Currently there are more than 400,000 people living in care homes in the United Kingdom. That’s around three times the number of hospital beds. The umbrella term ‘care homes’ covers a very diverse range of places, including those classified as nursing or residential, whether specially designed and staffed for people with dementia, mental health needs or complex physical or learning disabilities.
Although these facilities are sometimes used for temporary respite, rehabilitation or end-of-life care, the term ‘homes’ is crucial. They are places where people live. And although average length of stay in a nursing home is only 15 months, it’s important to make what is often a person’s last home as comfortable as possible. It’s increasingly rare for anyone to enter a care home now without very high levels of frailty, complex health care needs, dementia or disability. The fact that the number of care home places has reduced even during a period of rapid population ageing and significant reduction in hospital bed capacity shows the pressure that care providers must be under.
Of course, there is always more we could do to keep people in their own homes for longer and avoid or postpone the need for residential or nursing home care. This includes a greater focus on prevention, an adequately staffed and funded primary care workforce able to work in different ways, more emphasis on age-friendly housing and support for carers, better integrated health and care systems, use of technology, and support for end-of-life care. More capacity in intermediate care rehabilitation and in home-based social care support for older people and their carers could reduce care home use.
But as we have highlighted in recent reports on social care and district nursing services, there are major gaps in all those areas which means for the foreseeable future there is unlikely to be a reduction in need for care homes. The growing focus on this group of citizens and the staff and services who support them – not just by The King’s Fund but many other organisations too – is timely and overdue. Our second conference devoted to improving care for people in residential and nursing homes will take place in December, bringing together experts in the field to showcase innovative practice and discuss the challenges.
As we highlighted in our recent report, the social care funding crisis is exacerbating the pressures on all parts of the health and care system. Care homes are struggling to maintain a viable business model, to recruit and retain a workforce; often competing with the local NHS. Post-Brexit there is uncertainty around the status of thousands of EU workers in the care sector. There are also growing concerns about over-reliance on self-funding residents, whose financial contribution cannot be matched by constrained local authority social care budgets. NHS continuing care funding decisions are also increasingly contested.
We also need new solutions to meet the complex health needs of residents, including people living with frailty and those who are towards the end of their lives. General practitioners have expressed major reservations about their ability to continue with the current levels of provision for care home residents, given their own workforce and funding crises. In particular, too many care home residents are admitted to hospital acutely – often close to the end of life, and then staying too long or worsening during hospitalisation. Integrated approaches are now being implemented and evaluated as a potential solution, not only in the vanguards but also in many other health economies. These include Walsall Clinical Commissioning Group and Ashford and St Peter’s Hospitals NHS Foundation Trust, both of which will be presenting their transformative programmes at the conference.
Most of all, care home residents have some of the highest needs for both health and personal care in our society. Their carers are often older people and can be considerably distressed – and sometimes also relieved – by their loved one’s move into care. How we look after residents and their families is a barometer for care and compassion in society as a whole, and for our attempts to make services more integrated, co-ordinated and person-centred.
To make these aims a reality we need practical solutions, deliverable even within our current pressurised health and care system. But when we think about solutions we must focus on the residents whose health and wellbeing we are trying to improve. We should never lose sight of that in the face of our focus on systems, processes, money and targets.