Is there a Future for Residential Care?
Outlines of three presentations at a Leveson seminar on Wednesday 13 June 2007
1: Residential Care: A Positive Choice
Roger Davies, Chief Executive of MHA
2: The relatives’ and residents’ perspective
Gillian Dalley, Relatives & Residents Association
3: Independence, Wellbeing and Hobson’s Choice?
Senior Policy Adviser (Health & Social Care) Help the Aged
resources from the Leveson Centre
Residential Care: A Positive Choice
Roger Davies, Chief Executive of MHA
- Very pleased to be with you today.
- Roger Davies, Chief Executive of MHA, charity serving older people – 65 years no retirement planned – residential care, sheltered housing and community.
- Residential care has got a future and I think Britain needs it.
- from central government, mixed and negative messages
- from LAs, fees for Care Homes insufficient and now providing much larger care packages for more dependent people to stay at home
- from the media, almost exclusively negative stories
- from extra care housing, for rent or buy, which provides 24 hour care and independent living accommodation.
- from poor Care Homes, who let down their residents, themselves and the rest of the sector.
But residential care, delivered well, is a service people want – and it should form part of the options available to older people. In MHA, we feel passionately that Britain should be establishing a range of services which are person-centred and promote physical and spiritual well-being.
Residential care should be one of the options from which people choose.
Residential Care – A Positive Choice
So what are the benefits for older people:
- companionship and sense of community – relationships with staff, volunteers, other residents, as well as family and friends.
- personal care available 24 hours per day
- meals: no worries about shopping or cooking
- no worries about property/garden
- no worries about security
- ideally, should not have to move again
We have had so many people who have a new lease of life when coming into Homes:
- can enjoy life more/fewer burdens/opportunities to do things/better family relations without stress
But this does not just happen. As a provider, we need to work hard at it.
- Care Home providers need to consider their services from the point of view of older people and their relatives.
- Is it the service you would buy for your loved one? or yourself? If not, why not? and what can you do about it.
- Managers are key – people with the right skills and experience and the right attitude
- Staff: it is so important for MHA that staff understand and share the values and we invest in this.
Other action points are about:
- routines flexible to suit residents, not the company or staff
- food and meals
- personal and group opportunities for activities which are fulfilling
Some of MHA’s action points are building-related. Narrow corridors, small rooms, bathrooms which look like punishment rooms need to be changed. We are investing and borrowing money to improve our buildings, access to gardens and to be able to care for older people with higher care needs.
We are modernising some Homes, replacing some Homes – sometimes need to work with other providers to find solutions.
Wanless Report 2005 seems to me to be the best guide to future need. The headline-grabbing figures are:
in 20 years time:
- 53% more older people needing care
- 54% more older people higher dependency.
Quite challenging for Britain.
It is sensible for Government to be planning to take up some of this extra demand with home care and housing – based solutions, not just more Care Homes.
Two solutions being promoted:
- stay living in your own home: may be a good option but not necessarily - misleading question – we’d all say yes until our health, mental or physical, meant our quality of life deteriorated – high care packages, fewer people
- housing with care: good model it should grow significantly both LA and private – need more land, the bricks and mortar/capital cost is higher, the service charge is higher – popular in LA now ‘cos the cost is split with central Government . . . . higher spec service, fewer people.
Not substitutes for residential care but attractive options. To cope with the additional number of people and high dependency and to offer choices and options, we need all these services.
If providers make Care Homes attractive and positive places to live, and home care and housing with care are developed further, is there a future? Will individuals or the State want to pay for the service? Is good quality care affordable?
MHA’s typical prices:
|Residential dementia care
Most older people can afford only if
- Selling their own Home
- Home-ownership is rising and more people will be able to pay privately.
- How to compare with other options?
There is quite a lot of misunderstanding throughout the sector when seeking to compare Care Homes with other models. In MHA, we analyse weekly fees into component parts: e.g.
A Care Home is a very efficient way to deliver high value care packages to dependent older people and offers good value for money.
