Crisis in care homes: how can we improve standards in the context of austerity?

Liz Lloyd, Professor of Social Gerontology in the Centre for Health and Social Care discusses the factors behind deteriorating standards in care homes.

There is a crisis in British care homes, arising not merely from bad behaviour by staff members but from the economic and political context of the social care market.

There are currently close to half a million individual places (‘beds’) used by around 4% of the population aged 65+ and 17% of people aged 85+. Statistics vary somewhat, according to what is being measured, but we can be certain that although the number of older people in the population have risen, a smaller proportion of them live in a care home, that they are older on average when they first enter the home and have more complex, long-term illness that require more skilled assistance.

Older people are also increasingly likely to pay at least a part of their care home fees. According to Laing and Buisson’s 2012-2013 Care of Elderly People UK Market Survey, some 43.4% of older residents in the independent sector paid the full costs and a further 14% received partial council support and topped up their fees. The majority therefore still rely wholly or partially on public resources but this proportion is falling.

Running parallel to these changes is the rise in private ownership of care homes and payment of fees. Over three decades, the proportion of places in local authority run care homes in the UK has dropped while the proportion in the private, for-profit, sector has risen so it now has a 75% share of all places. The voluntary, not-for-profit, sector share has been more stable but is falling slightly. The current crisis involves increasing levels of provider failure and exit from the care home market. Several big providers are deeply in debt, raising fears of a major collapse like that of Southern Cross in 2008. Owners point to rising costs as a consequence of the introduction of the national living wage and falling profits because fees paid by local councils have not risen in line with increased costs. The consequences for providers is an unsustainable business model.

The consequences for older people who need residential care are evident in delayed discharges and hospital waiting lists, a point illustrated perfectly in the case of Mrs Iris Sibley, who remained in the Bristol Royal Infirmary for six months while her family sought a care home place. For residents and their families the insecurity associated with provider failure means added anxiety and stress. Add to this the associated problem of worsening standards, which the Care Quality Commission fears will grow in the absence of major reform. Mrs Sibley’s son described how one place she was offered was so bad that he ‘wouldn’t put a sick dog in there’.

Not all older residents experience the same thing, of course. According to Norman Lamb MP, former Health Minister, the market has come to benefit older people with enough money to pay for their own care while disadvantaging those who rely on state support. Care homes where all or most residents pay their own fees are more secure than those that rely mostly on the local authority payments and are more able to absorb the additional cost of the national living wage. We might question why anyone would argue against a decent level of pay for the people who care for us when we are sick and disabled, but the dominant theme in social care for older people is that it should be as cheap as possible – hence, high numbers of migrant workers in the care home sector.
In fact, debates about care homes focus overwhelmingly on keeping costs down and agreeing who should pay. Should it be individuals (during their lifetime or after their deaths), their families or the public in general? Health and social care are frequently portrayed as unaffordable in the context of the ageing of the baby boomer generation.

I declare an interest here, being a baby boomer, but take issue with such a simplistic argument. Demographic trends have an impact on demand for care, for sure, but there is evidently a wider set of factors at play. Indeed it is arguable that demographic trends provide a useful rationale for cuts to public spending that would be made anyway. Policy-makers have placed themselves in a bind as cuts to public spending have impacted on private sector profits, proposals to recoup the cost of care from older people’s estates after death are met with outrage in the press, as are stories like that of Mrs Sibley.

Evidence on what makes a care home a good place to live and work is abundant. Higher standards of care are usually reflected in higher levels of staffing, more skilled workers and a culture of person-centred care that attends to the whole range of an individual’s needs, not merely to their basic physical requirements. A culture of ‘person-centred care’ promotes a sense of belonging and security and enables residents to maximise their capacities, enjoy new experiences and take risks. Care homes are likely to remain a part of the care system, despite their reputation, so we need to focus on standards. A sizeable number of us who will live in a care home at some stage of our lives, or have a close relative who does. But more importantly, care homes are inextricably linked with other parts of the care system so it is in our interests to think about standards in care homes as a policy issue that affects us all.

European citizens who are disabled: what about them?

Val Williams, from the Norah Fry Centre for Disability Studies comments on the implications for disabled people of Brexit 

Val Williams

Val Williams

The shock of the BREXIT decision is not just an issue for disabled people who now have to live in a smaller, diminished country. It also has implications for disabled people across Europe, and particularly perhaps those with intellectual (learning) disabilities.

