Thread by @Trisha_the_doc

How did we end up in this situation, with the care homes so vulnerable and unsupported?

It’s worth remembering some of the history here. I started my training in Geriatric Medicine back in 1992 and there were some pretty major changes happening around then...

I’m going to quote some stuff from @TheKingsFund - I hope I get it right, but very happy to be challenged...

There was a revolution in service provision as a result of the 1989 White Paper, Caring for People, (enacted in the 1990 Community Care Act) which declared that local authorities should be the brokers and care managers of social care, but not necessarily the direct providers.

This led to a huge growth in the independent sector, which now provides the majority of state-funded residential care and 69 per cent of adult domiciliary care contact hours, compared with just 2 per cent in 1992.

Private nursing homes were springing up all over the place in the early 1990s to meet this new need. Or, viewed more in economic terms, to corner this new market.

The old NHS “long term care” facilities were shutting, and as I started to get my first lessons in NHS management, I learned that there was to be “resource transfer” from the NHS, to Social Care, to help fund people in these new care homes, and also (ideally) in their own homes.

Of course, both sides felt hard done by. The NHS needed to keep some money from closure of long term hospitals, to provide for people who might need to return for acute care... and Social Care Depts found themselves trying to do a “loaves & fishes” job to make the ££ go round.

Both were right of course. People did return for acute care (there was a junior Registrar who presented this at a @GeriSoc meeting in 1995...!who could that be?), but the growth in the need for social care was huge, and increasing...

It was a recipe for trouble.

Of course, this wasn’t a black and white issue... some of the old NHS facilities were pretty ghastly! And the idea of supporting more people at home or in more homely environments was a good one.

Many lovely care homes developed, often with small numbers of residents. The rules about everyone having modern facilities and en suite bathrooms came later, so a lot of these homes really did feel like proper homes.

Also on the positive side, many more people were supported at home with “packages of care”. The care sector blossomed and matured from the days of the “home help” as the carers started to do more and more personal care for their charges.

Not everyone was happy though. A proportion of the population was now being asked to fund their own care. Those with enough ££ in the bank were now expected to meet the costs of the care home they were moving to. Unlike the “free at point of need” NHS hospitals.

Many of those people were the very same ones who had bought their council houses in the Thatcher years, not so long before. They were shocked that they were now considered to have assets, which would be taken into account to pay for care. (That hadn’t been part of their plans..)

Lots of political aspects to this thread, but the end result was that a whole lot of people were in new institutions, funded variously on a private basis, or from government via social care. These places were now completely* divorced from NHS care & oversight.

*some exceptions.

Many of the smaller care homes have of course since closed, and ironically, the ones remaining are often large institutions with remarkably similar numbers to those pre 1990s NHS hospitals...

I’ve become aware over the last few years of some wonderful examples of care homes and how well they look after their residents. Just have a glimpse at the work of @CoxonGeorge @weejenhen and others to see heartwarming stories of a great quality of care home living.

Likewise, medical care has moved on from the random inputs of several different GPs into each home on an ad hoc basis (another Registrar project in 1996!) and most care homes have a relationship with a local GP practice. Again some great examples eg @KeebleM & @DavidAttwood12.

However the basic premise remains that the ££ for care in the nursing homes comes from a mix of private & social care funds, channelled to the private provider of that care home.

It’s tricky to provide high quality care on the council funds alone, so most have a mix of incomes.

The provider has to meet a whole lot of high standards these days, set by Care Commission & others, pay a decent wage to their employees, and yet also set a competitive rate for their “customers”.
That’s a really hard ask.

It’s only recently in my experience (last decade or so) that the NHS & councils have really woken up to the fact that we need to help the care homes who are struggling.

They are now as much part of the system as the old hospitals used to be. Lose them & the system collapses...

So we have support teams, and inreach teams and all sorts of “special measures” teams... but the homes are still (mostly) privately run. So there’s a divide. Who provides dressings for people with sounds etc? It’s blurred at the residential/nursing care home edges...

And all the while, we’re arguing politically in the background over how to fund this system... there are so many options, but none of them are cheap.

The care homes struggle on, outside the NHS, but now with people so much more dependent than the ones from the 1980s hospitals.

Until now, in 2020, when the system is under more strain than ever before...

And then on top of that, arrives the COVID19 virus. The nightmare begins.

It’s late now though and time for bed. We could talk endlessly about all this, and I haven’t even touched on the issues faced by those with learning disabilities and who are in care from a younger age.

Something needs to change though after this chapter in history. But what?

Wouldn’t it be nice if we could create a better tomorrow out of all this?

People are now starting to think about care homes, who is in them and how they aren’t just amorphous older people. They are mums, dads, aunties, uncles, grandparents and friends. Rightly we are grieving.

In grief, there is denial, then anger, blame and regret.

Let’s work through these and when we get to the harder stages of resolution and acceptance, let’s try to look at care homes in a new way. As real homes, looked after by colleagues caring for our older citizens.

Let’s work together...