The quasi-market for adult residential care in the UK: Do for-profit, not-for-profit or public sector residential care and nursing homes provide better quality care?

There has been a radical transformation in the provision of adult residential and nursing home care in England over the past four decades. Up to the 1980s, over 80% of adult residential care was provided by the public sector, but today public sector facilities account for only 8% of the available places, with the rest being provided by a mixture of for-profit firms (74%) and non-profit charities (18%). The public sector's role is often now that of purchaser (paying the fees of people unable to afford them) and regulator. While the idea that private companies may play a bigger role in the future provision of health care is highly contentious in the UK, the transformation of the residential and nursing home care has attracted little comment. Concerns about the quality of care do emerge from time to time, often stimulated by high profile media investigations, scandals or criminal prosecutions, but there is little or no evidence about whether or not the transformation of the sector from largely public to private provision has had a beneficial effect on those who need the service. This study asks whether there are differences in the quality of care provided by public, non-profit or for-profit facilities in England. We use data on care quality for over 15,000 homes that are provided by the industry regulator in England: the Care Quality Commission (CQC). These data are the results of inspections carried out between April 2011 and October 2015. Controlling for a range of facility characteristics such as age and size, proportional odds logistic regression showed that for-profit facilities have lower CQC quality ratings than public and non-profit providers over a range of measures, including safety, effectiveness, respect, meeting needs and leadership. We discuss the implications of these results for the ongoing debates about the role of for-profit providers of health and social care.

Overcoming the barriers to patient-centred care: time, tools and training.

AIMS AND OBJECTIVES: To investigate whether nurses experience barriers to delivering high quality care in areas that are of particular concern to patients and to describe which aspects of care are most affected when nurses lack the required resources, such as time, tools and training to do their job. BACKGROUND: Patient surveys conducted in the National Health Service of the United Kingdom tend to show there is variation in the extent to which they are satisfied with care in a number of important areas, such as physical comfort, emotional support and the coordination of care. DESIGN: A sample of nurses working in 20 acute London hospitals was asked to complete a postal questionnaire based on a prototype employee survey developed in the United States and adapted by the authors for use in the United Kingdom. METHOD: Staff in the human resources departments of participating hospitals mailed the questionnaires to nurses' home addresses. After two reminders, 2880 (out of 6160) useable responses were returned, giving a response rate of 47%. RESULTS: Nurses are aware that there are deficits in standards of care in areas that are particularly important to patients. The majority feel overworked (64%) and report that they do not have enough time to perform essential nursing tasks, such as addressing patients' anxieties, fears and concerns and giving patients and relatives information. Their work is often made more difficult by the lack of staff, space, equipment and cleanliness. They are often unable to control noise and temperature in clinical areas. Nurses in acute London hospitals are subject to high levels of aggressive behaviour, mainly from patients and their relatives, but also from other members of staff. More positively, high proportions of the nurses in our survey expressed the desire for further training, particularly in social and interpersonal aspects of care. RELEVANCE TO CLINICAL PRACTICE: This paper goes beyond reporting problems with the quality and safety of care to try to understand why patients do not always receive optimum care in areas that are important to them. In many cases nurses lack the time, tools and training to deliver high quality care in acute London hospitals. We suggest a number of low-cost interventions that might remove some of the barriers to patient-centred care. The questionnaire we have developed could be a useful tool for improving quality locally.