move on from using the biomedical to the biopsychosocial model of illness when planning services.
Further, the framework proposal would benefit from an informed understanding of rehabilitation, so we (rehabilitation clinicians) should get involved, help write a better version 3 within the next year, and ensure that when we need these services, they will help us properly! This post explores the framework in more detail to show how to improve it.
Radical new ideas (for an NHS document).
The Framework, when implemented, will provide England with an extensive network of potential community centres that will allow people needing to see an expert multidisciplinary rehabilitation team easy access, both on an inpatient and an outpatient or community basis. (I hope other nations in the UK will follow suit) The suggested development would supplement specialised level I and II inpatient rehabilitation services. As proposed, it would complement existing community rehabilitation services. Indeed, this post develops the idea of a unitary community service based in care homes. Elsewhere I have suggested they should be part of a rehabilitation network.
It emphasises personalised care as its first condition critical for success, a synonym for person-centred care which is, as I have shown, inextricably intertwined with the biopsychosocial model of illness and rehabilitation. The second crucial condition for success is ‘co-production’, which means ensuring collaboration and cooperation between currently separate services. The plea for partnership and cooperation is repeated endlessly in the NHS; until the divisive and siloed way of commissioning healthcare services is abandoned, it will not occur.
The document lists the people they consider interested in the proposal. This is mainly done using acronyms, but it includes many of the relevant services. It could and should add housing, employment, and social security departments to be more radical. Perhaps it is accidental, but I was concerned to note that “individuals with care needs, carers, and families” were the last interested party to be mentioned. Not quite compatible with the earlier emphasis upon the centrality of the patient!
It suggests that every care home should have a review of all residents weekly by a multidisciplinary team, including a doctor, to review medication. I attend a care home (50-60 residents) monthly, and we manage such a review in two hours. Depending on the nature of the care home, think weekly is too frequent.
It makes suggestions about the linkage between health and social care computer systems which is self-evidently reasonable. Still, the NHS has failed from the outset to have any coherent policy on Information Technology and has never funded it adequately. They do not consider other ideas, such as a single, patient-controlled care record that anyone could access with permission. They do not suggest requiring interoperability between NHS computer systems so that any system’s data can be accessed easily by any other system (just as the internet does).
Each care home is related to one healthcare commissioner and, I assume, will have a single GP practice providing medical input.
Notably, the residents’ review will be led by “a clinician with advanced assessment and clinical decision-making skills“. A rehabilitation consultant would best meet this role. This model has been used in the Netherlands since 1990, where there is a medical speciality of ‘nursing home physicians’ trained in rehabilitating older adults. This model succeeds in the Netherlands.
Each care home should have access to out-of-hours urgent care when needed. The care home where I work has access to a Rapid Response service based in the local hospital. It is excellent and provides occasional but much-appreciated support when someone is acutely ill.
There is an expected emphasis on important issues such as reducing falls, proper nutrition and medical review. Unfortunately, they seem to be separated into different Care Elements. They are all part of rehabilitation. This is a clear example of a significant internal inconsistency in NHS England’s thinking, asking for services to be joined up and collaborative while advocating separate services.
One excellent suggestion, hidden in Care Element four, suggests “Developing community assets to support resilience and independence“. This means developing links between local communities, local volunteers and local care homes to increase the social activities and social contacts available to a resident, thereby reducing the loneliness many residents probably experience. This would be an excellent outcome given the consequences of loneliness for people and health services.
It is unclear if this framework intends to develop some care homes as day centres, where individuals in the community could be seen by a rehabilitation team if needed and participate in community activities. This would be an excellent and quite radical development.
Care Element Four puts together, on no very logical basis, access to Mental Health services, Palliative Care and end-of-life services, and dementia care services. The idea that these three expert services should be freely and routinely available to all care home residents – as they are in principle to all other people needing them – is again fundamental and, unfortunately, radical.
It is similar to my suggestion concerning long-covid (here) and illustrated here. The Framework document emphasises that mental health conditions are frequent in nursing homes. It notes that mental health “conditions are often under-identified, under-diagnosed, and under-treated in residential care.” It outlines what a high-quality service should aspire to.