State-funding and Top-ups
- There are LAs who still pay less than £300 per week for residential care. Thankfully not many – but there is an average shortfall of say £70 per week.
- If resident is LA supported or runs out of money, providers ask families to make up the difference.
- Difficult for Home Manager – must make ‘reasonable’ decision in awkward circumstances.
This is not charging excessively. This is part of the sharing of cost between State and individual – but unofficial - LA funding does not facilitate good quality care in a new building.
It might be ok in relatively cheap capital asset/one that cannot or will not be replaced but that does not allow development for the future.
MHA have top-ups for around one third of State funded residents.
Our strategy is to work with LAs who recognise a fair price for good care – maybe contract.
As they get older, nobody wants:
- to lose independence and control
- to be patronised
- to have poor food not of one’s choice
- to have nothing to do
the criticisms of traditional care homes
equally, nobody wants:
- to be lonely or depressed
- to struggle with daily living
- to worry about money, house maintenance, security
the experience of many living in their own homes.
We must all work out the best contribution we can make to the lives of older people.
I expect to see:
- more older people in housing with care, with care packages in their own Home and in Care Homes
- a higher proportion of older people in Care Homes having high dependency – nursing and/or dementia
- the State paying almost exclusively for Care Home places for people with dementia and nursing needs
- a higher proportion of older people with care packages in their own Home/housing with care
- State-funded older people being denied the option of residential care
- a higher proportion of self-funders in residential care
- more local authorities offering differential pricing to reward providers for quality initiatives (or according to their * rating)
- more enlightened local authorities contracting with selected providers for the quality of services they want – including Care Homes
I would like to see:
- more clarity and openness about the sharing of the cost of care between the state and individuals. The present system soaks up a lot of LA staff time in assessments and leaves the issue of shortfall for personal contribution in the air.
- breaking down the artificial barriers, e.g:
between residential and nursing/dementia homes
between Care Homes and housing with care
Principle should be that care should be provided to the individual wherever
they live. Older people should not have to be moved.
I started working in this sector nearly ten years ago. One of the issues I remember debated internally and externally was ‘is there a future for residential care?’
Those of you who have been around for longer, you will know it has been asked for decades.
There are lots of challenges. But lots of opportunities too.
We need to be bold and self-confident to take forward care for older people for future generations.
The relatives’ and residents’ perspective
Gillian Dalley Relatives & Residents Association
- Currently, around 14,000 care homes for older people
- 375,000 residents in care homes
- Around 4% of people aged 85+ live in a care home
- 1 in 4 chance of going into a care home once over the age of 85
(likelihood increases with age)
Why residential care?
(1) Frailty and ageing
- Increasing longevity (30,000 centenarians predicted by 2031)
- Compression of morbidity? Will healthy ageing really happen?
- Increasing frailty – numbers of 85+ will rise by 80% by mid-century
- Levels of dementia rising (at least 75% of care home residents already have some level of dementia – likely to rise)
- The need for residential care will remain – and increase to cope with these trends
(2) Communities of interest
Remember our tradition of:
- Benevolent societies etc (e.g. musicians, gardeners, soldiers, religious)
- Almshouses (e.g. in c18th, home for 5% elderly widows)
- Residential hotels (Bevan’s ‘sunshine hotels’)
- Retirement villages (current rapid growth)
- Care homes (the choice agenda???)
Mixed emotions about a loved one going into care:
- Guilt: letting a loved one down, moving on
- Worry: will she settle in?
will she be unhappy, lonely, isolated?
will she be safe?
can we afford it?
- Relief: at last she is getting the care she needs
at last she’s safe
at last the burden of caring is lifted
- Satisfaction: her quality of life is improved
her health is maintained (and even restored)
Benefits of residential care
- Social interaction, activity
- Quality of life
- Access to services
For self funders:
- Isolation if no kith or kin – who is your champion, who will act for you?
Will you get lost in the system?
- Vulnerability – outside the Human Rights Act
- No monitoring/care review by local authority
- Risk of poor access to local healthcare services
For Local Authority supported residents:
- Is quality of care/life compromised by low fees?
