Registered Private Nursing Homes in Scotland: Referral and Assessment Practice
Summary The results on referral to and assessment for nursing homes, taken from a national survey of all registered private nursing homes in Scotland, are reported in this paper. The findings challenge the view that nursing homes do little by way of assessing potential candidates and that what is done is somehow at variance with the type of assessments carried out in the public long-stay sector. The implications for the future of the traditional view of which professionals should be involved in the assessment of candidates for nursing homes are discussed as are the criteria they might use to make their assessments.
Introduction
Methods
In recent years, the fastest growing provider of long-stay beds in Scotland, as in the rest of the UK, has been the registered private nursing home sector (RPNH). Provision within Scotland has risen from six beds per 1000 people aged 75 years and older in 1985 to 32 beds in 1990 [1, 2]. With this increase in provision, concerns have been voiced by clinicians about the extent and nature of the assessments used by private nursing homes in deciding whom to accept. In large measure these concerns stem from a lack of a comprehensive overview of what is happening in the private nursing home market with regard to assessment, a lack of knowledge as to the use made of general practitioners (GPs) and hospital doctors by the private nursing homes in any assessment processes, and the perceived challenge to the centrality of the clinician's role in the assessment of an elderly person for long-stay accommodation [3, 4].
A survey of all RPNH in Scotland was carried out by the Health Economics Research Unit, University of Aberdeen at the invitation of the Health Services Research Committee of the Chief Scientist's Office, Scottish Office Home and Health Department. A postal questionnaire on characteristics and resources was sent to all 285 nursing homes registered with Scottish Health boards in Scotland during December 1989 and January 1990. Questions covered type of ownership, type of residents currently in RPNH, age groups, source of funding, source of referral, whether assessments are done, by whom and what is involved, weekly charges, number and type of staff, access to paramedical services and provision of general practitioner services. Data on current places in nursing homes in Scotland were also collected through Scottish Health Statistics [2] and Health Board registration lists.
Results A total of 198 homes replied to the questionnaire, a national response rate of 70%, ranging Age and Ageing 1992;21:429-434
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ISOBEL M A C P H E R S O N , SHEENA DONALD, ANNE LUDBROOK
43°
I. MACPHERSON ET
Table I. Characteristics of nursing homes in Scotland
59% (116) 29% (59) 10% (19) 2% (4) 70% (133)
Bed occupancy
92% (5347)
Type of resident Frail elderly Mentally ill Terminally ill Other*
52% (2903) 14% (781) 14% (781) 20% (1116)
Residents aged 75 +
76% (4276)
86% (171)
• Includes physically or mentally handicapped, acute, respite care, convalescent and young chronic sick. from 89% in the highest responding Health Board to 4 5 % in the lowest responding Health Board. Characteristics of the RPNH: Table I gives the main characteristics of the homes. Fiftynine per cent (116) of the homes were owned by
private individuals. Seventy per cent (133) of homes with dates recorded had opened within the last five years. There was 92% occupancy of beds ranging from the highest Health Board area at 98% to the lowest at 85% occupancy. Respondents were asked to categorize residents from a list which represented the main groups for which Department of Social Security funding is given. Fifty-two per cent (2903) of residents were classed as frail elderly, with 14% (781) classed as mentally ill. Seventy-six per cent (4276) of all residents were aged 75 + years and of those 6 1 % (2626) were classed as frail elderly; other residents aged 75 + followed a similar distribution to total residents. Source of referral: Table 11 gives the source of referral to RPNH. For Scotland as a whole, families were the most common referrers accounting for 37% (1904) of referrals. Social workers referred 19% (963), general practitioners 17% (844), and hospital doctors 13% (648). The remaining 15% (749) of referrals came from hospital nurses, solicitors, accountants, the clergy, self-referrals, friends, and carers. Family referrals varied from 43% in Fife (106) and Grampian (256) Health Boards, to only 14% (24) in Borders Health Board. Social work referrals varied from 47% (138) in Tayside to 7% (55) in Lanarkshire. Referrals from GPs varied from 27% (57) in Dumfries and
Table II. Source of referral to nursing homes in Scotland Source of referral Family Social worker GP
Hospital doctor Self NHS nurse Other professional Other Total residents
FI
FV
GR
GG
HI
LA
LO T A
Total
94 42 45 41 10 14 2 6
256
233 107 76 68
336 55 180
235
1904
5
11 47 26
103 41 37 73 9 4
0
106 23 43 43 5 4 6 16
209
246
254
600
606
AC
AA
BO
DG
73 18 39 39 1 6 2 1
316 183 73 114
24 70 42 #
71 51 57 17
88 13 5 6
8 2 28 0
13 0
179
798
174
0
129
95 49 37 13 16
38
57 138
88 19
106 135 73 27 26
0
3
25
2
55
35
0 6 0
269
819
662
292
83
22
963 844
48
648
21
345 112 140
152
5108
• Two homes noted referrals from hospital doctors, but did not note numbers (also see text). Key: AC Argyll/Clyde; AA Ayr/Arran; BO Borders; DG Dumfries/Galloway; FI Fife; FV Forth Valley; GR Grampian; GG Greater Glasgow; HI Highland; LA Lanark; LO Lothian; TA Tayside.
