Admission to a nursing home can never become a ‘never’ event

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At Age UK’s excellent For Later Life conference, I sat next to new Chief Executive of NHS England, Simon Stevens, as he set out his vision to the audience. I agreed with much of what he said until he stated that he would be ‘disappointed’ if care homes still existed within the next 50 years. I was interested to hear how this vision might be delivered – ‘by use of new technologies, more social support and family help,’ he said, before moving onto another topic. I didn’t get the chance to challenge him because he had to dash off to another meeting. But I want to do it now.

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.



Comment date
02 November 2017

my grandmother suffered from Alzheimer's disease, and as the disease progressed, it was very difficult to live with it and to provide it with adequate care. We have long resisted the fact that we have to put it in a nursing home until the time has come. We placed it in Arija nursing home , and I must admit that we were overwhelmed. unfortunately my grandmother died, but employees in nursing home Arija in Belgrade Serbia, they took care of her better than we did.

Julie Ann Racino

Executive Consultant,
Community and Policy Studies
Comment date
24 November 2015
There is no evidence in the US that the recommendations made in the 1990s regarding community services development were followed at the "individual, family and community" health gates (support services) as relates to the "public health" department.

Specifically, the US did develop and pay for and continues to, short term rehabilitation, and the "retrograde government" placed these services in nursing homes that no one wanted to go to. They then claimed that they did not give the "nursing home physician" the right to keep them there, and never told the public (current, 2015) they cut off private physician access.

On the development of home and community-based services, which regretfully is associated with "one categorical population group", Long-term care services and supports (LTSS) has been fought "tooth and nail" by the "hospital system" (member "hospitals" charged and exposed, Christmas in Purgatory) from the beginning. Indeed, in 2015, the group blocked on several occasions, including deleting the word long-term services and supports (LTSS) from wikipedia.

Hello from the US, and the book which just "came" in, is Public Administration and Disability: Community Services Administration in the US (Racino, 2014) at

This author has met Professor David Guttman of geriatric psychiatry back at Northwestern University Medical School. He was indeed "piloting community day care" at their associated hospital and was affiliated with the multi-service agencies, similar to all universities and colleges for internships and field placements. I've found the entire approach to "dementia" (often permanent, irreversible changes to the brain) to result in relatively little positive life changes, and the brain research has not indicated significant changes either.

However, the research gates "allowed" in instead "retrograde practices" (e.g., behavioral instead of competency-based) back into the community (LTC not LTSS groups) for population groups with "cognitive disabilities" (Racino, 1994). This term refers to populations of intellectual disabilities, mental health, and brain injury; Alzheimers and dementia groups were "not involved" (at the state categorical level) in community services development for the other population groups (but affiliate with diabetes and cancer groups).

The latter was courtesy of the World Institute on Disability (Racino, 1999) which does not provide services (i.e., advocacy base) and is not recommended as a primary "service provider" for that population group. However, its affiliates are independent living service providers which obtain funds through a federal allotment that does not include the "cognitive disabilities" as of inquiry in 2015.

If I ever can find my own position, albeit free of the entire groups and departments, and universities and science centers, and professions involved, I personally do believe in a solid community system with a community lead in "health and human services". And the US government does, too, but believes it has that right now. The latter should not be health as I will control lifestyles in homes and communities. And the next step is government in the US should be cuts starts especially when it has not reduced infant mortality, engages in political control, and has increased prison rates.

Best wishes for a wonderful 2015 holiday season!

Georgina Craig

Director Experience Led Commissioning Programme,
GCA Associates Ltd
Comment date
06 December 2014
There is increasing evidence of the negative impact of loneliness on health. we have not yet recognised the huge value of the social connection and sense of community and family that living in a good care home can provide; especially for those with dementia. As we age and more people live alone, we should be thinking creatively of more ways to help people to live together to keep them connected and combat loneliness - not cheaper ways to keep them isolated in their own home with technology as their only friend

Care Rocks

Care Rocks CIC
Comment date
20 September 2014
Care Rocks C.I.C is a social enterprise that provides and promotes meaningful activities for older people in care homes and day centres. Spread the word to care home residents and activity coordinators to take a look at our website Lets support our ageing population!

