Summary; this talk was given by Judy Downey of the Relatives and Residents' Association at our AGM in autumn 2019. It gives some useful suggestions for what local authorities and lobbying groups can do in the current care crisis.
JUDY DOWNEY, CHAIR OF THE RELATIVES & RESIDENTS ASSOCIATION (R&RA)
‘Social care’ is a misleading term. It is unspecific and implies that the care is optional and somehow less serious than health or other important services. It hardly gives the impression that such services are regularly a lifeline to many people in desperate need of services. “Personalisation” is another jargon-ridden term and means little to those not in the ‘system’. Essentially, it is trying to convey that care should be focused on the individual. It is extraordinary that such a basic point has to be made and also implies that the service is normally organised on a one size fits all basis. The sector (often referred to as ‘the industry’) tends to use far too much jargon and pays far too little importance to communicating in a friendly and accessible way to those who need services to support them. For example, the term ‘carer’ is used interchangeably to refer both to ‘informal’ i.e. unpaid family, friends and neighbours looking after people, and to paid workers who should be referred to as ‘care workers’. Too often, public services are referred to as burdens on taxpayers as though they are a different group in the population. We are all taxpayers: everyone pays the regressive VAT on their purchases every day.
The R&RA was set up by a former civil servant who started her career in the then Ministry of Health, setting up the NHS working for Nye Bevan. JD has also been a civil servant in the renamed Department of Health and Social Care for much of her career.
The R&RA provides advice and support for the family and friends of older people (and older people themselves) looking for or needing care at home or in a care home and, often, for those moving from one to the other. As a result, the charity receives day-to-day informed intelligence about older people’s experiences of care. This means that we know what is going on from the unique perspectives of relative who are in touch with the realities of care day in and day out. We provide support and sometimes advocacy, which is often hard to come by.
Many relatives are themselves in their 70s and over and have the problems and responsibilities of a “sandwich” generation: looking after their own families and sometimes, grandchildren, while also caring for elderly relatives, sometimes involving long journeys. Many older people needing or in care have no kith and kin or any regular contact. They can, therefore, be even more vulnerable and isolated.
This sector is overwhelmed with problems of quality and regulation as well as problems of quantity and funding. For example, the number of hospital beds has been massively reduced since the 1980’s; exacerbated by a 40% reduction in beds since 2010. There are now something like 120,000 general and acute hospital beds in England, compared with some 500,000 in care homes, over 80% of which are owned by the private sector. It is, therefore, hardly surprising that older people in NHS hospitals are regularly described as ‘bed-blockers’ and referred to as an obstruction to providing enough facilities for everyone else.
The problem is now most often referred to by the euphemism ‘delayed discharge’ and local authorities are regularly now charged or fined i.e. for not moving patients out of hospital quickly enough when they are deemed ‘clinically fit’ for discharge (which is often another euphemism for not having enough beds to meet the increasing demand for hospital care). The effect of this policy is that far too many frail and vulnerable patients are discharged from hospital much too soon and arrive back in hospital having deteriorated badly. Many will need continuing care with physiotherapy, help with reablement and rehabilitation before going to a care home or coping well at home.
The state of the care workforce is yet other major hindrance to good quality care. The lack of training, the poor pay and status and the consequent massive turnover take their toll on those needing care. The average rate of turnover for managers in all economic sectors is 6 to 11% per year, for care it is over 30% and higher in some settings. An even higher percentage leaves in their first months in new care jobs. Less than half the workforce of approximately 1.6 million holds a relevant qualification and there are wide variations in the quality of care. There are no prescribed staff ratios for older people’s care unlike those specified for early years, for example.
It is an anomaly that service providers are responsible for training care workers for which they are neither qualified nor rewarded. For many years, it has not been perceived as a public responsibility, like the training of teachers, nurses and doctors. The regulations and guidance are ‘light touch’ not only in relation to qualifications and standards of care. For example, a proportion of staff (particularly in London and the South East) may have inadequate English to communicate easily with residents. Familiarity with local terminology and spoken English is even more important in communicating with people with dementia and other communication problems: e.g. the resident in a care home who complained about ‘eyes in his potatoes’ and was referred for possible psychotic symptoms!