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Respondent to questionnaire Owner or nurse in charge Ownership Private individual Private limited company Voluntary/charitable body Public limited company Opened in last 5 years
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REGISTERED PRIVATE NURSING HOMES IN SCOTLAND
43'
Table III. Persons involved in assessment of applicants to nursing homes in Scotland AC
AA
Owner of home Nurse in charge
3 6
GP
2 0
11 23 4
FI
GR
GG
HI
LA
10 14 7 4
5 7 5
6 18 10 6 4 5 1
7 19 9
3 6 4 1
3
3
5 4 2
6
8
0 0
3
3
LO TA Total
FV
0
6 0
0
0
0
0
0
1
2 1
3 2
2
3
0
4
3
0
0
0
2 1
0
6
4 9 5 4 3 5 1
8 1
31 6
7 0
7 1
7 1
10 0
20 2
15 6
11 1
21 1
26 4
9 2
172 25
9
37
7
8
8
10
22
21
12
22
30
11
197
Galloway to only 9% (73) in Ayrshire and Arran. Hospital doctors' referrals varied from 27% (73) in Highland to none in Borders (the reason being that social workers made referrals on behalf of a multi-disciplinary team which included hospital doctors). Self-referrals accounted for 11 % (88) in Ayrshire and Arran, and Lanarkshire (88) but only 1 % (1) in Argyll and Clyde. Assessment: Eighty-seven per cent (172) of homes within Scotland carried out some form of assessment of candidates. This ranged from 100% of homes in Borders (7) and Forth Valley (10) to 7 1 % (15) in Greater Glasgow (Table III). In 47% (81) of assessing homes, the owner or matron was the sole assessor. At the time of our survey the sole assessor in homes in Fife Health Board was the matron or owner. In Scotland generally, GPs were involved in assessment in 33% (56) of homes and hospital doctors were involved in 23% (39). Clinicians in total were involved in 37% (64) of homes assessing. Fiftytwo per cent (89) of homes undertook multiprofessional assessment. Of these homes, clinicians were involved in 7 1 % (63). The assessment process took four main forms: First hand: by a representative of the home Consultation with other professionals: discussion of medical history, needs and management Obtaining information from other professionals:
2
3
3
9 2
4 2 0 2 1
61 129 56 39 9 40 15
8 1
8
acceptance without discussion of information received Completion of form or questionnaire: either the home's own, or one from a nursing home association, or the use of a validated dependency questionnaire These methods were not mutually exclusive. For example, one home sent a questionnaire to the GP to obtain the current medical state of the potential candidate; a qualified nurse from the home would then assess the mental and physical ability of the candidate; thereafter, the family, if available, were interviewed. Respondents were asked to give brief details of the content of any assessment undertaken. These were coded into four main categories: Physical: medical history, physical condition, capabilities and needs, activities of daily living Mental: mental capabilities, alertness, degree of confusion, emotional state Social: social background, home circumstances, family circumstances, compatibility with others, likes and dislikes, ability to communicate. Other: trial visit to nursing home; meeting with family and applicant; the wish for such care on the part of the candidate (if possible to obtain their views); financial assessment. Of the 158 homes with details of assessments undertaken, the most common form of assessment carried out in the RPNH was physical,
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Hospital consultant NHS nurse Social worker Other Number of homes: Assessing Not assessing Total number of homes
BO DG
I. M A C P H E R S O N ET
432
Table IV. Combinations of assessment undertaken by nursing homes in Scotland
Total homes assessing multiple categories
22 21 20 19 17 9 8 6 2 1 1 126
undertaken in 82% (128) of homes assessing. Eighty per cent (126) of homes assessing used multiple categories, the main combinations being physical and mental (17%) (22) or physical, social and other (17%) (21) (Table IV). Two broad modes of assessment practice can be identified: firstly, a focus on the resources required to care for the prospective resident with the intention of providing this within the home's resources, and secondly, a focus on the ambience of the home being maintained and/or reasonable workloads being maintained given staffing levels and their flexibility.
