Age and Ageing 2001; 30-S3: 24±32 # 2001, British Geriatrics Society

Nursing homes: a suitable alternative

to hospital care for older people
in the UK?
A DRIAN T URRELL
Trent Institute for Health Services Research, Core Unit, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK

Fax: (q44) 114 2724095. Email: a.turrell@shef.ac.uk

Abstract
Over the past two decades nursing homes have become the major supplier of long-stay care for frail older people in
the UK. Demographic projections indicate that the volume of nursing home places will continue to increase to keep
pace with demand and that the population of homes will become steadily more dependent. Little systematic research
exists to indicate how nursing home care compares with hospital care; the evidence that does exists tends to be
restricted to local studies and thus is not generalizable. Local studies indicate that in both care settings there are
shortfalls in terms of meeting basic quality of care standards. Despite this, there is obvious potential for nursing homes
to act as an alternative to hospitalization, provided that there is suitable access for residents to specialist care and, for
example, appropriate administration of medicines. Proposed changes in government policy will introduce more
uniform standards in nursing homes and associated inspection structures and procedures. However, further research is
needed to ascertain the clinical and consumer value of different interventions in nursing homes, and the cost-bene®t
of enhancing provision available in terms of preventing or forestalling demand on hospitals or reducing hospital
length of stay. In the light of the commitment to develop evidence based practice, it is important that such research is
urgently advanced to eliminate poor practice. In our rights conscious society, future generations of older people are
unlikely to be as tolerant of substandard care.

Introduction UK nursing homes operate outside the NHS,

Over the past two decades, UK nursing homes have
become the largest provider of long-stay health care for
frail older people. In 1995 they provided care for an
estimated 158 000 residents, compared to 34 000 in long-
stay NHS beds [1]. Despite this shift to non-NHS care,
the over 65's (constituting 16% of England's popula-
tion), account for 37% of general and acute ordinary
admissions and 63% of general and acute bed days [2],
47% of health expenditure [3, 4] and 48% of social
services expenditure [5].
Resident dependency in nursing homes has increased
over time [6], particularly since the introduction of the
1990 NHS and Community Care Act [7, 8]. This has
put increasing pressure on nursing homes [9], possibly
exacerbated by earlier discharge [10], although the
evidence is equivocal [11±13]. The recent Royal
Commission on Long Term Care estimated that the
demand for care home beds would double by 2050 [1].
The nursing home sector can thus anticipate accom-
modating larger numbers of increasingly frail older people.
predominantly as pro®t-making institutions. Nursing
homes have not been subject to the kind of systematic
research or audit that routinely pre-occupies the second-
ary care sector of the NHS: something recognized for
well over a decade [14], and more recently by the Royal
Commission [15].
This review of the UK evidence on nursing homes
explores whether nursing homes provide a suitable altern-
ative to hospital care for older people given the aim of
the Department of Health to secure comprehensive,
high quality of care for all those who need it, regardless
of where they live [16].
Hospitals and nursing homes:
two sides of the same coin?
Patient ¯ows between nursing homes and hospitals
re¯ect a range of factors that are affected by the quality,

