Less than the sum of the parts
It is the view of the RNHA, and the view of many other organisations and commentators, that the care system for older people in this country is not working as effectively as it could be or should be. For varied and complex reasons, the sum of the parts is less than the parts themselves. Health and social services do not seem to be working well enough together. Joint planning between the statutory and independent sectors is erratic and, in many places, non-existent.
The biggest losers of all are the very people whom the system is designed to help. Some may not receive the care they need at all. Some may find the commencement of their care delayed. Some may have to pay for care out of their own pockets when it should be the responsibility of the State to do so. Some may receive inappropriate care or care in an appropriate setting.
The ‘crunch’ question
Putting sectional interests aside, we ask: what can all the stakeholders in the care system do in order to improve the quality of service provided to older people? Among those stakeholders we would include Government, the NHS, local authorities and care providers in the independent and voluntary sectors. Older people themselves and their families are key stakeholders too, as receivers of the services which, collectively, the different agencies involved seek to provide.
Not public v private, not institutions v community care
This is not, and should not be seen as, a private versus public debate as far as the provision of services is concerned. This is not, and should not be seen as, an institutional versus community care debate. To meet the enormous level of need in a country of nearly 60 million people, there is and will continue to be a need for a multiplicity of services provided by all sectors, including domiciliary care, day care in the community, rapid response services, residential care, nursing home care, intermediate care and hospital-based care.
Meeting a spectrum of needs, providing choice to individuals
Whilst we, as an association, represent registered nursing homes, we readily acknowledge the inter-dependence of all the different forms of care provided and the importance of maintaining a full spectrum of services in order to offer choice to service users and meet their widely varying needs and circumstances.
Meeting people’s needs, whilst giving them a choice about how those needs are met, must surely be the goal we should all be striving to achieve. Individuals are individuals. They should not be channelled into a pre-ordained route simply because the ‘professionals’ think they know what is best. For many, domiciliary care packages may be the right solution. For some, the need for round the clock nursing care is such that a residential solution is required. There is no universally right model of care for every patient. Flexibility is essential.
We make this point early on because we are aware of an occasionally expressed point of view which pre-supposes that all residential care is inherently a bad thing and that all community care is inherently a good thing. We believe that such a viewpoint is inherently wrong. Community care is absolutely right for some people but by no means for all.
Getting it right
What we should all be doing – in nursing homes, residential care homes, NHS hospitals and social services – is to ensure that the right package is provided to the right person in the right place for the right cost. If we can achieve that, the system will be serving a useful purpose. At present, the system is often disjointed and dysfunctional.
Higher levels of dependency
It is no exaggeration to say that registered nursing homes today care for thousands of patients who, twenty years ago, would almost certainly have been cared for in the long-stay or even acute wards of hospitals throughout the country. The modern nursing home is looking after more highly dependent patients with multiple nursing needs than its predecessor from the 1960s, 1970s and early 1980s. Indeed, the levels of dependency now found generally in nursing homes are such that it is difficult to see how such patients could be effectively be cared for in their own homes, even if sophisticated and well funded domiciliary support packages were available.
A ‘first choice’ in many cases
There is also ample evidence to show that nursing homes are a ‘first choice’ for many patients. Whilst, theoretically, most of us would instinctively prefer the notion of being able to live at home throughout our old age, the onset of serious health conditions can and does change that perception in many cases. For many patients, the possibility of remaining at home is untenable because their needs are too great and too complex for safe and effective care to be provided to them at home. For some patients, the feelings of ‘security’ and companionship which they feel in a well run nursing home counter-balance their natural desire to remain in their own home for as long as possible.
Research on future population trends and levels of need
We believe that one of the fairest and most objective assessments of likely future needs has been undertaken by the Personal Social Services Research Unit (PSSRU) in its report entitled Demand for long-term care for older people in England to 2031. The following points are of particular relevance:
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The Government Actuary Department projects that the number of people in England over 65 and over will rise from 7.8 million on 1996 to 12.4 million in 2031, an increase of 60 per cent. The number of very elderly people (aged 85 and over) will rise even more rapidly, by 88 per cent, from 0.9 million in 1996 to 1.7 million in 2031.
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According to the PSSRU’s model, the numbers of people with the greatest level of dependency will rise by 63 per cent between 1996 and 2031.
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As far as the number of people likely to require care in institutions in thirty years’ time, the PSSRU has made projections based on possible increases and decreases in dependency rates. From these different models, it concludes that there could be anything between a 16 per cent and 119 per cent rise in the number of people who will require care in a residential setting.
Realistic assumptions
Making projections about future needs is a difficult and complex exercise. Mindful of the many variables, the PSSRU has taken account of past trends and the possibility that, thirty years from now, people may be living longer and healthier lives. However, it has not foreseen a scenario in which there is likely to be a diminution in the requirement for institutional care.
