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Quality care services are not just about more money


I recently read an article in the Times that reaffirmed my view that quality care services are not just about money. The article referred to a woman who had spent weeks looking at places for her father, who has had dementia for 12 years and now needs specialised nursing. In her search she came across the average, the diabolical and the inspirational, all within a few miles of his town.

Surprisingly, money didn’t seem to have the greatest effect on quality. The most expensive felt like a prison with the dementia inmates locked in, staff vacancies, grey sloppy food, a regimented timetable and dark, echoing corridors.

Elements of a good care home

The most impressive was the cheapest not-for-profit charity home where even the handyman stopped for a chat while putting up a curtain, there were packets of digestives on tables, the vicar popped by, the Brownies sang a song, and there were signs on each door with instructions such as: “Mrs. Jones likes her tea lukewarm, her hand shaken not squeezed and a cuddle at night”. The staff were motivated, kind and chatty. Everyone wandered freely, couples were welcomed, their bedrooms were covered in cards and photos, the garden was full of benches and bird feeders and when they demanded liver and bacon it was provided instead of pizza. But it has a long waiting list.

Difficulties facing social care services

We all know that financially it’s tough to run a care home. At least 148 businesses became insolvent in 2017, up 83 per cent on the previous year; 2,492 residents were evicted with nowhere to go because their homes closed, up 39 per cent on the previous year. This is particularly harsh for those with dementia who need familiarity. They are also often the ones being charged the highest rates. According to a report this week by the Alzheimer’s Society, providers can add as much as 40 per cent to the bill for dementia patients. About 850,000 people have dementia in Britain and pay an average of £100,000 for their end of life care. Increasingly, families cannot find anywhere that will take them, so they end up on hospital wards.

There are also not enough staff for care homes, with vacancy rates running at 11.4 per cent and 90,000 places unfilled. That’s before Brexit curbs the number of EU migrants. Caring is viewed as “unskilled labour” but the British need to see it as a vocation and a worthwhile career.

The elderly staying at home often aren’t faring any better. According to Age UK, 1.4 million older people are now not getting the necessary help to carry out essential tasks such as washing and dressing, a 20 per cent increase in only two years. There are already 7.6 million people caring for elderly relatives but even with their help the Local Government Association is warning of a £3.5 billion funding deficit by 2025.

When a care home place is not available the NHS fill the gaps. Simon Stevens, chief executive of NHS England, said recently that the equivalent of 36 hospitals were out of action because of a lack of social care.

Funding in the future

This week Matt Hancock, the new health and social care secretary, announced £240 million for the elderly, which could provide 71,000 more domestic care packages to help pensioners stay at home. This will alleviate some pressure on wards but it’s not going to address the long-term issues. Mr Hancock hasn’t been allowed to announce anything more radical, although he has been pushing quietly for a new social care fund where payments could be deducted by employers for future care costs. By the end of this parliament there will be a million more people in Britain over 75 than there were at the start of it.

Summary

We bang-on about the lack of funding for social care services, which it badly needs. But, as this lady found a cheapest not-for-profit charity home in her opinion provided the best service. Reading between the lines what she found was a home, who knew the service users and their preferences. Staff who were motivated and chatty and made everyone feel welcome. These things are not about money, they stem from the leadership of the manager, supported by staff who are committed to a culture based on the values of a quality service.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

True cost of dementia care


A recent research report Alzheimer’s Society has uncovered the true cost that people are paying for dementia care.

The research (2017) shows the typical total cost of dementia care for one person is £100,000. For many it can be much higher. It would take someone 125 years to save that much if they put away the amount they contribute, on average, to a pension. It’s impossible to expect everyone to be prepared for these costs, and there can be devastating consequences. The Society often hears from people affected by dementia who have spent everything they have on care and have even sold their home. Others who need significant support have felt forced not to access care because of the expense.

This puts their health, and sometimes the health of those around them, at risk. ‘Some of us can’t afford basic adaptations – I couldn’t afford a bed sensor for my mother. She went missing one night and the local police force sent out two helicopters and two cars to search for her. What would’ve been more cost effective?’ People living with dementia face higher charges for care and support than those with other conditions.

