On Thursday last along with a good number of folks I attended the first meeting of what was called the National Care Home Contract Redesign. Sounds dull and boring but it was both an interesting and critical meeting.

The National Care Home Contract (NCHC) is now over 15 years of age and has had one or two significant changes in that time, but most partners believe it is time for a radical re-envisioning of its core elements. It is a Contract often mentioned in social care circles in Scotland and is frequently held up by others across the UK as a model of best practice. However, at 100 pages plus I doubt many have read it from cover to cover!

What is it? It is a Contract between local authorities and providers of residential and nursing care home support services across Scotland. It grew out of a time when there was a challenging dispute and disagreement between care homes and both local and central government. The dispute centred around what was a reasonable fee rate to pay care homes for the care support of some of our most important citizens. Whether charitable or private in their business models care homes at the time argued that what they were being offered was insufficient to deliver dignified care. Out of this dispute and the very real risk of a ‘care strike’ the NCHC arose.

The National Contract is unique in the UK in that as well as setting standards of quality and expectations of what a service should deliver it also determines through an annual national negotiation what the rate of fees should be. Over the years a ‘cost model’ has been partially developed and partly agreed which sets costs for various lines including what staff should be paid, what cost payments should be for commodities such as food and energy, what should be allocated to resident activity and what level of return an organisation whether charitable or not should expect for providing both the premises and building and also the services delivered in that building. And a lot more besides.

Unlike in the rest of the United Kingdom the majority of care homes in Scotland are run by small, often family businesses, with an economy of scale unlike that of the larger groups which dominate the scene in England. Scotland also has the challenges of a very diverse population as well as rural and remote geography.

Over the years the gap between what some consider to be a reasonable level of fee charge and the National Rate has widened. Some have argued that the failure of public authorities to pay adequate fees has led to those who pay for the care home place themselves – known as self-funders – to effectively be subsidising the shortfall from the State. Others have pointed to the disparity between local authority care home provision (at a rough average of £1,300 a week) compared to what those same authorities offer independent (private or charitable care homes) at just under £800 a week. Independent analysis has recently suggested that the average weekly fee rate should be between £1200-1400. Now whilst mention of finance can be off-putting to ignore the realities of cost and resource causes huge damage to the ability of any organisation or system to be able to deliver the services that they want, to invest in improvements and to develop and innovate.

So all this is up for re-design and for completion in a relatively short period of time. The process last Thursday was inclusive of a wide range of interests from residents’ groups, advocacy organisations, care home providers, the trade unions, commissioners, government at local and national level and so many more. It is critical that such inclusiveness occurs to enable the end vision to be one shared by the majority.

One of the exercises we have all been charged to consider is what is our vision of the care home of the future? What is it that we aspire to? This is central and important because there is little point in looking at and agreeing on the detail of a contract if the service offered or sought is not what is needed and wanted. As colleagues have researched and written at length care homes today are very very different from what they were ten years ago, and I suspect in ten years’ time they will be unrecognisable from what we see today.

Some of those who read this piece will come from a position which states that there is no room for what they call ‘institutionalised’ care. I respect the strength of those views but disagree with them, nonetheless. Care homes at their best are not institutions in the sense that personal autonomy and individual control are removed, where in a Victorian sense, choice is withdrawn, regimental behaviour expected, and routine becomes the god of occurrence. Care homes, as I know so many of them, are places where in community with others an individual is able to flourish and reach their potential; where the care and support of persons who cannot be supported in their own home ( and this is true for so many) is delivered in a manner that respects their autonomy, values their dignity, puts the individual at the centre, and at the same time keeps someone safe from harm whilst enabling them to grow until they die. Care homes as I know them offer sensitive dementia care and enhanced quality palliative and end of life care.

I do believe that we will always need places – hopefully in the hearts of our communities – where those who cannot be supported to live independently and those who choose not to live alone – are supported in a way that values their personhood and enshrines the best of who we are as communities of women and men.