24
 Nursing homes: an alternative to hospital care for older people
con®guration and organization of health care provided
in these two care settings [2, 17]. For example:
. two-thirds of general medicine and geriatric patients
admitted are over 65 [18], thus admissions from
hospitals to homes are likely to continue to be
important [2];
. average length of stay for older hospital inpatients is
falling [2, 19], fuelling the prospect of problematic
early discharge [20] to nursing homes [21];
. the spectre of `bed-blocking' by older people in
hospital is partly related to slow access to nursing
homes [22±24] and inappropriate hospital use by
older nursing home residents [25, 26];
. the ef®cacy of emergency hospitalization for older
people is questionable [27±29], feeding the undesir-
able seasonal phenomena of `winter pressures' (which
poor nursing home care can exacerbate [30]), which in
turn can prompt premature discharge and subsequent
poor recovery [31]. The government objective to
reduce emergency hospitalizations of the over 75s [2],
[16] emphasises the need to address this problem;
. hospital care for older people in general has been
criticised [32±35] with its potential to exacerbate
stress, anxiety and illness [36±39]. Nursing homes
could prevent hospitalization [26, 40];
. unplanned hospital readmission rates for older
patients [41, 42] can be reduced by providing effective
care and treatment in nursing homes;
. comprehensive assessment before nursing home
admission [28, 38, 43, 44], involving GPs [45] can
forestall or avoid subsequent hospital admission.
Arguably, there is much that nursing homes could do
to prevent or forestall hospitalization and reduce length
of hospital stays [2].
A changing policy context
The location and con®guration of UK nursing homes
since the 1980's has been unplanned and hence
uncoordinated [46]. As a result, wide variations in the
availability of nursing home beds per capita prevail
across the UK [47], failing to re¯ect demographic need
or complement local primary and secondary care NHS
services [22, 48]. Nevertheless, a wide ranging policy
initiatives are now being applied to the older population
in general and the long-stay population in particular:
. the advent of the National Care Standards
Commission in April 2002 with responsibilities to
provide new independent inspection arrangements
for care homes [49±52];
. the establishment of national and local Long Term
Care Charters [53, 54];
. the development of national standards for older
people in acute hospitals [33, 55] and residential care
and nursing homes [56±58];
. the drive to increase participation of older people in
policy development [59, 60].
What remains to be seen is whether these initiatives
can deliver improvements in health care for the long-stay
elderly population in nursing homes.
Nursing homes and long-stay
hospital care: no comparisons?
Few direct comparisons of nursing home care and
hospital care in the UK have been published. Perhaps
the best known are studies of experimental NHS nursing
homes. Other studies comparing nursing homes with
care in hospitals have tended to focus on reporting
differences in dependency levels [61±70], although some
have been more general [71±75]. The evidence from
studies of NHS nursing homes indicated that there was
little to choose between these two care settings [76].
However, two differences were noted: the more rapid
deterioration in mental and physical functioning [77]
and a greater risk of accidents [78] for nursing home
residents. These differences were attributed to the
greater freedom (and hence superior quality of life) of
nursing home residents compared to their hospital peers
[79±81].
Hospitals and nursing homes:
physical environments compared
The trials of NHS nursing homes indicated that they
offered a better physical environment compared to
geriatric wards, and could cater more easily for indi-
vidual lifestyle choicesÐan argument supported else-
where [71, 76]. Whether this is typical of nursing
homes today is questionable: resident's perspectives on
this issue may differ markedly [82] and homes and
hospital wards vary up and down the country [43,
72, 74]. Although the Royal Commission commented
that standards of buildings and amenities within care
homes were improving [83], they are still thought to
fall below proposed national standards [58] to be
enforced by the proposed National Care Standards
Commission.
A recent report criticised many aspects of acute
hospital treatment of older patients, prompting the
Secretary of State for Health to establish a National
Service Framework for Older People [55] and the
Dignity on the Ward campaign [84]. Similar scope to
improve the quality of nursing home accommodation
has been identi®ed [71, 85, 86], although greater
criticisms sometimes applied to the hospital ward
environment which were viewed as less personal, private
and homely environments [43, 71, 73, 87].
25
A. Turrell
Nursing homes: markers
of good quality care and support
In this context the UK nursing home literature is
reviewed against ®ve markers of nursing home care,
chosen because some evidence of practice exists in these