We make the above points because we believe that future policy-making on long-term care should recognise that, for the foreseeable future, registered nursing homes will continue to make an important contribution to the overall care system of this country. It would be unrealistic to pre-suppose a state of affairs in which every older person with long-term care needs and a high level of dependency could be supported in their own home.
Getting the balance right
If it is acknowledged that registered nursing homes already play, and will continue to play, a significant role in caring for older people, it follows that they, like other vital parts of the care sector, require the necessary input of resources to maintain and improve standards as well as to continue in existence. If either now or in ten years’ time the number of nursing home places is insufficient, there will be ‘knock on’ effects in the rest of the care system and, ultimately, patients may fail to receive the level and type of care they need.
Whether we are talking about NHS hospitals, domiciliary services provided by Social Services and Primary Care Trusts, or registered nursing homes operated by independent and voluntary organisations, they all need appropriate levels of funding and they all need to operate in ways that are mutually supportive. The care system is like a complex piece of machinery with many interconnecting parts. If one part is not functioning as it should, the other parts are affected and the machine loses efficiency and fails to do what it is supposed to do.
Symptoms of the current malaise
Unfortunately, the system is not currently operating in the most efficient and effective way. Symptoms of this malaise include:
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continued blocking of NHS acute hospital beds in many parts of the country as a result of delayed discharges of older patients into more appropriate types of care;
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inability of social services departments to fund placements in registered nursing homes and residential care homes as and when those placements are required;
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closures of nursing homes, with consequent loss of bed capacity.
Recent Parliamentary debates on the care system (notably the debate which took place in the House of Commons on 16th January 2002) have highlighted the different views about the causes of these problems and the solutions. There are also arguments about the precise figures in terms of beds lost or delayed hospital discharges.
Local variations
In the debate of 16th January 2002, Members of Parliament recounted their varied experiences of the care system within their own constituencies. This suggested wide local variations reflecting particular local circumstances. It is not surprising that the situation in Stockton on Tees should not necessarily replicate the situation in Eastbourne, or that the situation in Birmingham may differ from that which pertains in Wakefield.
The ‘care domino effect’
If we momentarily set aside the seemingly contentious issue of figures and statistics, it would be fair to say there is an interconnection between delayed hospital discharges, bed blocking, cancelled elective operations, social services funding and nursing home closures. This could be described as the care domino effect.
The lack of resources in social services to fund long-term placements in nursing homes and residential care homes inevitably means some hospital patients will occupy beds for longer than they would otherwise have done. Sometimes, their discharge is delayed for a few days. Sometimes, the delay lasts for a few weeks. Sometimes, the weeks stretch into months and, in extreme cases, into more than just a few months.
The impact on individual patients
Delayed discharges mean that beds which would otherwise have been occupied by patients admitted for diagnostic investigations and elective surgical procedures are no longer available for that purpose. This not only causes distress to those patients who have to wait longer. It also causes a potential logjam in the waiting list, with patients at the very end of the line having to wait longer. It further puts back the prospect of significantly reducing the longest waiting times, as outlined in the NHS Plan.
For the older patients whose discharge is delayed, there is the frustration of having to remain in a hospital ward, which is the least conducive environment to rehabilitation and recovery from an acute phase of illness. Patients who remain on hospital wards are exposed to increased risk of picking up infections, often potentially dangerous ones. They are also exposed to the noise and general hustle and bustle of the typical hospital ward, which at best may be sub-divided into bays of six beds or, in the worst cases, may still be laid out in the old-fashioned ‘Nightingale’ style with 16 or so beds along one wall and 16 or so facing them along the other.
Delayed discharges may be due to:
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delays in patients’ needs being assessed by social services, which subsequently slows down the discharge process;
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insufficient money being available at any one time to fund the number of places required in long-term care, leaving patients to wait in hospital until their place can be funded;
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insufficient places being available because of loss of bed capacity through closures.
The ‘lose-lose’ situation
The consequence is a ‘lose-lose’ situation for everyone involved. Hospitals are prevented from admitting more patients more quickly and attract negative press coverage for bed blocking and long waiting lists. Nursing homes have no financial stability and, in some cases, are forced to close. Social services are unable to ensure appropriate care for vulnerable people. Patients are innocent victims of a system that is failing them.
The scale of the problem
How big a problem is it? We cite not from our own statistics but from official figures which have been published by the Department of Health or have been given by Ministers to the House of Commons:
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On any one day, approximately 6,000 NHS hospital beds are blocked as a result of delayed discharges (We presume that this figure varies from day to day and week to week and that the position also varies between regions and between individual hospitals).
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The cost to the NHS of blocked beds is calculated to be £720 million a year (These resources could presumably have been used to treat more patients more quickly if the beds had not been blocked by patients who did not need them).
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Total gross expenditure on the NHS increased by 8 per cent in the last financial year. The budget for social services expenditure went up by only 1.4 per cent.