But what about our partnership with disabled people across Europe?  In 1973, when we joined the EU, disabled people in this country did not commonly have a ‘voice’, nor were they taken seriously as a political force. At that time, I had just started working with young people with learning disabilities, within a largely segregated system, which had only just started to recognise their right to an education. Since then, disabled people have themselves taken a lead, and are rightly proud of their achievements within the disabled people’s movement – for instance, over institutional closure, and the ideas of the social model and inclusion. During the 1990s and 2000s I took part in various EU Social Fund projects, where our experiences as UK partners was not just to speak English, but to offer progressive and supportive ideas, while learning alongside other member states. The European Disability Forum has posted the following since the BREXIT decision, which reminds us of some fundamental values:

We strongly believe that a common EU human rights agenda is better achieved together. The tone of the UK campaign, which was characterised by a divisive public debate on migration, reminds us of what is at stake and what we need to fight for, within a strong EU: common values of non-discrimination, human rights and freedom of movement.

Will UK ideas on disability now be discredited?  What of the gains in thinking on independent living?  Institutional closure across parts of Eastern Europe?  Turning specifically to the position of people with intellectual (learning) disabilities, during the latter part of the 1990s, People First groups in the UK set out to link with their European counterparts, and to set up a ‘Europe People First’, genuinely led by people with intellectual disabilities themselves. The movement in Europe has always been within the framework of families’ organisations, but the umbrella organisation ‘Inclusion Europe’ now has a self-advocacy section. This is a European Platform of Self-Advocates, which is composed of member organisations across Europe.  Nothing is perfect, but compared with the 1990s, there has been progress towards an understanding that Europeans with intellectual disabilities have a right to live like others, to self-organise and to get support to have a voice.  And importantly, UK self-advocates have always been strong in demanding these things, and in making a common cause across Europe.

In the UK we are still aware of the many steps that need to be taken towards including people with intellectual disabilities in the wider disabled people’s movement. There is also already a European network, not just through the Disability Forum and an EU umbrella organisation for disabled people’s organisations (DPOs) across Europe.  In the light of the BREXIT decision, they have themselves reached out to disabled people in the UK, as mentioned above in their moving statement on the need to continue the struggle for human rights together across Europe.

Not least, accessible information is key to a meaningful conversation with all disabled people, including those with intellectual disabilities – see the progress made for instance by public and Government organisations in communicating with all. One out of many examples would be Public Health England’s easy English guide to avoiding Flu. UK efforts to work for equality in information, in voice and within public debates and research are now widely recognised across Europe, with a recent publication in Austria on Inclusive Research for instance, written both in English and in German.

As with all disabled people, the position of people with intellectual disabilities has moved on. In the 1990s I was able to visit both Germany and France, on some visits accompanying people with intellectual disabilities. Both countries had strong segregated (albeit meaningful) policies on employment – people lived within a ‘network’ of services, particularly in Germany, and in both countries, they were to some extent treated (and addressed) as children, unlikely to have anything useful to say or to contribute to the debates.  Compare that with the debates in those countries today. On June 26th, the Frankfurter Allgemeine newspaper in Germany led its Society section with a discussion of sexual rights of disabled people with autism. The headline is that people with intellectual disabilities would have aspired merely to be ‘satt und sauber’ (fully fed and clean) until now; the argument is that they can also aspire to enjoy life!   That would not have happened before the progress made by bringing disabled people together, through the European Union. The UK voice is important, and the connection between disabled people across Europe needs to continue, so that disability rights remains a common cause.

Val Williams is Reader in Disability Policy and Practice, Head of the Norah Fry Centre for Disability Studies, and Executive Editor of Disability and Society.

 

Co-production and change for disabled people

VW

Val Williams discusses research around support for disabled people

Social practices can be enabling or disabling

Imagine you are the woman in this picture, a patient going to your doctor to talk about symptoms you’ve been having. The patient here is a disabled woman who is sitting directly in front of the doctor, with her personal assistant taking notes for her, out of the doctor’s direct line of sight. This might seem a trivial thing, but going to the doctor might not always work so well for some disabled people. The doctor might talk exclusively to their carer or to a family member, instead of engaging directly with them. Or of course, they may not have a third party to help them remember what has been said. All these things are important when you want to get good health care, and they may require just a few changes in the way things are routinely done. Kerrie Ford, in the picture above, set up this scene back in 2010 as part of a training pack arising from a research study about support practices, in which she was a researcher.

Although disabled people might traditionally be seen as part of the problem, they can find their own solutions. For instance, in our research about support practices, disabled people suggested and developed ways of getting their messages across, to shift practices and to enable them to challenge inequalities. Disabled people have their own movement, which is now a global one, and have banded together to re-define some of the problems that confront them, and to redress the power imbalances that they face when professionals, practitioners and medical authorities dictate what is best for them. The most pressing issues are to find better ways to understand how to change disabling practices, while we listen to and work with disabled people themselves.  Our new study is aiming to do just that.  ‘Tackling disabling practices: co-production and change’ has been funded by the Economic and Social Science Research Council (ESRC) which I lead at the Norah Fry Research Centre at Bristol. Disabled people’s organisations, represented by ‘Disability Rights UK’ (DRUK) are joining with us to explore the ways in which we can understand and theorise change, in a way that really makes a difference to disabled people’s lives, on their own terms.