Regular readers of this blog can probably guess what some of the characteristics of my vision might be, but as a starter for 10 here are some:

1. Care homes must be places where people are able to flourish – where we better achieve the balance between the individual and collective living. Inevitably one of the challenges of living in community with others is that we cannot always get what we want, we have to engage in the rub of compromise and association. Equally one of the strengths is a solidarity of mutual support and concern, with less likelihood of loneliness or isolation. Sadly, the pandemic and especially the response to it as instructed by ‘experts’ to care homes has diminished the significance of the individual as blanket rules and assumptions have held sway. It led to the unacceptable long-term exclusion of family and friend. That is the antithesis of what a good care home should be – a place where it is possible to be yourself even in community with others. Where the care and support are not off the shelf but designed to fit your uniqueness and individual characteristics. It should be person-led rather than what we often experience in other settings.

It is this emphasis on enabling an individual to have their own self valued that witnesses the truth that many who have faced discrimination in their lives attest to namely that they find acceptance, welcome and identity in a care home setting.

Care homes are also places which challenge the widely held assumption that its residents and older persons in specific have nothing to say, contribute or offer to the common weal – nothing could be further from the truth. They are and can be places where individuals grow, create and flourish until the end of their days. They are not so much God’s waiting room, as the anteroom to a fulfilled and fulfilling life.

2. Care homes must be places with two-way doors. The physical shutting away of care homes during the pandemic has led to an even greater exclusion of them from the heart and hearth of community. They should and must always be places with an openness to the community and vice-versa. They are not prisons or shrines but rather should be the beating heart of all community. This necessitates them being local, proximate and in the middle of our living, where the flow in and out is reflective of the rhythmic river of community.

Perhaps that is best evident in those care homes which have worked so hard to create dynamic inter- and multi-generational living and sharing. Early learning centres and nurseries in the same place as a nursing home bring the generations together in lessons of insight, shared respect and knowledge which benefits the whole of our society. We need to do a lot more to foster such connection and inter-relatedness so that older age ceases to be feared and stops being a ghetto of exclusion.

3. The pandemic has highlighted that care homes at their best are places which put not just the resident and her or his needs at the centre, but which have a critical role for family, friends and others. In the future regardless of legislation such as Annes Law there needs to be a much greater focus on seeing family as co-carers and supporters in the lives of those they love. At the same time there needs to be an enhanced role and value given to volunteers and their resourcing so that we acknowledge that for too many people there is no family or friend to visit. For those who want to and need to there must be opportunity for relationship and togetherness.

Care homes must be places where people are enabled to receive appropriate clinical and social care. A lot is being done at the moment to redress the imbalance evident before the pandemic – and during it – where the health care needs of those who live in our care homes had become a lesser priority and focus. Just because you move into a care home does not mean that your rights to access the same level and quality of clinical care and treatment should be diminished. Equally true – and this will be a real challenge – we need to make sure we do not turn our care homes in the shadow of Covid and its tragedies into miniature clinical settings. A care home is first and foremost a place where someone lives, loves, cries and laughs in community with others – it is only secondarily a location where many of the residents have significant clinical and medical needs.

There is a very real prospect that if we get the balance between social care and health care delivery right in a care home then we will mirror the best of what integrated health and care services could and should be – a seamless pathway of experience with consistency of quality social care and a continuum of high-level clinical care.

As part of all this care homes given the particular needs of their population have the prospect of building on the excellent specialist skills that already exist in the sector in terms of the care and support of people living with all stages of dementia, and in the delivery of focussed excellent palliative and end of life care. This of course does not happen without the skill and support of a workforce trained and nurtured in such clinical and social care specialisms

5. As part of my vision for the future I know that care homes must cease to be the sector which every year holds out a begging bowl to appeal for resource – often when other priorities and sectors have spent already limited finances. As part of the work already under way all parties have to seriously examine whether or not the monies we spend on the care and support of our most important citizens, and on those who work with and for them, and the organisations who deliver care – is at all adequate. I believe it shamefully to be wholly inadequate and reflective of an ageist view which considers maintaining people in older age worthy of expense but holds back from enabling older people to exercise the fullness of the rights held by others. I would cite the failure to allow care home residents to have personal budgets under Self-directed Support legislation as an example of such a bias.

We cannot continue to deliver care which is affordable when we all know that whether it is a care home or homecare service, we are not delivering care which is necessary and needed, dignified and rights based.

All of this involves our society having a serious, inclusive, and grown-up debate about how with a declining working age population and thankfully more and more people living in to older age we are going to pay for all this. In Scotland we are simply not having those conversations at a sufficiently strategic and senior political level. What we are doing is engaging in Elastoplast initiatives which stop the bleeding but do not heal the wound and which store up problems because they are not thought through but reactive.