Dementia can be complex and involve symptoms that need tailored support. This means care providers often charge a premium rate for dementia care. We know that in some places this is up to 40% more than the ‘standard’ price. This extra cost isn’t covered by the NHS, even funding meant to cover both health and care needs, such as NHS Continuing Healthcare, is normally out of reach for people with dementia. Instead, people who need the care to survive end up paying more. Cash-strapped councils fail to pay or are unable to cover the extra money needed to provide complex support. When councils can’t cover the full cost, people with dementia and their families are forced to pay a ‘top up’ payment. This can be hundreds of pounds a week.

The Alzheimer’s Society are adamant that no one should have to spend everything they have on care. But people living with dementia spend a disproportionate amount of their assets on the care they need. Of the £26 billion a year spent on dementia care in the UK, two thirds is shouldered by those affected. There is a strong feeling about how unbalanced the division of responsibility between individual and state currently is. People affected by dementia accept that they should make some contribution towards the cost of their care. But this should be a fair amount that does not impact on their wellbeing or ability to live a normal life.  The cost of home care for some people can cost up to £38,000 a year.

Unfair Approach to care costs

This issue is made worse by the lack of a cap on care costs. In England, the amount after which someone pays for care – assets above £23,350 – has not changed in eight years. The combination of expensive care, and no limit on what someone can spend, means some people spend nearly everything they have.

At the same time, the number of local authorities offering an increased rate to providers to reflect the extra cost of dementia support has dropped. This has meant increased demands for top-up fees from families, poor quality care from providers operating on a shoestring budget, and providers even refusing to accept people with dementia. What aggravates people most is a person with dementia who paying for expensive care sitting next to someone who is paying nothing.

The research (Alzheimer’s Society and YouGov, 2018) shows people’s strong feelings about costs. Nearly three quarters (73%) of the public think it’s unfair people with dementia face using their assets to pay for care, while those with a different condition get support through the NHS.

The researchers also found 79% of respondents believed someone could face spending everything they have on dementia care. Also, three in five people now worry that any savings they have will be spent on care and support, leaving nothing to pass on to their loved ones. This is compared to 40% before the General Election in 2017 (Alzheimer’s Society and YouGov, 2017).

Summary

This report provides further evidence of a fractured social care system that is blatantly leaning on carers to pay for services that people with dementia so desperately need. It is an indictment of central government that arguably the people who need the most expensive care are being given the least support. We rightly bang on about equality in social care services and society as a whole, but, it is hard to see why people with dementia are paying for expensive care, while some others are paying nothing. Where is the equality in that?

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Why are we needlessly admitting so many to hospital?


Whilst everyone with an interest in the crises faced by the NHS is fully aware that the situation is exacerbated by bed blocking caused through delays in discharging patients from hospital. What is not so widely known is that almost 1,000 elderly people a day are being admitted to hospital needlessly amid a crisis in social care, according to Age UK.

Analysis of NHS figures by the charity found that there were 341,074 avoidable emergency admissions for people aged 65 and over during the year to April 2017.

The number has risen by 107 per cent since 2003 for those aged 65 to 69, and by 119 per cent for older people aged 75-79.

Among the general population of England, the number has risen by 63 per cent.

Reason for admissions

The figures relate to admissions because of conditions such as ear, nose or throat infections, kidney and urinary tract infections, and angina, for which hospitalisation could potentially have been avoided had the person been better looked after.

Many older people rely on family and friends to help them in the absence of reliable social care, the charity warned.

One in three over-65s live alone, and one in ten have no children, and these figures are expected to rise as younger generations, who are less likely to have married or had children, reach retirement age.

Many of those who do have loved ones to care for them rely on elderly relatives who may have health problems of their own.

One case study highlighted by the charity involved a 67-year-old woman who has been a carer for 40 years, first for her parents and more recently for a younger sister who has Alzheimer’s disease.

In another case a 73-year-old woman has been the sole carer for her 75-year-old husband since he had a stroke and brain hemorrhage four years earlier. She cancelled previous at-home care because it was “unreliable and lacking in continuity”.

Its report also highlights the problem of older people stuck in hospital and unable to go home, putting more strain on the healthcare system.

Unavailability of care

Care not being in place was the main reason there were delays for older people leaving hospital in England last year, according to figures released by the NHS.