Discussion Our results on referral practice stand in contrast to a major survey of private nursing homes in England conducted by Challis and Bartlett [5]. Although the referral sources are essentially the same, the balance of contribution is quite different. First, relatives were less prominent in the Scottish survey at 37% (1904) compared with 49% (2474) in England. Second, Scottish clinicians were involved in more referrals than their English colleagues at 29% (1492) compared with 17% (839). Third, self-referrals were slightly higher in the Scottish survey than in the English survey at 7% (345) compared with 5% (243). The varying contribution of relatives may
reflect differing cultural attitudes to the private market as well as different economic circumstances. The variation in referral source between the Scottish Health boards may be a reflection of the location of the potential resident (own home, relative's home, hospital) at the time of referral and the relationships prevailing between the public and private sector within a Health Board. However, interpreting the data is complicated by the notion of what we term the 'hidden' referral agent, an issue Challis and Bartlett [5] touched upon in their study: ' It is not possible from the data to assess the extent to which the patients were involved in the decision making where a relative or a professional was the prime mover in arranging care: it is possible that these findings underestimate the part played by the consumers in the admission process'.
In similar vein, respondents in the Scottish survey commented that while families might make the actual referral, it was often on the advice or instruction of the GP or hospital consultant. This suggests that the clinician may be playing a more prominent role in the referral process to RPNH than our data show. Very little is known about the assessment process in RPNH. Articles making reference to such assessment have done so in terms of: whether the review of applicants to homes is carried out by any outside professionals, but specifically clinicians [6]; the need for independent medical assessment before public resources are committed to care that might be inappropriate [3, 4, 7, 8]; the view that only certain professionals have the necessary skills to ration these resources correctly [4]. The general views expressed can best be summed up in a comment by Primrose and Capewell [3]: 'Within the NHS and local authority Social Work Departments there is considerable rationing of scarce resources with careful assessment part of placement procedure in most areas. This contrasts with the lack of independent assessment prior to placement in the private sector. Where public funding is involved, whether for Residential or Nursing Home patients, it would seem essential to have a proper assessment system.' However, none of the aforementioned studies
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Physical and mental Physical, social, other Physical, mental, social Physical and other Physical, mental, social, other Physical, mental, other Physical, social Social, other Mental and social Mental, social, other Mental, other
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clinicians will not produce less variability in assessment practice. The implicit notion in the literature that current assessments in the nursing home sector are at variance with those in the public long-stay sector remains to be substantiated. Our findings on the content of the assessments in RPNH accord with previous research findings in residential care, long-stay geriatrics and long-stay psychogeratrics [9]. The issues considered are the same, that is, degree of confusion, physical capabilities, home circumstances, resident and family wishes, the resource position and ambience of the facility in question. From the comments received from the matrons and owners of the RPNH, criteria of need and suitability are being utilized in a similar way for RPNH assessments to that used by the clinicians involved in McKeganey's study. It would seem that clinicians are currently viewing assessment for a nursing home place in the same light as that for a hospital long-stay ward. In the latter, their central assessment role remains unchallenged, and need is presented as a more prominent criterion than suitability. However, we would argue that the nursing home sector is more akin to the residential care sector in its philosophies and abilities to negogiate its clientele. The ward sister/charge nurse must accept the patients who are sent to the ward regardless of the impact this may have on the functioning of that ward both as a working unit and as a home. In general, transfers would only be effected if the patient needed acute or psychiatric care. The officer in charge of a local authority residential home has more freedom in '. . . different clinicians would ask different ques- terms of whom they will accept, given that their tions in different sequences but rarely would the staff are not geared to highly dependent clients. total number of questions be asked. More often In the first instance the officer in charge may than not the clinicians would ask a few key have to accept a marginal client but mechanisms questions and on the basis of the answers received exist which allow that client to be transferred if to these infer the likelihood of being provided the placement is found to be unsuitable from with similarly correct or similarly incorrect the point of view of both parties. The matron or answers to the remaining questions.' owner of the nursing home has the maximum Secondly, criteria of 'suitability' figured more freedom with regard to declining candidates at prominently in clinicians' assessments than did the outset, as indeed have the candidates themcriteria of 'need'—although the two are not selves. Suitability as a main criterion does not unconnected. Suitability usually related to the operate