6. The future of care homes is intimately linked to the future of the social care workforce. Unless we are able to attract the right men and women to work in the sector, unless we collectively as a whole society start to value the work of social care, to create real and meaningful career pathways, then all the edifices of our imaginations and aspirations will but be built on sand.

We need to adequately reward and value the workforce in our care homes in a way that values them as individuals intrinsic to contributing to maintaining the very fabric of our society – we currently are far from that treatment.

Associated with such value is the need for all involved in health and social care to properly bestow respect and professional regard on the care home workforce. This is palpably not the case now and for some time, be that the diminishing of social care nursing or the lack of appreciation of domestic and catering staff in a care home. All have a valuable role. All are skilled, dedicated professionals who deserve less scrutiny and more support, less oversight and more autonomy.

This all of course demands resource not least to enable the continuous professional development and training of these critical frontline staff. Excellence and quality do not come about on a budget approach to care.

7. It is also very clear to me that if we are to have a national model for care homes, in whatever form that takes, then such a model needs to be flexible and appreciative of the very diverse and different nation we live in. What works in Stranraer may or may not work in Stornoway, but we should not presume it does. The last few months have seen a saddening demise of some high quality rural and remote care home services simply because they are no longer sustainable or are unable to attract staff to work in them. Care has to be local and approximate. People need to be supported in the places they belong to and have connection with. Yet we are in danger of people having to travel dozens of miles in order to visit residents and family because there is no local care home. That is wholly unacceptable. We urgently need to do something to rescue the truth that care needs to be local and that care homes should be in communities proximate to our people not detached from memory and association.

Part of this involves the need to recognise that significant financial investment is required to ensure that care homes are of a right size to enable people to possess a sense of home and space. It is clear the current estate is not addressing the needs of all.

7. Already today but even more so into the future care homes will be required to be locations which use cutting age, person-led and citizen-controlled technology. It will be critical that the use of technology is not – as sadly is being seen elsewhere in some parts of the world – premised on the basis of saving money and reducing workforce demand, but rather that technology serves to enhance the personal and human rather than limiting or replacing both. Data systems for instance should be able to evidence practical benefit which values individual privacy and autonomy, and which is as less burdensome as possible.
8. Anyone who has visited a care home in the years before the pandemic will know that they are vibrant, active and lively environments, with loads of activities and celebrations. These are places where creativity is discovered or renewed, refreshed or illuminated. Care homes are places where the artistic and poetic, the musical and the dynamic of touch and sense, of the arts and creativity in general has the potential to be enhanced and celebrated. But yet again this needs to prioritised and resourced not as an occasional extra but as fundamental to the creation of an environment which is all about living rather than surviving, all about discovery rather than maintenance.
9. Lastly but certainly not least care homes must be places where human rights are central and core – not as something taught and as a tick box exercise but as a way of being in relationship with others, especially in times of challenge and hardness, which is so automatic and natural that it infuses the air of the place. It is indeed important that every worker in a care home is trained in human rights but equally as important that everyone in the space knows what human rights mean in application especially in situations of dispute and disagreement. The nature of living in community is learning to live with divergence and difference and human rights-based approaches are intrinsic and fundamental to enabling that to happen.

But of course, all visions are illusory unless they are worked for which Simon Armitage the Poet Laureate puts so well.

A Vision

The future was a beautiful place, once.
Remember the full-blown balsa-wood town
on public display in the Civic Hall.
The ring-bound sketches, artists’ impressions,

blueprints of smoked glass and tubular steel,
board-game suburbs, modes of transportation
like fairground rides or executive toys.
Cities like dreams, cantilevered by light.

And people like us at the bottle-bank
next to the cycle-path, or dog-walking
over tended strips of fuzzy-felt grass,
or model drivers, motoring home in

electric cars, or after the late show –
strolling the boulevard. They were the plans,
all underwritten in the neat left-hand
of architects – a true, legible script.

I pulled that future out of the north wind
at the landfill site, stamped with today’s date,
riding the air with other such futures,
all unlived in and now fully extinct.

From:  Tyrannosaurus Rex Versus The Corduroy Kid

Copyright ©:  Simon Armitage

 

Last Updated on 23rd April 2022 by donald.macaskill