George Coxon

Comment date
04 September 2014
I confess to being a little bamboozled by the last comment from 'meet and greet' but perhaps an explanation might be forthcoming ?!!
Again I simply want to add my words of thanks to Prof Oliver who I met for the first time at the recent 'Innovations for Older People' Kings Fund event in June.
I am so glad that the responses to his sensible and balanced words have been positive in favour of retaining choice of care for older old people including residential 24/7 support - the 'take the worries away' principle as I see it and often describe to those older folk and families with ambivalence and uncertainties about care homes, mostly based on the persistent adverse media attention ( I won't condone poor care of course but the 'Anita' Factor - the so called care staff who was at the centre of the Old Deanery scandal featured on Panorama) is the extreme outlier in a care system that is based on being kind and helping people laugh and have fun in the main. By and large we are talking about the over 80 yr old population - in Devon we have over 50,000 in this age group - many living full, active, meaningful and sociable lives at home with family and friends ensuring they remain in good health and spirits but many more lonely, anxious and enduring difficulties not met by the system and who we are seeing being admitted to hospital too easily too often, staying too long there, not doing well there and too many dying in hospital due to problems of onward care restrictions . I am a strong advocate for the KPOOH principle Prof Oliver alludes to - keeping people out of hospital but do agree that we must make sure the right to treatment and access to all NHS care is provided to all those needing it - I do say ( with a tin hat on however) that no one with dementia should EVER die in hospital and we still are struggling to address the 50/50 chance of a hospital death that most of us can look forward to unless we see a sizable shift in current policy, philosophy and commissioning practices. sorry about a long reply but this issue is very important and needs an elevated status as we head for the general election in May 2015 not long away

Judith Hodge

Comment date
02 September 2014
Thank you Professor Oliver for your thoughtful response. As a carer of a 93 year old mother who just this week went into a local nursing home, I am eternally grateful for the this wonderful facility being available. For the past 10 years I have worked hard to keep my mother in her own home by making adaptations to her home and bringing in every-increasing levels of care and support as each year and hospital admission took its toll on her ageing body; all at her and our own cost I would add! No support from the state apart from her state pension. But ultimately, her knees and her failing physical strength because of heart failure, would no longer allow her to transfer to chair or the toilet without the help of two carers. For the past 6 months she had enjoyed the care of two wonderful women who came to live with her on a fortnightly rotational basis, on call 24 hours a day and very often through the night and as this was happening at least once every hour, it would have meant employing 2 carers for 24 hour round the clock. Her financial reserves (nor the size of the bungalow) wouldn't accommodate this option, so I took the really difficult step to move her to Highfields, our local care home where she is receiving excellent care and attention. It's not what she ultimately wanted - I'm sure we'd all prefer to go peacefully in our own beds when the time comes- but no amount of new technology would have been able to change things for my mother. We need care homes for the future and we need good training and support and pay for those who work in them; this is where our investment should be for the future.

David Oliver

Visiting Fellow,
The King's Fund
Comment date
02 September 2014
Thanks to all who have commented and contributed to a lively discussion. Despite nuances of opinion, i feel we are all on pretty much the same page. More than anything else, i wrote this because day in day out, week in week out i deal with real life service users and i know that for some of them whatever we offer in terms of support at home, things have gone far too far for remaining there to be viable and that often they or their families actively and gladly choose long term care. Are we about listening to what people say they want and respecting their choice or telling them what they want "surely you dont want to be in a care home, surely everyone would rather stay at home"

Also because we have to deal with the world as it currently is and not some utopian fantasy of adequately funded social care, housing, carer support etc before we start closing all our care home capacity.