within the hospital sector, for example operational needs of staff. Thus, as McKeganey geriatrics, at 'base' level, by this we mean a indicates, merely concentrating the assessment ward. However, 'suitability' is as, if not more, process on the 'medical' and locating it with important than need in sectors where there is reported what was being done by way of 'inhouse' assessments. We have no way of knowing what the level of assessment was in RPNH in Scotland and even who was involved at the time of the Primrose and Capewell [3] study. If their suppositions were correct, then our findings suggest that the picture within Scotland has changed in the intervening period. Just over half of all the RPNH undertaking assessments involve external health and social services personnel. Clinicians are contributing to the process in over a third of homes carrying out any form of assessment, although there is considerable variation between the Health Board areas. Despite the lack of evidence on what assessments are being carried out in RPNH, the inference from the literature is that any assessments done which are not 'independent', 'formal', 'medically orientated' are in some way not valid. Further, it is implied that within the public long-stay sector, any assessment processes and their criteria are adhered to and administered in a consistent fashion from case to case. Yet research on the reasons for accepting referrals to services such as geriatrics, psychogeriatrics and residential care, and the way in which assessments are carried out by clinicians, demonstrates that this is not so [9]. Indeed McKeganey [10], researching the way in which assessments for residential care were carried out, highlighted two crucial aspects. First, when using standardized assessment instruments such as the Mental State Questionnaire (MSQ) there was no standardized application by clinicians:
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I. M A C P H E R S O N ET
any element of negogiated choice at a base level, for example the individual residential home, or the individual nursing home. McKeganey [10] pointed out that the fact that the clinicians assessing for residential care focused on suitability as a key criterion was a crucial strength of their assessment procedures:
The results presented in this paper suggest a more prominent role for Scottish clinicians in referral and assessment to private nursing homes than their English colleagues, though our results still may be underestimating the extent of their contribution. Whatever the situation might have been in previous years, nursing homes in Scotland do carry out assessments which may involve clinicians. Calls from the medical profession that emphasize the sole rights of the clinician are now out of step with current thinking and planning. The proposed community care arrangements as outlined in the N H S and Community Care Act 1990 make it clear that assessment of potential applicants for nursing home care is to be multi-disciplinary. The goodwill and co-operation that already exists between the various professionals involved in placement for residential care has to be carried forward into the nursing home sector where everyone respects the expertise and legitimate concerns of all parties involved in the referral and assessment process. In order to make an effective and positive contribution, clinicians must adjust their view of the administration of nursing homes from that of long-stay wards to that of residential homes. Despite the unpopularity of suitability as a key criterion of assessment [11], its use in combination with need is unavoidable if potential residents are to get the best deal in their personal care.
References 1. Donald SC, Ludbrook A, MacPherson IA. The role of registered private nursing homes in the care of elderly people in Scotland, Report to Health Services Research Committee, Scottish Office Home and Health Department, 1991. 2. Information Services Division, Scottish Home and Health Department. Scottish health statistics, 1985 to 1990. 3. Primrose W, Capewell A. Registered nursing home places caring for the elderly within Scotland, Health Bull, 1986;44:81-4. 4. Evans J Grimley. National Health Service nursing homes. Age Ageing 1989;18:289-91. 5. Chalhs L, Bartlett H. Old and ill: private nursing homes for elderly people. London: Age Concern Institute of Gerontology, 1988. 6. Hepple J, Bowler I, Bowman CE. A survey of private nursing home residents in Weston Super Mare. Age Ageing 1989;18:61-3. 7. Campbell HA, Crawford V, Stout RW. The impact of private residential and nursing care on statutory residential and hospital care of elderly people in South Belfast. Age Ageing 1990; 19:318-24. 8. Stanniland P. Nursing home care: a report on private nursing homes including types of care, statistical analysis, the law, and recommendations for future developments. Registered Nursing Home Association, 1986. 9. Hunter DJ, McKeganey NP, MacPherson IA. Care of the elderly: policy and practice. Aberdeen University Press, 1988. 10. McKeganey NP. Clinicians and residential home assessments. Soc Policy Adm 1991 ;25: 149-59. 11. Secretaries of State for Health, Social Security, Wales and Scotland Caringfor people: community care in the next decade and beyond, Cm 849, London: HMSO, 1989. Authors' addresses I. MacPherson Department of Public Health, S. Donald, A. Ludbrook Health Economics Research Unit, Department of Public Health, University of Aberdeen, Medical Buildings, Foresterhill, Aberdeen AB9 2TY Received 11 March 1992
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'. . . the observed clinicians were quick to point out the dangers of placing an individual into an environment for which he or she was unsuitable. Such a move, it was felt, would lead not only to a neglect of the individual's own initial needs but also, and perhaps more importantly, to the creation of new needs and increased levels of dependency.'
