This realist evaluation in 12 English care homes for older people
explored contexts for ‘relational working’ in three service delivery
models alongside the theoretical mechanisms by which this type of
working achieves better outcomes for residents.
What did it find?
- Healthcare provision for care home residents is reactive and
patchy. This includes unnecessary hospitalisations; inadequate out of
hours/emergency care including psychiatric; and a lack of dentists and
speech and language therapists.
- Established respectful relationships between NHS practitioners and
care homes enable ‘relational working’ in the co-design of services and
in shared healthcare planning for individual residents. Over-emphasising
NHS agendas such as hospital admissions as a rationale for joint
working can lead to short-termism and distrust.
- Commissioners and managers support relational working by formally
endorsing, incentivising and paying for the protected time of GPs, other
NHS practitioners and care home staff. This results in practitioners
prioritising this joint work against the backdrop of routine
professional work and their wider caseload.
- GPs’ regular presence in care homes is important, even where nurses
and other NHS practitioners provide input such as care plans and
service development. GPs find their input sustainable when supported by
dedicated NHS care home-specific services, not just services aimed at
- Care home staff appreciate a range of clinical input relevant to
older people: for example, from nurses and others skilled in the care of
dementia. When supported with this expertise, staff are more confident
in dealing with challenging behaviours. This reduces distress for
residents and can lead to less antipsychotic prescribing.
- Regular, GP-held clinics in care homes facilitated access to
medicines and more frequent medication reviews. Nurses prescribed and
reviewed medication, but this did not substitute for GP involvement.
Pharmacists were rarely involved in reviews across these three sites.