I realise that live in nursing care can be a great thing and can make the difference that helps someone stay out of long term care, but we also have to be realistic that it doesnt come cheap and that few people can afford it, let alone secure NHS continuing care funding to pay for it. Also that whilst 78% of all people over 75 may say on surveys that they would hypothetically rather receive care in their own home this is very different when people actually have become frail, dependent or demented or when carers can no longer cope - you dont know how you will react till you are in that position or your parent or spouse is. (And of course its often the carers calling the shots because the older person being placed no longer has mental capacity regarding their ongoing care needs)

I also agree broadly with the "keep people out of hospital and get them out of hospital view" but with the important rider that older people with complex needs have a statutory entitlement to the full facilities of the general hospital and should not be denied those - its about having access to high quality acute care when you need it and then leaving as soon as you don't. Though i re-iterate, i see dozens of older people who actually want to stay in (or whose families want them to stay in) and are hard to persuade to leave. They often feel safer in a bed based facility with staff around. This extends to end of life care. People may have a better experience of end of life care in their own home or in hospices on surveys but in my practice, i always offer people the choice to be supported at home to die and work with first rate palliative care teams to achieve this but many people make a positive choice to stay on the ward where they feel safe and supported

Finally, though i do feel we underfund social care including long term care and that through an accident of history we have managed to turn dementia and frailty into social rather than health problems and therefore means test for them, there are still many care homes which do deliver person centred care, good environments, caring staff and more choice and control than might be available with a poorly funded care package at home. They arent all Panorama specials

However, care home residents tend to be "out of sight, out of mind" for health services - the residents are entitled to the full range of primary., community and mental health services and as the BGS "failing the frail" report outlined, they arent consistently getting them. This is a shameful situation which we should rectify. There are three times as many people in care homes at any time as there are in general hospital beds. No integrated locality plan is adequate without factoring in their needs


Susan Haworth

policy worker,
Comment date
01 September 2014
The NHS Chief Executive should have been clearer on his vision for the future. There is so much to commend in this excellent article. Perhaps it is large homes he wishes to see close and see more smaller units emerge. A sensible economic model is needed though. I recently called on my CCG to specifically spend more of the budget on elderly people (anti QALYs) and have done the same in LA spending surveys. I look forward to England importing the best models that are found in Europe you have described.

Lisa Wimborne

Head of PR & External Affairs,
Jewish Care
Comment date
01 September 2014
We at Jewish Care are continually disappointed with the implication from some policy and decision makes like Simon Stevens that care homes are last resort places that only have a place in history. I wonder if Simon would continue to preach an end to care homes if he spent time with Harry who lives in one of our 12 care homes. When his wife passed away some 18 months ago he chose to move into a care home not wanting to spend his later years living alone relying on his children to support him. Talk to him and he will tell you how the home has given him a new lease in life, he has friends, he is well cared for and is enjoying every day. We accept that not all of our residents are like Harry. Many didn’t have a choice. Ill health, discharge from hospital, no other options have forced them to leave their home and move into residential care. When you meet some of these people you will realise that even with new technologies, more social support and the possibility of family help a stay at home could be incredible difficult and almost certainly won’t provide them with the quality of care they can receive in a good care home.

Older people should be able to choose how they want to live, spend their days and who provides them with care and what that looks like. If care homes don’t exist within the next 50 years it should be only because people are choosing alternative care be it in their home or alternative options like a move to a supported living environment not because policy and decision makers have decided it’s time to close the shutters on our care homes.

Martin Green

Chief Executive,
Care England
Comment date
01 September 2014
These are wise comments from Prof David Olive and they come from somebody who has the credibility and experience to understand the issue. I find Simon Stevens comments totally bizarre and at variance with his supposed desire to reform the health service and make it more fit for purpose in the 21st-century.

Residential care services provide excellent care for people who have many very challenging health issues and if they were not in a residential care setting, they would have to be supported in hospitals.

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