AL.
Summary The results on referral to and assessment for nursing homes, taken from a national survey of all registered private nursing homes in Scotland, are reported in this paper. The findings challenge the view that nursing homes do little by way of assessing potential candidates and that what is done is somehow at variance with the type of assessments carried out in the public long-stay sector. The implications for the future of the traditional view of which professionals should be involved in the assessment of candidates for nursing homes are discussed as are the criteria they might use to make their assessments.
Introduction
Methods
In recent years, the fastest growing provider of long-stay beds in Scotland, as in the rest of the UK, has been the registered private nursing home sector (RPNH). Provision within Scotland has risen from six beds per 1000 people aged 75 years and older in 1985 to 32 beds in 1990 [1, 2]. With this increase in provision, concerns have been voiced by clinicians about the extent and nature of the assessments used by private nursing homes in deciding whom to accept. In large measure these concerns stem from a lack of a comprehensive overview of what is happening in the private nursing home market with regard to assessment, a lack of knowledge as to the use made of general practitioners (GPs) and hospital doctors by the private nursing homes in any assessment processes, and the perceived challenge to the centrality of the clinician's role in the assessment of an elderly person for long-stay accommodation [3, 4].
A survey of all RPNH in Scotland was carried out by the Health Economics Research Unit, University of Aberdeen at the invitation of the Health Services Research Committee of the Chief Scientist's Office, Scottish Office Home and Health Department. A postal questionnaire on characteristics and resources was sent to all 285 nursing homes registered with Scottish Health boards in Scotland during December 1989 and January 1990. Questions covered type of ownership, type of residents currently in RPNH, age groups, source of funding, source of referral, whether assessments are done, by whom and what is involved, weekly charges, number and type of staff, access to paramedical services and provision of general practitioner services. Data on current places in nursing homes in Scotland were also collected through Scottish Health Statistics [2] and Health Board registration lists.
Results A total of 198 homes replied to the questionnaire, a national response rate of 70%, ranging Age and Ageing 1992;21:429-434
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ISOBEL M A C P H E R S O N , SHEENA DONALD, ANNE LUDBROOK
43°
I. MACPHERSON ET
Table I. Characteristics of nursing homes in Scotland
59% (116) 29% (59) 10% (19) 2% (4) 70% (133)
Bed occupancy
92% (5347)
Type of resident Frail elderly Mentally ill Terminally ill Other*
52% (2903) 14% (781) 14% (781) 20% (1116)
Residents aged 75 +
76% (4276)
86% (171)
• Includes physically or mentally handicapped, acute, respite care, convalescent and young chronic sick. from 89% in the highest responding Health Board to 4 5 % in the lowest responding Health Board. Characteristics of the RPNH: Table I gives the main characteristics of the homes. Fiftynine per cent (116) of the homes were owned by
private individuals. Seventy per cent (133) of homes with dates recorded had opened within the last five years. There was 92% occupancy of beds ranging from the highest Health Board area at 98% to the lowest at 85% occupancy. Respondents were asked to categorize residents from a list which represented the main groups for which Department of Social Security funding is given. Fifty-two per cent (2903) of residents were classed as frail elderly, with 14% (781) classed as mentally ill. Seventy-six per cent (4276) of all residents were aged 75 + years and of those 6 1 % (2626) were classed as frail elderly; other residents aged 75 + followed a similar distribution to total residents. Source of referral: Table 11 gives the source of referral to RPNH. For Scotland as a whole, families were the most common referrers accounting for 37% (1904) of referrals. Social workers referred 19% (963), general practitioners 17% (844), and hospital doctors 13% (648). The remaining 15% (749) of referrals came from hospital nurses, solicitors, accountants, the clergy, self-referrals, friends, and carers. Family referrals varied from 43% in Fife (106) and Grampian (256) Health Boards, to only 14% (24) in Borders Health Board. Social work referrals varied from 47% (138) in Tayside to 7% (55) in Lanarkshire. Referrals from GPs varied from 27% (57) in Dumfries and
Table II. Source of referral to nursing homes in Scotland Source of referral Family Social worker GP
Hospital doctor Self NHS nurse Other professional Other Total residents
FI
FV
GR
GG
HI
LA
LO T A
Total
94 42 45 41 10 14 2 6
256
233 107 76 68
336 55 180
235
1904
5
11 47 26
103 41 37 73 9 4
0
106 23 43 43 5 4 6 16
209
246
254
600
606
AC
AA
BO
DG
73 18 39 39 1 6 2 1
316 183 73 114
24 70 42 #
71 51 57 17
88 13 5 6
8 2 28 0
13 0
179
798
174
0
129
95 49 37 13 16
38
57 138
88 19
106 135 73 27 26
0
3
25
2
55
35
0 6 0
269
819
662
292
83
22
963 844
48
648
21
345 112 140
152
5108
• Two homes noted referrals from hospital doctors, but did not note numbers (also see text). Key: AC Argyll/Clyde; AA Ayr/Arran; BO Borders; DG Dumfries/Galloway; FI Fife; FV Forth Valley; GR Grampian; GG Greater Glasgow; HI Highland; LA Lanark; LO Lothian; TA Tayside.