The emphasis on dementia is fully justified. The document records that 76% of nursing home residents have dementia. I am unsurprised, but I did not realise it was relatively high. It is also growing as a percentage, increasing from 56% in 2002; this may reflect an increasing reluctance of anyone without dementia to move into a care home.
Care Element Five is Joined-up commissioning and collaboration between health and social care. Maybe the authors know something we do not. This is far from radical as a suggestion. If the document contributes towards achieving this, it will be a revolutionary outcome.
Care Element Six is Workforce Development. Again the suggestion is moderate. “Joint workforce planning across all sectors” may be relatively radical. Still, as planning the workforce up to this point has been, in reality, “planning to spend what the government allows us”, it will require a radical change in the culture of the Department of Health and Social Care to achieve proper, needs-based planning whether jointly or singly.
In the same vein, the suggestions concerning Information Technology are scarcely radical. They require adequate funding (capital and revenue) and, to an extent, clarity about the freedom to choose between different IT platforms. Easy interoperability is needed so that anyone (permitted) can access information. My local hospital has many systems that cannot work seamlessly, so I am not optimistic about this care element.
In summary, the document repeats many long-established, sensible, yet-to-be-achieved ideas for service improvement. However, there are also some quite radical suggestions. The proposed development of care homes will form a network of community rehabilitation centres. The framework will ensure that all care, home residents, have sufficient expert health input for the best care and social life possible. It will also enable most disabled people in the community to access rehabilitation expertise easily.
Weakness in the Framework
The framework demonstrates an inadequate understanding of rehabilitation and a failure to use the biopsychosocial model of illness as a framework for the proposed development. This weakness may also explain the continuing tendency to refer to separate services.
For example, the document considers hydration and nutrition support, oral healthcare, and multidisciplinary team support as three separate matters. Any proper multidisciplinary rehabilitation (or ‘reablement’) team would, or certainly should, consider feeding and oral health as an integral part of its concerns. Despite the increasing recognition that there should be integration between mental health and all other services, it also separates mental health services.
There are many possible explanations for this, but I suspect one is a conflation of ‘being expert‘ with ‘being separate‘. They assume that an expert service has to be separate from other services. A moment’s reflection shows this is untrue. A neurology department would contain experts in, for example, multiple sclerosis, muscle diseases, and auto-immune encephalitis, but they are all within the expert neurology service.
Therefore, as I have argued elsewhere (e.g. here and here), it is quite possible within a rehabilitation service to have expertise in particular problems, such as feeding and oral health, or specific conditions, such as dementia or Huntington’s disease. I have more recently proposed a rehabilitation network as a more achievable and better solution.
Therefore this Framework could be much improved by explicitly using the biopsychosocial model of illness throughout, by recognising that rehabilitation services will meet the needs identified, and by emphasising the wide capabilities of rehabilitation, covering most of the needs identified.
Nursing Home Rehabilitation; conclusion
The proposal requires serious attention and can be improved and simplified by stating that the principles of nursing home healthcare are as follows.
- All care homes within a commissioning area (e.g. an Integrated Care Board area) will be provided with health services by that commissioning group;
- and each care home will be covered by one general practice group.
- All care homes will have input from a multi-professional rehabilitation team;
- each care home will have a regular review of all residents by the team, including a consultant doctor and mental health and palliative care team members.
- All care homes will also have the following:
- similar input from an expert mental health team;
- equal input from an expert palliative care and end-of-life team.
- Centred on one or more care homes in a locality, groups of volunteers and others will support and develop links between the care home(s) and the local community;
- this may extend to other disabled people coming to the care home for rehabilitation assessment, advice, and treatment and to participate in social activities with residents.
- The services will all be commissioned jointly by health and social services.
- The Department of Health and Social Care will ensure adequate numbers of appropriately trained staff are trained and that ongoing staff training is available.
- The electronic record systems will be interoperable to allow seamless shared use across all boundaries.