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Care homes: coming out of the shadows?

In Untold stories Alan Bennett draws on the experiences of his mother, who had dementia, to capture his unease that ‘something is not right around care homes for older people’. He wrote ‘a home is not a home but neither is it a hospital nor yet a hotel. What do we call the old people who live (and die) there… residents? Patients? Inmates? No word really suits. And who looks after them? Nurses? Not really since very few of them are qualified. As Mam pointed out early in her residency: “They’re not nurses these. Most of them are just lasses”.’

Ten years on, these persisting ambiguities were reflected, albeit in less inimitable prose, at our recent conference on the role of care homes in delivering integrated care. David Oliver has described elsewhere why care homes are hugely important to the prospects for our health and social care system – their places outnumber hospital beds by about three to one. So it was not surprising that the event attracted an enthusiastic and engaged audience of more than 200 people, many drawn from the care home sector. The diverse range of presentations and case studies will no doubt elicit different reactions and views. I was struck by three strong themes that emerged.

The first is the transformation in the level of acuity and complexity of the needs that most care homes for older people now face. Dementia, frailty and complex co-morbidity are now the norm among people in care homes. Yet the way their care is commissioned, organised, delivered and funded has not kept pace. One example is the difficulty of ensuring residents can receive good health care – aimed at essential needs such as podiatry, continence and good primary care management of long-term health conditions. ‘The NHS does not stop at the door of the care home’, Andrea Sutcliffe, the Care Quality Commission’s Chief Inspector of Social Care, reminded us.

The second theme is workforce recruitment and retention. A big worry is the growing difficulty of recruiting qualified nurses from a limited pool with stiff competition from hospitals that offer higher status, esteem and career opportunities. The ability of providers to pay little more than the national minimum wage for mainstream care staff also acts as a huge brake on career progression and opportunities to improve the quality of care.

The third theme that stood out is there is much good practice to celebrate, as Professor Julienne Meyer pointed out to much applause. The conference heard many examples of innovation in areas such as reablement, supporting nursing in care homes, and housing-based models of care. NHS England’s programme of vanguard sites for developing enhanced health in care homes excited great interest, though it is pause for thought that this was the first time many attendees had heard about it.

All of these issues were brought into sharp focus in the final panel discussion involving people who are at the coalface of residential care, directly managing or owning care homes. What was top of their wish lists for good joined-up care? They wanted care homes to be accorded the same respect and esteem as other valued public services such as hospitals; to have more staff to respond properly to the growing needs of residents; to be able to pay staff more than the minimum wage; and to have better access to quality – adding services such as physiotherapy.

That none of these ‘asks’ seems unreasonable reflects how long care homes have operated in the shadows of public and political awareness, with policy attention focused on reactions to service failure rather than the promotion of good care.

Historically, care homes have received but a fraction of the time and resources bestowed on other parts of the health and care system. Many, but not all, of the sector’s woes are fuelled by under-funding, of which low staff pay is one symptom. The NHS’s £30 billion funding shortfall has created much noise, but the sound of silence surrounds the deeper funding malaise in social care. And though the NHS five year forward view vanguard programme is a welcome starting point to treating care homes as part of the whole system of care, a much more ambitious programme will be required to reflect the scale and diversity of the care home sector. Care England and the National Care Forum have each offered a clear prospectus for improvement and reform. If our event is any guide, care homes are eager for change. But what about everyone else?