How the gap in nursing care for patients with dementia is a critical commissioning challenge

By Susan Adams, CHS Healthcare, south of England

While the problem of DTOC (delayed transfers of care) is widely recognised, what is perhaps less well understood is the capacity gap that impacts on one particular patient cohort.

In the hospitals where we work, spanning from the south coast of England to Durham in the north-west, one feature is commonly apparent: patients with dementia and nursing needs often face a delayed discharge because there is no capacity in the community to meet their needs.

It is the combination of dementia together with nursing needs that makes it particularly hard to find a community placement. We can usually find residential beds for patients with dementia and general nursing beds, but there are very few for those with both complex dementia and nursing needs.

To put this into context: in one large city in south-west England, we do care home brokerage for the two main hospitals. Recently, we were co-ordinating the care for 13 people with dementia and nursing needs and in the whole city, there were only two suitable and available beds for the 13 people requiring one.

Another example: in a north-west London borough where we have worked for many years, there are only two care homes who will regularly accept patients who have dementia with challenging behaviour. Recently, when we were looking for a placement for a patient in this category, there was one available bed and five individuals in need of that bed.

For patients and families in this group, there is rarely a choice of home and they often go onto waiting lists; this means staying in hospital for weeks beyond the time when they ought to be discharged.

The challenge of providing good care for a person who has high level nursing needs is well recognised. In the most recent State of Care Report, 2015, the Care Quality Commission notes nursing homes provide a poorer quality of care than other adult social care services. A higher percentage of nursing homes are rated inadequate and when admissions to a nursing home are suspended due to CQC concerns, this necessary measure further squeezes overall capacity for patients with the higher levels of needs. The report notes the problems of recruitment and retention in the sector and how the introduction of the Living Wage in April 2016 will create further pressure.

Many homes struggle to recruit the staff they need and with occupancy levels high across the country, they will often not accept patients with the highest level of need, especially those with the combination of nursing care and complex dementia. Some will take one patient within this category but with the demand on resources this necessitates, they will then not take any others.

This presents a clear commissioning challenge. We understand the process of hospital discharge management: we know all the steps that need to be taken to support and manage a patient’s transfer from hospital into a care home. We know how to iron out all the potential causes of delay, for example, family difficulties in making a choice or care homes taking too long to carry out their own assessment. These are all parts of the process of the transfer of care; things that we can address. But when the community based care simply does not exist, this requires a different, commissioning based solution, otherwise for many patients with higher levels of needs, hospitals will increasingly become the places where they stay because there is simply nowhere within the community where they can be safely cared for.