A National Care Home Service

Clive Bowman,
December 2018


The green paper still deferred,
advisors doubtless once more considering well-thumbed evidence supported by
economic expertise in the attempt to find the elusive politically acceptable
solution that is sustainable financially.

These can be predicted to distill
down to who pays for what rather than a broader view of what epidemiologically is
needed and practically achievable both in terms of available staff and funds.

It is widely agreed that the
burgeoning demand overrunning health and care services is principally older
people that are variously frail, burdened by multiple illnesses and
disabilities, dominated by neuro-degenerative disease a population we have
previously described as progressively dwindling.

Whilst Health Services span
prevention, diagnosis and treatment and social care may be summarised as
seeking to meet locality needs of housing, support and the promotion of safety,
independence and personal autonomy. This population simply don’t neatly fit
either established health or social care paradigms; even though responsibility
for care is somewhat arbitrarily allocated to one or the other or both without
a complete mandate. Current initiatives integrating health and care
organisations in partnership are promoted to establish greater capability,
though even the most optimistic are unlikely to be heard suggesting this
approach of its own will create a sustainable service let alone reconcile the
fundamental differences in eligibility and funding.

This is an expanding population;
their escalating dependence means inevitably care home admission becomes a
commonplace when personal dependency and care needs are unpredictable and
around the clock. Whilst people’s medical conditions may be beyond specific symptomatic
treatment, frailty and vulnerability to inter-current illness are best suited to
a proactive rather than reactive approach to maintain the best possible sense
of well-being.  It’s important to
distinguish the population we are describing from the terminally ill, they are
not actively dying with a typical 1-3-year life expectancy on admission to a
care home. 

So perhaps a focus on care homes
may be in order after all the greatest resource is presently committed to the
funding of care homes. In broad terms 80% of adult social care budgets and cumulatively
a significant health service resources are committed to care home residents
whether through assessment, funding or support from CCG’s or hospital outreach.
The reality is that no existing organisation has a national coherent approach
for the leadership of care homes and their staff. The fact that for every NHS
bed there are some 4 care home beds and thousands of professional nurses
employed relatively dis-articulated from the NHS. The NHS beds inappropriately occupied
by frail older people waiting for care because of difficulty accessing funding further
emphasises the lack of fitness of the present approach.

There remains much confusion
regarding the responsibilities for care home outcomes. They are the sum product
of care home provider, their staff, commissioners and various aspects of
primary and secondary care with assurance largely dependent on regulation. There
is no compelling argument that that more of the same in terms of services and
support will achieve any more than more of the same.

A radical rethink could address
and define the population in a way that could make confidence in care homes
rise as well as quality and clarity of funding, components of this may include:

A new national approach to care
home residents, the homes in which they live and the staff who provide care.

recognition that the assessment of need is largely based on health not
socioeconomic needs means standardised approaches to assessment of needs, care
leadership, planning and monitored delivery.

A rethinking of the purpose and
distribution of skills

A new publically funded national
body could employ professional nurses and social workers. So the assessment of
needs, commissioning, care planning, monitoring and coordination of specialist
support would be vested within a public body that has a joined-up approach.
This would recognise and develop the professional role for nurses and/or social
workers working in groups. These professional groups would be subject to clear
standards both in respect of their practice, governance and would provide care
home residents and care homes with a clear single point of contact.

Care staff would be employed by
care providers, their training through an apprenticeship type system and
technical capability through licensed recognition. The progression of their
capability should provide clear career opportunities such as conversion to
professional nurse.

Medical support would be much more
planned than reactive and be undertaken in collaboration with the responsible
nurse. This may be achieved by General Practitioners with an interest and
special responsibility for care home residents or specialist doctors, typically
those with limited time availability under the aegis of a medical director or specialist
consultant employed by the national organisation

Care Homes would be licensed and
benefit from:

National policies and procedures and
standardised electronic care records enabling consistent approaches to processes
and seamless linkage to the national body facilitating improved governance and
some much-needed consistency in the provision of the essential elements of care

Care Home providers would be
responsible for facilities, hotel services and the employment of care staff.

