James Mumford

How to reform the care home system

How to reform the care home system
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The care home residents had been left on the landing in wheelchairs. That was the sight that greeted me as I walked up the stairs of the nursing home I was visiting in Wembley, north London. From above, sawdust fell as builders blithely went about their business, fixing the roof. Apart from the drilling there was no noise. No one cried for help. No one complained. It was as if no one expected anything different.

The abandonment of the elderly in residential care was driven home recently by revelations of the full extent of failing homes. This year, forty per cent – yes, forty per cent – were found wanting by the regulator, the Care Quality Commission (CQC). Of a whopping sample of 5,300, 2,000 care homes were found inadequate or in need of improvement. Inspectors discovered the all-too familiar stories we wish we could consign to a Dickensian past. Men and women left soiled or locked in windowless rooms. Scenes from films and newscast nobody wants to watch.

The awful findings chime with the chilling things I saw during a two-year review of social care I led at The Centre for Social Justice think tank. Even in the past ten years, care home residents have radically changed in profile. Indistinguishable now from nursing home residents, the demographic shift has meant the people you see are more like patients than residents – frailer, older residents, with shorter lengths of stay. People suffering from many illnesses at once. A higher proportion than ever with dementia. In the past a care home was somewhere you went to forestall the decline to dependency. Now you go there when you are ill. And your future looks bleak.

Our immediate reaction is to leap to the Funding Question. The sector is 'teetering on the edge', warned Chai Patel this week, chairman of one of the biggest care operators in the U.K. The reason? Because of local authorities' 'chronic shortage of funds' for the 220,000 people they place in residential care. And when we then ask the further question of why that is, we then retreat to wrangling over the issues left unsolved by royal commissions (like Lord Lipsey’s in 2000), to back-to-the-drawing-board reviews (like Sir Andrew Dilnot’s in 2011), to party manifestos (the Tory’s fateful dementia tax fiasco). Funding is critical, of course. Which, if we think it is, raises the question of hypocrisy. The north London home I visited was in part so ghastly because the majority of residents were local authority-funded. But it seems mauvaise foi to scream bloody murder about travesties derived from chronic state underfunding while writhing about the possibility of means-testing winter fuel allowance. As ethnographer Mary Douglas put it, ‘solidarity without sacrifice is mere gesture.’

Yet the assumption is always that once we inject the right amount of cash everything will work out. This is where we need a reality check. Care homes are fiendishly expensive for the 177,000 self-payers in this country. It is not a funding issue when a resident isn’t given a glass of water. It is not a funding issue when people in charge fail to deliver. And it is also not a funding issue that we, so often, look the other way or quite simply stay away.

‘The outside world never comes in here,’ said one 99-year-old resident I spoke with in the decrepit Wembley home. Care home managers told me about family members who admitted their ageing parents to hospital and then, as the days and months pass, visit them less and less.

Put mum in a home and let other people look after her. The recent Channel 4 documentary, Old People’s Home for 4 Year Olds, depicted movingly the extraordinary difference intergenerational contact has. Quality of life soared on every measure. Yet these are the aspirations, the best practice, the models we need to ‘scale, not the culture. All too often we don’t want to know.

In her powerful ethnographic study, Experience of Death: An Anthropological Account, Jennifer Hockey writes: ‘The literal meaning of daily life within a care home is that forty-five people have lived so long as to have outgrown their places within the outside world.’ When an older person has to go into a home, she is coming to live with strangers – people she has no ties or association with. She has to shed her possessions, those things that made her home a home. ‘From now on she will typically become a solitary eater, retarding the civilisational step whereby the human need for regular fuel became a chance to affirm sociality by eating together.’ Homes constitute for Hockey ‘institutionalised marginality’, ‘a virtual exile from society’, ‘zones of social abandonment’.

Despite the harrowing reality of so many homes, the future does not have to be the same as the past. Nothing is written. And first off, we need to empty care homes, demolish the buildings and dream big.

Dr Bill Thomas was trained at Harvard medical school to be a geriatrician. His first job was at a nursing home in upstate New York, his home state. His Damascus Road experience came when he was sitting at a nursing station one afternoon, idling away the time. Suddenly he heard a resident call for help. He disregarded the call. Moments later the junior doctor was wracked with guilt, appalled by how quickly he had come to tolerate the institutionalisation of the elderly. ‘Older people’, Thomas told me, ‘represent an important part of the wealth of our nation and we have been squandering that wealth.’ So he decided to start from scratch and dream up a whole new design for residential care. There had to be another way of doing it.

The answer he came up with were ‘Greenhouses’. The model is masterly. The facilities are much smaller – for 10 to 12 people – allowing them to be homes bereft of clinical corridors and covert kitchens. Nurses are peripatetic, while staff are assigned to run each home, in effect promoting each carer to care home manager, with the greater prestige and responsibility that entails. Meanwhile, Thomas was determined that the model could not be a dime more than traditional models, now proven by peer review.

For the last five years the aspiration in the care sector has been towards ‘Extra Care housing’. Essentially a specialist housing offer, domiciliary care is brought to people in their own flats. The aim is to do everything possible to help them maintain their independence. Yet while arresting decline is crucial, we must make friends with the fact many people can’t stay at home forever. Thus we have to rethink the places where older people live out the last scene of all. And this requires reform on a scale that, in 1960, Enoch Powell envisaged when, in a surprisingly enlightened stint as health minister, he proposed vis-à-vis mental institutions ‘we must storm the asylums which our Victorian ancestors built with such immense solidity.’

James Mumford is a fellow at the Legatum Institute