- Are relatives pressurised to pay top-ups?
- Does the local authority intrude in family decisions?
- Risk of poor care, neglect abuse
- Need for high quality staff and management
- Need for close scrutiny
- Regular and frequent inspection
- Need for involvement of outside community
- Relatives’ involvement
- Volunteer involvement
- Combat the stigma associated with residential care
- Champion residential care
- Recognise its benefits and its proper place in the range of options available to older people
In answer to the question – Yes, there is a future for residential care!
Independence, Wellbeing and Hobson’s Choice?
Senior Policy Adviser (Health & Social Care) Help the Aged
Current Policy Context
- Our health. Our care, our say
- Who will pay for long-term care?
- My Home Life
- In Control
Key question: Why are people so critical of residential care?
What do we really mean by Dignity?
- Human Dignity is inviolable; it must be respected and protected
- Everyone has the right to respect for his or her physical and mental integrity
- ‘Do as you would be done by’
- Access to economic, social, recreational and cultural activities
“Only a minimum of ordinary human empathy, to appreciate her situation and to understand that to avoid unnecessary hardship – she has to be treated differently from other people because her situation is significantly different”
Implement the Human Rights Act
- Need to embrace this key piece of legislation
- It should underpin all our practice and behaviour
- Apply it to health and social care
- It is our legal duty to do so
Who will pay for long-term care?
- Caring Choices: is a nationwide initiative to help shape future policy on long-term care for older people.
- A series of events round the country to stimulate a public debate on what long-term care will look like in the future and how it should be paid for
The three big questions
- Who should pay for personal care?
- How do we encourage people to contribute to care costs?
- How do we support the provision of informal care?
At present, just over half of all care costs in England are paid for by the state, concentrated on those who have the fewest resources in terms of income and capital. These costs include nursing care, personal care and, for those in care homes, the cost of accommodation, sometimes called ‘hotel costs’. About 60 per cent of the total cost of personal care in England is paid for by the state. Participants will be asked to discuss whether the state should pay for some or all of an individual’s personal care costs, regardless of income and assets, as well as how any increase in eligibility could be funded.
in Control stands for...
- in Control believes people who need support can control their own lives and be full citizens.
- in Control is helping to change the system of social care. The problem with the system now is that many people are not in charge of their own support or life. in Control is making a new system - people know what they are entitled to and can control their money as much as they want.
In Control Principles
- Right to independent living
- Right to an individual budget
- Right to self-determination
- Right to accessibility
- Right to flexible funding
- Accountability Principle
- Capacity Principle
In Control's mission is:
to change the organisation of social care in England so that people who need support can take more control of their own lives and fulfil their role as full citizens: the complete transformation of social care into a system of Self-Directed Support.
My Home Life: Quality of Life in Care Homes
- 3 year programme to enhance the care experience
- Literature review
- Understanding the small things that make a difference to a resident’s life….to
- Changing our perception of care homes
Quality of life
“Being able to live comfortably and walk about… That’s what it [quality of life] means to me anyway.”
“I was always very keen on the garden, and they’ve given me a room where I can get out easily and do bits and pieces.”
“I‘ve always been very sociable, and its nice to know that the other people here are too, and we’re encouraged to mix”
Working to help residents maintain their identity
“It is important for people to realise that what may seem a small matter to the management of the organisation is of great importance to some people living in a place. Everyone has different standards and tastes, but knowing the individual and their ways is helpful”
Creating community within care homes
“When I was not well one day, a lot of residents came up to see me as they missed me and visited me. It has helped. It is the other residents and staff together – everybody. I have more friends here.”
What’s the ‘problem’ with residential care?
- History of institutions
- Fear of old age, frailty and death
- Lack of funding
- Not in tune
How can we breathe new life into the sector and help to increase real choice?
- Culture change
- Tackle attitudes
- Learn from others and
- Engage, engage, engage!
by the Leveson Centre
resources from the Leveson Centre