areas. These markers are:
. prescribing practice;
. access to medical care;
. access to nursing care;
. access to rehabilitation therapists and facilities; and
. patient documentation and assessment.
Prescribing practice
Multiple drug use is common amongst older people with
the risk of hazardous consequences if not carefully
monitored [88]. Comorbidity in older nursing home
residents manifests itself in the high levels of medication
per capita [73, 89, 90]. Drug therapies in nursing homes
are not subject to adequate scrutiny: with wide vari-
ations in prescribing practice, overuse of psychotropic
drugs and infrequent medication review [86, 91±98].
Poor drug management by GPs in relation to older
patients carries a higher risk of hospital admission
[99, 100]. Although medication should be reviewed as
part of the annual over 75's health check [101], these
may be undertaken by nurses, not GPs [88].
However, recent reports on prescribing practice in
general [102], and GP prescribing support initiatives
in particular [103], may help improve medication
management and monitoring in nursing homes.
Current nursing home inspections have to be under-
taken at least twice per annum. Inspections should
include an audit of drug records; the inspection team can
be advised by pharmacists. However, recommendations
for change based on prescribing anomalies are not
enforceable.
Existing home inspection mechanisms have been
described as `incomplete and patchy' having developed
in a `piece-meal fashion', resulting in new proposed
standards in areas such as the administration of medi-
cines in homes [58]. These and all other proposed
standards were out for consultation until March 2001
in anticipation of the establishment of the National
Care Standards Commission in April 2002. Given the
pockets of evidence indicating poor prescribing practice
in nursing homes [104±106], there seems no defence for
failing to adopt these new standards.
Access to medical care
Frail older patients, especially with comorbidity, need
regular medical supervision. Medical assessment on
admission, and systematic monitoring thereafter are an
26
essential prerequisite of appropriate treatment and
rehabilitation. Whilst consultant physicians, geriatricians
and psychogeriatrians are responsible for medical care
of their older patients in hospitals, GPs bear this
responsibility in nursing homes.
Older residents of nursing homes suffer from a range
of conditions that commonly occur and can be poorly
managed (for example: diabetes mellitus, incontinence
and confusion [48, 98, 107±114]. It is the manifestation
of such conditions in frail older people that demand
the particular expertise of specialists if they are to be
managed effectively [115]. However, such specialist
expertise is not routinely available to nursing homes
[86, 116], even though one study revealed that the
presence of specialist advice or equipment could have
prevented over 60% of hospitalizations [26].
A GP's input to nursing homes may be contracted
through a variety of arrangements, but delivering care to
nursing home patients under the terms of their General
Medical Services (GMS) contract is proving onerous
and has elicited calls for nursing home residents to be
excluded from the GMS contract [117, 118]. Evidence
that GPs are struggling to institute regular medical
review of nursing home patients clearly exists [85, 89±91,
95, 96, 119, 120] and may be compounded by whether
residents keep their GP following transfer to homes [43,
87, 95, 121]. The requirement, under their GMS con-
tract, to make home visits can determine whether GPs
agree to keep their patients when they move into a
home, bearing in mind the extra workload involved
[90, 97, 122, 123].
Access to nursing care
All registered nurses, whether in hospitals or homes
must demonstrate that they are updating their clinical
practice through training. In hospitals, nurse training and
ward skill-mix are monitored. Even so, hospitals still fail
to deliver quality nursing care [32, 33].
Nursing homes must provide on-site trained nursing
care 24-hours a day. However, the number of trained
nurses employed in homes is agreed with the registering
authority when the home is ®rst registered and empty,
based on the number of beds. If average resident
dependency increases over time, the need for more
trained staff grows too, but it is dif®cult to enforce
changes in levels of trained nursing staff because:
i) the original registration is based on an agreed (lower)
staf®ng level;
ii) a twice annual inspection only provides two
potentially unrepresentative snapshots of resident
dependency, and
iii) there are no nationally agreed measures of resident
dependency to rely upon.
Nursing home nurse staf®ng and training levels may
be equivalent to, if not better than those in geriatric
 Nursing homes: an alternative to hospital care for older people
hospitals [73]. But most evidence indicates that there
are a range of concerns in respect of the level of training
and skilled nursing care in homes [21, 58, 71, 74, 95,
104, 119, 120, 124±128].
Hospitals use the skills of specialist nurse practi-
tioners, clinical nurse specialists, link nurses and practice