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Respondent to questionnaire Owner or nurse in charge Ownership Private individual Private limited company Voluntary/charitable body Public limited company Opened in last 5 years
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REGISTERED PRIVATE NURSING HOMES IN SCOTLAND
43'
Table III. Persons involved in assessment of applicants to nursing homes in Scotland AC
AA
Owner of home Nurse in charge
3 6
GP
2 0
11 23 4
FI
GR
GG
HI
LA
10 14 7 4
5 7 5
6 18 10 6 4 5 1
7 19 9
3 6 4 1
3
3
5 4 2
6
8
0 0
3
3
LO TA Total
FV
0
6 0
0
0
0
0
0
1
2 1
3 2
2
3
0
4
3
0
0
0
2 1
0
6
4 9 5 4 3 5 1
8 1
31 6
7 0
7 1
7 1
10 0
20 2
15 6
11 1
21 1
26 4
9 2
172 25
9
37
7
8
8
10
22
21
12
22
30
11
197
Galloway to only 9% (73) in Ayrshire and Arran. Hospital doctors' referrals varied from 27% (73) in Highland to none in Borders (the reason being that social workers made referrals on behalf of a multi-disciplinary team which included hospital doctors). Self-referrals accounted for 11 % (88) in Ayrshire and Arran, and Lanarkshire (88) but only 1 % (1) in Argyll and Clyde. Assessment: Eighty-seven per cent (172) of homes within Scotland carried out some form of assessment of candidates. This ranged from 100% of homes in Borders (7) and Forth Valley (10) to 7 1 % (15) in Greater Glasgow (Table III). In 47% (81) of assessing homes, the owner or matron was the sole assessor. At the time of our survey the sole assessor in homes in Fife Health Board was the matron or owner. In Scotland generally, GPs were involved in assessment in 33% (56) of homes and hospital doctors were involved in 23% (39). Clinicians in total were involved in 37% (64) of homes assessing. Fiftytwo per cent (89) of homes undertook multiprofessional assessment. Of these homes, clinicians were involved in 7 1 % (63). The assessment process took four main forms: First hand: by a representative of the home Consultation with other professionals: discussion of medical history, needs and management Obtaining information from other professionals:
2
3
3
9 2
4 2 0 2 1
61 129 56 39 9 40 15
8 1
8
acceptance without discussion of information received Completion of form or questionnaire: either the home's own, or one from a nursing home association, or the use of a validated dependency questionnaire These methods were not mutually exclusive. For example, one home sent a questionnaire to the GP to obtain the current medical state of the potential candidate; a qualified nurse from the home would then assess the mental and physical ability of the candidate; thereafter, the family, if available, were interviewed. Respondents were asked to give brief details of the content of any assessment undertaken. These were coded into four main categories: Physical: medical history, physical condition, capabilities and needs, activities of daily living Mental: mental capabilities, alertness, degree of confusion, emotional state Social: social background, home circumstances, family circumstances, compatibility with others, likes and dislikes, ability to communicate. Other: trial visit to nursing home; meeting with family and applicant; the wish for such care on the part of the candidate (if possible to obtain their views); financial assessment. Of the 158 homes with details of assessments undertaken, the most common form of assessment carried out in the RPNH was physical,
Downloaded from http://ageing.oxfordjournals.org/ at Purdue University Libraries ADMN on June 6, 2016
Hospital consultant NHS nurse Social worker Other Number of homes: Assessing Not assessing Total number of homes
BO DG
I. M A C P H E R S O N ET
432
Table IV. Combinations of assessment undertaken by nursing homes in Scotland
Total homes assessing multiple categories
22 21 20 19 17 9 8 6 2 1 1 126
undertaken in 82% (128) of homes assessing. Eighty per cent (126) of homes assessing used multiple categories, the main combinations being physical and mental (17%) (22) or physical, social and other (17%) (21) (Table IV). Two broad modes of assessment practice can be identified: firstly, a focus on the resources required to care for the prospective resident with the intention of providing this within the home's resources, and secondly, a focus on the ambience of the home being maintained and/or reasonable workloads being maintained given staffing levels and their flexibility.