Disabled people of all ages experience inequalities in society, in every part of their lives. There is strong evidence that disabled people are often amongst the poorest, as the recent poverty survey carried out at the University of Bristol has revealed and that they face abusive or inadequate support practices in everyday settings (Antaki et al., 2007).  Further Pauline Heslop and her team found that people with intellectual disabilities were dying prematurely, with men dying 13 years earlier than non-disabled men, and women some 20 years earlier. Health care is simply not adapting to meet the needs of all. In the UK, most of these problems are the subject of intensive investigation, resulting in legal and policy reform. For instance, in 2011, a Panorama television documentary exposed the abusive treatment being perpetrated against people with intellectual disabilities in an ‘assessment and treatment unit’.  Following this, that particular hospital was closed down and a Government Concordat was signed in 2012, which pledged a reduction in hospital placements for people with intellectual disabilities and ‘the closure of large-scale inpatient services’. Support was also provided for commissioners and practitioners in the form of workforce development, guidance and toolkits to ensure better practice. However, in 2014, a further report acknowledged that:

For decades people have argued for change and described what good care looks like, and how we can commission it….. but the problem remains. Why?  (Bubb, 2014: 17)

The conclusion in the 2014 report is that we do know ‘what good looks like’, and indeed we also know how to get there, but that it is simply too easy to ‘do the wrong thing’.  Yet again, a further series of recommendations ensued, which invoke the rights of disabled people and their families to better community services, along with a system for holding local authorities and other agencies to account.

Why then are some practices so difficult to shift?  Our new project starts in April 2015, and aims to interrogate the turn towards ‘practice’ in social science, in order to see what it can offer to our understanding of what is going on in practice and how the goings-on could be malleable, could be shifted, and maybe made more productive. We do not want to demonize those who are there to provide health and social care support. Indeed, we know that all of us could be inadvertently discriminating against disabled people by the way things are set up – even in our own Higher Education institutions. One of the strands of research in our new project is being led by Sheila Trahar in the Graduate School of Education, to explore the experience of disabled students, from their own point of view, while Sue Porter will lead on research about the experience of disabled academics. Other strands will be led by Beth Tarleton, building on the ‘Working Together with Parents Network’ working with Nadine Tilbury, Danielle Turney and Professor Elaine Farmer, to analyse how to achieve better support for parents with intellectual disabilities; by Pauline Heslop, who examines reasonable adjustments in healthcare provision; and by Val Williams and David Abbott, who build on the approach to micro-analysis of interaction (Williams, 2011) collecting videos and recordings of what goes on between support workers and disabled people. All our research work in this project is about how we can make a difference, and how we can theorise those changes in a way that is useful for social science and for disabled people themselves. Therefore Bernd Sass at Disability Rights UK is central to everything, and in the research strand based at DRUK will be taking forward the notion of ‘user-driven commissioning’ to see how disabled people’s own actions can have an effect on changing local authority and health care structures.

We are particularly pleased that our ESRC project is based on several partnerships. Not only is the DRUK a key partner, but the project will also include Professors Charles Antaki from Loughborough University, Celia Kitzinger from the University of York, Chris Hatton from the University of Lancaster, Alan Roulstone from Leeds, Dr Stanley Blue from Manchester, and Sue Turner from the National Development Team for Inclusion (NDTI), as well as Professor Andrew Sturdy from our own Department of Management at Bristol.  We are working with experts across the disciplines, who have different ways of conceiving of practice – from the high level policy and strategic decisions made by government, to the micro-detail of front-line support offered to disabled people. Instead of pointing fingers of blame at particular individuals or institutions, we want to find out more about how to understand social practices, so that we can enable them to change.

Val Williams is Reader in Disability, Policy and Practice in the Norah Fry Centre the School for Policy Studies

References

Antaki, C, Finlay, W.M.L., Jingree, T and Walton, C.(2007) “The staff are your friends”: conflicts between institutional discourse and practice. British Journal of Social Psychology, 46, 1-18.

Bubb, S. (2014) Winterbourne View – Time for Change. http://www.england.nhs.uk/wp-content/uploads/2014/11/transforming-commissioning-services.pdf

Heslop, P. et al. (2013) Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD): final report. http://www.bris.ac.uk/cipold/

Williams, V. (2011) Disability & Discourse: analysing inclusive conversations with people with intellectual disabilities. Wiley-Blackwell.