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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