Discussion Our results on referral practice stand in contrast to a major survey of private nursing homes in England conducted by Challis and Bartlett [5]. Although the referral sources are essentially the same, the balance of contribution is quite different. First, relatives were less prominent in the Scottish survey at 37% (1904) compared with 49% (2474) in England. Second, Scottish clinicians were involved in more referrals than their English colleagues at 29% (1492) compared with 17% (839). Third, self-referrals were slightly higher in the Scottish survey than in the English survey at 7% (345) compared with 5% (243). The varying contribution of relatives may
reflect differing cultural attitudes to the private market as well as different economic circumstances. The variation in referral source between the Scottish Health boards may be a reflection of the location of the potential resident (own home, relative's home, hospital) at the time of referral and the relationships prevailing between the public and private sector within a Health Board. However, interpreting the data is complicated by the notion of what we term the 'hidden' referral agent, an issue Challis and Bartlett [5] touched upon in their study: ' It is not possible from the data to assess the extent to which the patients were involved in the decision making where a relative or a professional was the prime mover in arranging care: it is possible that these findings underestimate the part played by the consumers in the admission process'.
In similar vein, respondents in the Scottish survey commented that while families might make the actual referral, it was often on the advice or instruction of the GP or hospital consultant. This suggests that the clinician may be playing a more prominent role in the referral process to RPNH than our data show. Very little is known about the assessment process in RPNH. Articles making reference to such assessment have done so in terms of: whether the review of applicants to homes is carried out by any outside professionals, but specifically clinicians [6]; the need for independent medical assessment before public resources are committed to care that might be inappropriate [3, 4, 7, 8]; the view that only certain professionals have the necessary skills to ration these resources correctly [4]. The general views expressed can best be summed up in a comment by Primrose and Capewell [3]: 'Within the NHS and local authority Social Work Departments there is considerable rationing of scarce resources with careful assessment part of placement procedure in most areas. This contrasts with the lack of independent assessment prior to placement in the private sector. Where public funding is involved, whether for Residential or Nursing Home patients, it would seem essential to have a proper assessment system.' However, none of the aforementioned studies
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clinicians will not produce less variability in assessment practice. The implicit notion in the literature that current assessments in the nursing home sector are at variance with those in the public long-stay sector remains to be substantiated. Our findings on the content of the assessments in RPNH accord with previous research findings in residential care, long-stay geriatrics and long-stay psychogeratrics [9]. The issues considered are the same, that is, degree of confusion, physical capabilities, home circumstances, resident and family wishes, the resource position and ambience of the facility in question. From the comments received from the matrons and owners of the RPNH, criteria of need and suitability are being utilized in a similar way for RPNH assessments to that used by the clinicians involved in McKeganey's study. It would seem that clinicians are currently viewing assessment for a nursing home place in the same light as that for a hospital long-stay ward. In the latter, their central assessment role remains unchallenged, and need is presented as a more prominent criterion than suitability. However, we would argue that the nursing home sector is more akin to the residential care sector in its philosophies and abilities to negogiate its clientele. The ward sister/charge nurse must accept the patients who are sent to the ward regardless of the impact this may have on the functioning of that ward both as a working unit and as a home. In general, transfers would only be effected if the patient needed acute or psychiatric care. The officer in charge of a local authority residential home has more freedom in '. . . different clinicians would ask different ques- terms of whom they will accept, given that their tions in different sequences but rarely would the staff are not geared to highly dependent clients. total number of questions be asked. More often In the first instance the officer in charge may than not the clinicians would ask a few key have to accept a marginal client but mechanisms questions and on the basis of the answers received exist which allow that client to be transferred if to these infer the likelihood of being provided the placement is found to be unsuitable from with similarly correct or similarly incorrect the point of view of both parties. The matron or answers to the remaining questions.' owner of the nursing home has the maximum Secondly, criteria of 'suitability' figured more freedom with regard to declining candidates at prominently in clinicians' assessments than did the outset, as indeed have the candidates themcriteria of 'need'—although the two are not selves. Suitability as a main criterion does not unconnected. Suitability usually related to the operate within the hospital sector, for example operational needs of staff. Thus, as McKeganey geriatrics, at 'base' level, by this we mean a indicates, merely