development nurses to inform nursing practice. Nursing
homes can, in theory, gain access to such nursing
expertise if it is locally available. But there is no statutory
duty on them to do so and no evidence that homes
systematically obtain such support [21, 86, 107, 121].
The government's reluctance to adopt the Royal
Commissions' recommendation to fund nursing care
provided in nursing homes, in spite of recent legal
judgements [129, 130], indicates that any development
in this ®eld may continue to rely on private ®nance in
a sector where pro®t margins are already being squeezed.
Access to rehabilitation therapists
and equipment
Rehabilitation services in hospitals may or may not be
better than in nursing homes: studies making compar-
isons are rare [73, 74]. However, if access to specialist
nurses is relatively rare in nursing homes, the same is true
of rehabilitation therapists and mobility aids/equipment
[43, 71, 73, 89, 121, 131±133]; an area where resident
entitlement to support both is confused and confus-
ing [43, 134]. Limited availability of local rehabilitation
resources may explain the poor support to nursing
homes, rather than nursing home policies or funding
[131, 133]. Either way, the effect may be to increase the
risk of hospitalization [132].
Patient documentation and assessment
Good quality assessment and documentation of nursing
home patients is an essential prerequisite to ensuring that
care is delivered ef®ciently and effectively. The public
sector may not set an example for nursing homes to
follow, given accounts of poor or inconsistent assess-
ment and documentation on hospital admission or dis-
charge [45, 85, 86, 89, 135] and in relation to continuing
care placement [21, 86, 89, 136±141]. Assessment in
nursing homes by GPs [88, 91] or by other staff can also
be de®cient [86]. Nursing documentation in the form
of care plans must be systematically kept in nursing
homes (as in hospitals), but whilst hospital nursing
documentation is subject to routine audit, nursing home
documentation is reviewed twice per year.
Developing a research agenda
The debate about the potential of UK nursing homes
to develop services to older residents is seriously
hampered by a lack of evidence. Given the important
relationship between nursing homes and hospitals,
improving nursing home care may offset demands
made on hospital and/or GPs. Many research issues
are worthy of pursuit:
. the impact of nursing home interventions in relation
to hospitalization, GPs, quality of life and health
outcomes;
. the impact on care costs and quality by improving
access to specialist practitioners;
. the impact of protocols on standards in homes;
. an analysis of nursing home data collected by the
National Care Standards Commission.
Conclusion
Nothing referred to here can prove that health care
support to older residents in UK nursing homes is
endemically substandard, compared to the care that
would be provided if these residents were in hospital.
Excellence does exist in UK nursing homes. However it
is unclear how commonplace it is. This is unacceptable
in an evidence-based health service and merits urgent
remedy.
Government initiatives in the ®eld of long-term care
suggest that a crossroads is about to be reached in terms
of policy that will determine in which direction practice
is encouraged to go. It is tempting to argue that to take
nursing homes in any clear national direction would
be substantial progress. Key stakeholders in the process
are geriatricians [142] and over-burdened GPs. Key
issues include how to involve these clinicians appro-
priately in nursing homes, improving facilities and
training in homes, gaining access to more community-
based specialists. Looked at broadly, such investment
may be cost-effectiveÐif inappropriate hospitalization is
to be avoided.
Future rights-conscious consumers of long-term
care are unlikely to be as tolerant of the gaps in our
knowledge, the inconsistencies in practice, and the cost-
shunting between care sectors that now prevails in a
disjointed long-term care system. The opportunity to
address these issues should be grasped now, or the
disparity between standards set in other areas of health
care and in long-term care will be rightly exposed
by future generations expecting excellent care in all
nursing homes.
Key points
. Frail older people will place increasing demands on
nursing homes.
. High quality nursing home can prevent or forestall
hospitalization and reduce length of stay.
27
A. Turrell
. Government policy on long-term care is at a cross-
roads with new national standards and inspection
mechanisms due to be implemented in 2002.
. Standards of care in nursing homes vary widely and
residents needs should be addressed by ensuring, for
example, that required levels of specialist clinical
support are accessible.
. There is no conclusive evidence to indicate whether
or not nursing homes do or can provide a suitable
alternative to hospital care.
. Further research is needed to evaluate the impact of
nursing home interventions in terms of quality of life,
health outcomes and cost-effectiveness.
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