The national survey found that residential care homes with no on-site nursing are a hub for a wide range of NHS activity with up to 26 different services identified. On average, homes reported accessing between 14 and 15 different professionals or services in the six months before the survey, with the highest proportion of homes reporting links with DNs, opticians, chiropodists/podiatrists, community psychiatric nurses and continence services. However there was no single recognised way in which homes and primary care services work together. Arrangements continue to be ad hoc, and largely dependent on individual relationships between care home staff and NHS professionals.
Three levels of collaboration have been identified, ranging from linkage, through co- ordination to full integration
. The survey findings suggest that most collaboration between care homes and primary care services are linkages, fostered by good working relationships between care home staff and NHS professionals
. These were perceived to be more important than particular systems or processes, but were person-specific, and vulnerable to change. There was evidence of some coordination at a clinical level, (e.g. shared care planning and joint training). Also, some care homes reported holding contracts with the NHS for provision of extra services, such as respite care, but this did not appear to affect working practices or be associated with more integrated patterns of working. Collaboration thus appeared to be largely at the lower level of linkage and co-ordination, determined by the powers of actors who are working on the front- line of service delivery, and limited by operational factors. Care homes reported that working practices were dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents. Moreover, there was often a lack of willingness by NHS professionals to share information, and perceived low levels of trust and respect for the experience and knowledge of care home staff.
Given the frailty and complex needs of the care home population, more integrated working between care homes and primary health services has been promoted as a cost-effective means of improving the quality of care
. With increasing financial pressures on health and social care resources
, the focus on integrated care processes as a mechanism to improve co-ordination, efficiency and value for money of patient care is likely to increase
[28–30]. Integrated working has been described as a dynamic process, developing over time, and requiring trusted leaders who use organisational systems and processes to work together to fulfill shared goals
. The survey identified many examples of positive working relationships between health care and care home staff, but few examples of systems of working that were recognised as supporting truly integrated working. Future mechanisms for commissioning integrated care services will be through Commissioning Care Groups, supported by the NHS Commissioning Board, and workable frameworks to support decision making about contracting and procurement of services will need to be agreed
Strengths and Limitations
The strengths of the study are that the questionnaire was carefully prepared and piloted, the sampling was systematic, reminders and other means were used to try and boost the response rate, and the findings were rigorously analysed using a mix of quantitative and qualitative methods. The results provide up-to-date information on a currently important issue where little evidence already existed.
Survey work in care homes is difficult to conduct
[32, 33], and a major limitation of the study is the poor response rate (16%). The questionnaire was shortened considerably after piloting, but it was not set up with required fields, or to block inconsistent answers, missing items and non-logical responses, and this limited the analysis to some extent. Although homes were invited to ask for a paper version of the survey, (and a small number did), the online method of data collection may have been inappropriate for a sector that anecdotally is seen as having limited online capability. Surveys of physicians have shown lower response rates from online compared to other methods
Problems arose within the survey regarding the interpretation of the concept of integration. A definition of integrated working was provided to respondents (close collaboration between….your care home and the NHS), but this did not provide sufficient information to enable care home managers to distinguish between loose linkages, coordinated care and formal collaborative arrangements, or to relate sufficiently to the concept of integration. Significant proportions (30-60%) of home managers that stated that they did not work with the NHS in an integrated way reported that they did engage in activities that were used in the study as indicators of integration (joint learning and training, shared documents, integrated care planning, provision of remunerated services) used in the study. Such inconsistencies might have been avoided if explanation of the nuances surrounding the concept of integration had been made clearer to respondents. The finding that no care home characteristics were associated with reporting of any of the integration indicators used in the study may further reflect lack of understanding of the practical manifestations of integrated working.
The study only aimed to survey homes with 25 or more beds due to the logistical difficulties of covering the large number of smaller residential facilities. The nature and extent of collaboration between care homes and the local NHS may differ amongst smaller homes, and the views of their managers about the benefits and barriers may not accord with those of managers of the larger homes. The survey instrument used in this study was also completed by 102 homes in a major chain. Homes in the chain (in line with recent trends for increasing care home size) were significantly larger than those in the national survey reported here (mean 55.3 vs. 39.0 beds, Students t test p < .001), and were significantly more likely to provide extra remunerated services for the NHS than homes in the national sample (58% vs. 36%, chi square p = .002). There were few other differences between the samples regarding integration indicators or managers’ views (full data not shown).