concentrating the assessment ward. However, 'suitability' is as, if not more, process on the 'medical' and locating it with important than need in sectors where there is reported what was being done by way of 'inhouse' assessments. We have no way of knowing what the level of assessment was in RPNH in Scotland and even who was involved at the time of the Primrose and Capewell [3] study. If their suppositions were correct, then our findings suggest that the picture within Scotland has changed in the intervening period. Just over half of all the RPNH undertaking assessments involve external health and social services personnel. Clinicians are contributing to the process in over a third of homes carrying out any form of assessment, although there is considerable variation between the Health Board areas. Despite the lack of evidence on what assessments are being carried out in RPNH, the inference from the literature is that any assessments done which are not 'independent', 'formal', 'medically orientated' are in some way not valid. Further, it is implied that within the public long-stay sector, any assessment processes and their criteria are adhered to and administered in a consistent fashion from case to case. Yet research on the reasons for accepting referrals to services such as geriatrics, psychogeriatrics and residential care, and the way in which assessments are carried out by clinicians, demonstrates that this is not so [9]. Indeed McKeganey [10], researching the way in which assessments for residential care were carried out, highlighted two crucial aspects. First, when using standardized assessment instruments such as the Mental State Questionnaire (MSQ) there was no standardized application by clinicians:
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any element of negogiated choice at a base level, for example the individual residential home, or the individual nursing home. McKeganey [10] pointed out that the fact that the clinicians assessing for residential care focused on suitability as a key criterion was a crucial strength of their assessment procedures:
The results presented in this paper suggest a more prominent role for Scottish clinicians in referral and assessment to private nursing homes than their English colleagues, though our results still may be underestimating the extent of their contribution. Whatever the situation might have been in previous years, nursing homes in Scotland do carry out assessments which may involve clinicians. Calls from the medical profession that emphasize the sole rights of the clinician are now out of step with current thinking and planning. The proposed community care arrangements as outlined in the N H S and Community Care Act 1990 make it clear that assessment of potential applicants for nursing home care is to be multi-disciplinary. The goodwill and co-operation that already exists between the various professionals involved in placement for residential care has to be carried forward into the nursing home sector where everyone respects the expertise and legitimate concerns of all parties involved in the referral and assessment process. In order to make an effective and positive contribution, clinicians must adjust their view of the administration of nursing homes from that of long-stay wards to that of residential homes. Despite the unpopularity of suitability as a key criterion of assessment [11], its use in combination with need is unavoidable if potential residents are to get the best deal in their personal care.
References 1. Donald SC, Ludbrook A, MacPherson IA. The role of registered private nursing homes in the care of elderly people in Scotland, Report to Health Services Research Committee, Scottish Office Home and Health Department, 1991. 2. Information Services Division, Scottish Home and Health Department. Scottish health statistics, 1985 to 1990. 3. Primrose W, Capewell A. Registered nursing home places caring for the elderly within Scotland, Health Bull, 1986;44:81-4. 4. Evans J Grimley. National Health Service nursing homes. Age Ageing 1989;18:289-91. 5. Chalhs L, Bartlett H. Old and ill: private nursing homes for elderly people. London: Age Concern Institute of Gerontology, 1988. 6. Hepple J, Bowler I, Bowman CE. A survey of private nursing home residents in Weston Super Mare. Age Ageing 1989;18:61-3. 7. Campbell HA, Crawford V, Stout RW. The impact of private residential and nursing care on statutory residential and hospital care of elderly people in South Belfast. Age Ageing 1990; 19:318-24. 8. Stanniland P. Nursing home care: a report on private nursing homes including types of care, statistical analysis, the law, and recommendations for future developments. Registered Nursing Home Association, 1986. 9. Hunter DJ, McKeganey NP, MacPherson IA. Care of the elderly: policy and practice. Aberdeen University Press, 1988. 10. McKeganey NP. Clinicians and residential home assessments. Soc Policy Adm 1991 ;25: 149-59. 11. Secretaries of State for Health, Social Security, Wales and Scotland Caringfor people: community care in the next decade and beyond, Cm 849, London: HMSO, 1989. Authors' addresses I. MacPherson Department of Public Health, S. Donald, A. Ludbrook Health Economics Research Unit, Department of Public Health, University of Aberdeen, Medical Buildings, Foresterhill, Aberdeen AB9 2TY Received 11 March 1992
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'. . . the observed clinicians were quick to point out the dangers of placing an individual into an environment for which he or she was unsuitable. Such a move, it was felt, would lead not only to a neglect of the individual's own initial needs but also, and perhaps more importantly, to the creation of new needs and increased levels of dependency.'
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