The population of older people needing care often has complex needs but is too often reliant on non-specialist GPs for care and treatment of a number of long-term conditions, sometimes needing complex drug therapies and the expertise of geriatricians and psycho-geriatricians, as well as pharmacists and other specialist care professionals, particularly for those needing dental care, with hearing and sight problems and possible needing speech and other therapists.
Local authorities pay for approximately 60% of residential care, most of which is provided by the private sector. The massive underfunding of local councils contributes to poor standards since local authorities regularly need to buy places at the lowest possible rate to meet the growing imperatives of need and demand. Nonetheless, local councils need to consider ways of improving standards to benefit their communities. They could be more stringent in the conditions they place in their contracts with providers and thus improve standards for those receiving care. They could, for example, insist that care home residents have their records and medication and are accompanied when sent to A&E or for other medical appointments. London boroughs could come together to demand or provide better training arrangements. This could be linked to better retention and recruitment which would reduce costs for providers. There is an urgent need for there to be a nationally accredited training programme which would not only enable a proper career structure, higher status and better pay, it would also recognise the importance of the skills needed to provide good quality care for older people at the end of their lives. This could then lead to the registration of care workers.
The latest R&RA publications are geared towards improving the quality of care and enabling care workers to better carry out their roles. The ‘Keys to Care’ were developed to be resources for both the home care and care home sector as well as being useful for informal carers.
Some current proposals about the future of care have made a number of assumption about future ownership. For example, speaking about taking care “back into public ownership” implying a local authority acquisition or buy out. There are 18,500 providers in England. Many of the indebted care home chains would probably be delighted to sell off their homes, particularly those in areas of high deprivation where profits are lower. This would simply be transferring problematic ownership and would achieve little for quality standards or regulation. The smaller providers tend to have better outcomes than the big chains. The key objective for any new government must to improve both the quality of care and the workforce, raising standards and improving enforcement.
The lack of skilled and professional assessment is another casualty of reduced budgets and cuts in skilled social work practitioners. This is now regularly carried out by administrative staff with little or no training and budget imperatives, often now done online or over the telephone. They may well be unaware of many aspects of the legislation, for example, where people need information about alternatives and their eligibility for, say, deferred payments for residential care. As Gordon has argued, the loss of children’s services in an integrated social services department has been a great loss to the interchange of professional expertise and professional development.
Questions also arise about whether small local authorities like Haringey can provide appropriate career structures, good enough care and quality professional development in climates of continuing austerity. Osborne Grove is a case in point.
Inspection of care homes needs a radical overhaul with improved basic standards, staff ratios and a strong improvement agenda. The rating system has inherent contradictions and is inconsistent and unsatisfactory. Relatives regularly find the CQC reports mechanistic and unhelpful. Only 1% of homes for older people is rated as ‘outstanding’ compared with 7% of hospitals and 50% of GPs. A fifth (20%) of residential care homes were described as ‘inadequate’ or ‘needing improvement’ compared with 30% of nursing homes (2017). Inspectors have far too little training and should all have skills and experience in the care sector they are evaluating. Standards should once again be defined by the Department of Health, not by the regulator, which has conflicting objectives since part of the CQC’s remit is to ensure a functional care market – an inappropriate role for a regulator. In addition, complaints investigation should be reinserted into the regulator’s role.
Examples of inadequate regulation mean that there are no requirement for outings, links with the community, access to appropriate specialist and other health services e.g. dental care, hearing and sight services, and many others. The latest statistics show many major deficits in training for care workers, particularly in dementia care, a condition affecting a high proportion of older people needing care.. Nurses in care homes with nursing do not need to have any speciality in older people’s care. This is yet another area where improvements in standards and expectations need to be implemented urgently.