Where do I begin? First, I think we can all agree that some older people end up in care homes avoidably. In England there is a six-fold variation in the number of patients discharged to new care home places straight from acute hospital, and an eight-fold variation in the number of council-funded placements. Clearly, some localities are better at maintaining people at home.
Common precipitants of care home admission include dementia, falls and fractures, declining mobility and incontinence. These medical conditions require skilled diagnostic and holistic assessment and support, and we know that undertaking a ‘comprehensive geriatric assessment’ (whatever you think of the ‘g’ word), either at home or in hospital, can maximise people’s chances of being alive and in their own home up to a year later.
Carer stress is also a precipitant, so providing more support and respite for family carers has the potential to delay or prevent admission to long-term care. However, given massive cuts to local government support grants, we have to ask where the money will come from to deliver this and meet the housing challenge.
The House of Lords Ready for ageing report estimated that there are already 6 million carers in the UK and that the demand for family care will outstrip supply by 2022. More social support is also a good notion, but the coalition has cut direct support grants to local government by 28%. Age UK recently estimated that around 800,000 older people whose care needs would be classified as moderate or substantial are not receiving formal care. Who will pick up the pieces?
As the Anchor Trust and the All-Party Parliamentary Group on Housing and Care for Older People have said, more investment in age-friendly housing and communities that people want to move to could improve their chances of remaining at home. Adaptations from care and repair charities also enhance people’s ability to remain in their own homes.
The National Audit of Intermediate Care also showed a major lack of capacity in rehabilitation and re-ablement services outside hospital, which give frail older people every chance to regain their independence.
Even if we were able to invest in some of these health and care services, with the population over 80 and the prevalence of dementia doubling over the next two decades, the idea that we can lose 325,000 care home places in England is plain bonkers – especially when the fastest growing demographic is the over 80s – the same group who form the majority of care home residents.
We have already undergone a mass shift of care from institutions to people’s own homes, and the kind of people now in residential homes – who are highly dependent and with complex medical issues – would have been in nursing homes 10 years ago. A report by the British Geriatrics Society, A quest for quality in care homes, showed that typical care home residents have combinations of disability, frailty, cognitive impairment, multiple long-term conditions and numerous medications. They aren’t in those institutions for fun and are generally admitted after prolonged efforts to support them at home and repeated failed discharges from hospital and when other options have been exhausted. They probably have the most complex care and support needs of any members of society.
As Bette Davies said, ‘growing old isn’t for sissies’. In his Age UK speech, Mr Stevens compared care homes to TB sanatoria, which were closed down by mass vaccination and effective antibiotics. There is no vaccine nor cure for ageing, so the analogy is not valid.
When community support involves two unfamiliar carers calling for 20 minutes or so four times a day, when you are living in old and unsuitable housing and are socially isolated, being in a well-run care home with a good physical environment, a good degree of choice and control, and caring staff may be preferable.
And despite serial scandals, as shown in the recent Panorama programme on abuse and neglect, there are plenty of good care homes.
Even Sweden and Holland – much praised for their approach to ageing well, preventing unhealthy lifestyles, age-friendly housing and communities – still require care homes, with some older people regarding it as their right to go to one, much the same as a general hospital in England.
We talk the language of person-centred care, of involving patients and their families and respecting their wishes, but we need to walk the walk as well. In my day job as a hospital doctor, I frequently see older people who have freely made up their mind that they no longer want to live at home. They actively choose to go into care (in some cases to accommodate the wishes of their relatives). We are pretty good at respecting choice if it’s the one we want people to make – often the cheaper one. But care homes can never become a ‘never’ event, even if that mantra suits the current zeitgeist.
Let’s accept that some people need or want long-term care, make sure every care home is fit for purpose and that residents have the same access to high-quality health care as people living in their own homes.
- Related report: Making our health and care systems fit for an ageing population