To an extent the approach proposed
reduces the risks for providers and combined with intelligent commissioning
would make new long-term investment in care homes attractive.

The management of the care home market
has been somewhat boom and bust with little
effective market management other than by fee incentive or restriction.
Licences may be linked so that providers seeking a specific licence may find it
linked to a license providing facilities in underprovided areas

Care Homes may be incentivised via
the financial recognition achievement of training achievements and resident and
relative satisfaction.


A national body should through a
planned period of change relieve local authorities of their funding
responsibilities for care homes

CCGs existing responsibilities for
commissioning care home places and monitoring provision would be vested in the
national body

Budgets from both health and social
care would be acquired by the National body

Professional nurses and/or social
workers employed by the national body would have responsibility for assessment
of need and development of the funded care plan.

Accommodation hotel services and
personal care would be means tested

The new clarity over funding
liabilities for individuals and standardised assessment processes would provide
a basis for insurers to offer viable new products that might enable further
innovation funding.


The personal care leadership by a
professional who is independent of the home provision together with standardised
policies and procedures and care plans and delivery managed through ECR would facilitate
person centred governance through stratified analysis.

Monitoring the standard of a provider’s
care home(s) and staff would require a much-simplified inspection system

Crucially, resident, family and
staff perspectives on care and the care home could be gathered through simple questionnaires
and solicited feedback.

d.     The new national body could provide local, regional and national
reports on trends and standards that would allow government to financially plan
in a way that has proved difficult to date.

The proposals outlined draw on a
range of international approaches observed as well as consideration of the UK’s
established practices. The formulation is an added division of the Department alongside
the NHS and Social Care. The approach would mean that whether in hospital or in
the community once an agreed decision had been made that a care home would be
the most appropriate solution they would be referred and managed through not
just the transfer to care but the establishment of a clear care plan. 

Consolidation into one newly purposive
organisation should bring efficiencies and clarity over the role of care
homes.  The NHS is becoming unwieldy and
this proposal should enable it to concentrate on its core responsibilities.
Similar considerations hold for local authorities where housing and care in the
community are shaped greatly by socio-economic factors as well as
geography. Care Homes are frequently run
by national organisations whether they are charitable or for profit, whatever
their corporate structure standardised approaches offer efficiency and
alignment with national approaches. This national approach would circumvent the
current often local issues over funding bringing consistency to eligibility. These
approaches would allow providers to focus on care delivery rather than
reinventing what should be standard policies and procedures.

Historical requirements for nurses
in care homes
are poorly evidenced or purposed and certainly unsustainable, the
role we propose reflects both the scarcity of availability now and the evolving
career expectations of graduate nurses. It potentially clarifies their
alignment to resident needs rather than a presence dictated by regulatory
compliance. Clearly our proposals require development of healthcare assistants to
an accredited skilled practitioner. Evidence from established programmes (e.g.
Evercare) of managed care suggest that a professional nurse can be a case
manager and coordinator for some 60-90 care home residents. At the very least
freeing nursing care homes from the necessity of perhaps 4 or 5 WTE nurses per
30-40 beds. The enhancement of the terms and conditions for care assistants is
similarly likely to prove a positive development for both recruitment, career
progression and retention.

The journey from where we are now
to realising the proposals would require an unparalleled change programme over several
years necessitating broad political agreement and commitment. The prize is
confidence of older people; their families understanding the care home is centred
on providing the best possible quality of service for their relatives whose life has been reframed by progressively
dwindling conditions.

Published by Residential Forum

The Residential Forum is to promote the achievement of high standards of care and support for children and adults living in residential care and nursing homes, supported housing, residential schools and colleges, hospices and hostels. It contributes to improving the quality of service to the public. Members of the Forum are people of standing and experience drawn from the public, private and voluntary sectors, as well as some who can speak for service users and carers.

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