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According to DoH figures, between 1998 and 2001 the number of general nursing homes in England fell by 13 per cent from 4,822 to 4,172 and the number of general nursing home beds fell by nearly 22,000 from 165,836 to 144,068. These are the net figures, which take account of both homes closed and new homes opened during the period in question.
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There are regional variations in the speed of closure of nursing homes in the recent past. According to DoH figures, the fastest decline has taken place in the North Thames region where, between 1999 and 2001, the number of general nursing homes fell by 21 per cent from 369 to 292, with a loss of nearly 1,350 beds from 12,199 to 10,850.
At the nub of this multi-faceted problem is the fact that many social services departments are not apparently able to fund sufficient places to meet the level of need. The additional resources which, in the winter of 2001/02, the Government earmarked for social services specifically to tackle bed blocking are likely to prove a case of ‘too little, too late’. The picture across the country may be varied, but there are signs that the bed blocking problem is still significant in many parts of the country and that nursing home closures are continuing at or around the same rate as before.
A national problem, a local problem, or both?
This raises a fundamental point: why is there a shortfall of cash both for residential placements and for domiciliary packages? Does the problem lie at a national level? Is the amount of funding provided by central government to local government inadequate to cover the costs of providing care? Is it a local problem? Are local authorities not adequately managing the resources they have at their disposal? And whether the source of the problem lies with Government expenditure-setting or local authority resource management – or both – what needs to be done about it?
We believe these are issues worthy of particularly close scrutiny because they lie at the heart of problem of delayed discharges, bed blocking and patients not receiving the care they have been assessed for.
Unrealistic fee levels for State-funded patients
There is a second ‘financial’ issue to address: the level of fees paid by social services departments for nursing home care to be provided to patients who qualify for State assistance. Overall, around two thirds of patients in nursing homes are supported financially by the State, with payments being made on their behalf through social services.
Lower fees for nursing care in the independent sector than social care in the public sector
Independent and voluntary sector nursing homes are expected to provide 24-hour care to highly dependent patients with substantial nursing needs for a figure that is well below what social services themselves spend in order to provide only ‘social’ care to residents in local authority-run homes.
On average, a nursing home receives about £340 per week (less than £50 a day) per patient. Out of this sum, it has to ensure the presence of qualified nursing staff around the clock, pay the wages of all the full-time and part-time staff employed on the premises, provide accommodation in accordance with required standards and meet all the other running costs of a health facility open 365 days of the year, including food, heat, lighting, equipment and furniture. Bank loans incurred in purchasing, constructing, converting or improving properties also have to be serviced.
On average, a local authority-run residential care homes costs around £400 to £500 per patient per week. The average cost of a long-stay hospital bed is around £1,300 per patient per week. From these figures it can be seen that nursing home care is not the ‘expensive’ option. The margins of running a nursing home are very tight.
Independent research evidence on costs
As long ago as 1998, a report commissioned from Laing & Buisson by the Rowntree Foundation said that, at 1997/98 prices, the cost of providing nursing home care would be £368 per week on the assumption of a minimum wage of £4 per week. Four years later, with a minimum wage of £4.10 per week, the average payments made for State-funded nursing home patients are well below £368. Currently, they average out at £343.
The image of ‘profiteers’ seeking to make huge financial gains from care is not and has never been fair or accurate. Running a nursing home requires a high level of commitment by owners, managers and staff to caring for older people and others with long-term nursing needs. Most nursing homes do well to break even or make a small profit which needs to be ploughed back into making improvements to their facilities. Many nursing homes, as the DoH figures show, do not break even and are obliged to close.
Independent body to determine realistic fee level
It is the RNHA’s view that, right now, the average weekly fee level for a publicly funded nursing home place should be closer to £420. In some parts of the country with higher costs, the figure needs to be significantly higher than that.
We believe there is a wealth of evidence to support our estimate, which we would be happy to submit to an independent body for analysis. What the country needs is a broad consensus on a fee level which is realistic, fair and capable of meeting the cost of providing good quality care to patients. What we need, in effect, is a new deal for the care of older people and others with nursing needs.
Costs likely to rise faster than general inflation
Nursing homes’ costs are likely to rise over the next five years faster than the general rate of inflation. This is because, between now and 2007, they have to meet over 200 new care standards introduced by the Government in an attempt to achieve greater consistency across the country. Meeting those standards will inevitably have cost implications for many nursing homes. In some cases, major structural alterations will be required. Some nursing homes will end up with fewer places available, leaving them with a reduced weekly income but the same or even higher overheads.
Against this background, it is imperative that nursing homes should be able to plan improvements and changes in the knowledge that the fee levels paid for publicly funded patients will fully meet the costs involved.
Nursing homes need is a firm 5-year financial plan, agreed with the Government, local authorities and the NHS, which will ensure that they can deliver what is expected of them.
Whether you are an RNHA member, a patient in a nursing home, a relative, a health care professional, a nursing home employee, or a member of the public with an interest in nursing care, we should like to hear your views on the way ahead.
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