A social care green paper, set to be released this autumn, is due to set out the Government’s plan for reforming the sector. It was originally supposed to be released before the summer recess.

Caroline Abrahams, charity director of Age UK, said: “The safety net for older people living at home has worn dangerously thin after years of underfunding and an absence of workforce planning across both health and care – this is why the numbers of older people whose emergency admissions to hospital could have been avoided are rising so fast.”

Councils warned of a “crisis in adult social care”. Cllr Ian Hudspeth, chairman of the Local Government Association’s community wellbeing board, said: “With people living longer, increases in costs and decreases in funding, the system is at breaking point and is ramping up pressures on unpaid carers who the backbone of the care system.

A department of health and social care spokesman said: “Patients should only be admitted to hospital when absolutely necessary, and we expect the NHS to work closely with local authorities and ensure people have a care plan in place when they are discharged.

“The Government has committed to a long-term plan with a sustainable multi-year settlement for the NHS to help manage growing patient demand.

“Health and social care are two sides of the same coin and reforms must be aligned – that’s why our forthcoming Green Paper will be published in the autumn alongside the NHS plan.”

Summary

This report by Age UK into avoidable emergency admissions for people aged 65, brings to light that bed blocking is not the only contributor to the crises that besets the NHS. Unavoidable admissions can also be a preventable cause, if sufficient resources were made available to community social care services. Central government continues to exacerbate the problem, by continuing to take advantage of unpaid carers who form the backbone of the care system, rather than properly funding the social care service.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

New policy for payment of social care


At long last a realistic means of paying for social care is appearing to gain some traction.  A recent report from the Health Secretary Matt Hancock confirms that he has endorsed proposals for every adult in England to pay into a second ‘pension’ that will be used for funding their old age care.

Mr Hancock said he wants people take more ‘personal responsibility’ for their health and care by regularly saving from their salary.

He said people could be automatically enrolled – in a system similar to workplace pensions – but those who did not wish to contribute would be able to opt out, but Mr Hancock doubts many would choose to do so.

Those who opt-out would have to fund their own social care. He said: “I’m attracted to the model of auto-enrolment, which has been so successful in pensions.

“If you make it the norm, tell people what it is they have to do to look after themselves, it’s often the case that very few people will opt out.”

The idea is the first from a major policy paper on overhauling social care that is due to be finally published within weeks. The so-called ‘green paper’ will include a range of options for consultation and may not make a specific recommendation.

The intervention comes as new figures reveal the number of pensioners who will be looked after is to rise from 657,000 in 2015 to 1.2 million by 2040 and the bill by 159 per cent, from £7.2 billion to £18.7 billion.

Mr Hancock claimed he wants to end the situation where people can lose almost all their money paying for social care.

‘It takes away the injustice of people losing all that they have saved for.’

Those who opt out would still face care bills in the future meaning they would face the same choices over selling their home, as today.

Previous proposals for an overhaul of care funding as part of Theresa May’s ill-fated 2017 general election manifesto – which proposed taking money retrospectively from people’s assets to fund home care – was nicknamed a ‘dementia tax’.

Since auto-enrolment was introduced for workplace pensions in 2012, the number of workers with a pension has almost doubled to 93 per cent.

Under the current Care England system, those in residential care can end up losing all their savings except for the final £23,500, at which point the state steps in.

This includes any property you may own.

While the average cost of care is £25,000 per year, one in ten people can end up paying more than £100,000.

Full details of the proposed social care funding scheme have not been drawn up, but ministers claim it could mean the end to crippling care costs.

This new social initiative is not without its problems however. Should this scheme be implemented it would have an impact on people in their 50s, who would have to contribute more than people in their 20s. Nor does the proposal address the care needs of those who are past retirement.

Former pensions minister Baroness Altmann said “This could be part of a long-term solution for younger generations. Older people who are now retired will need social care soonest, so there is no silver bullet.

Summary

Payment for social care has posed a challenge to all political parties over many years because it is recognized as a high octane political issue. Mr Hancocks plan should be considered on merit as there does not appear to be any other proposals on the table. The proposal to pay into a second pension may well be of benefit to younger people, but for those who are retired it says little about how their care needs are to be met.

The Government is expected to publish a Green Paper, a preliminary report, on social care shortly. This should show whether Mr Hancock’s plan is being further developed.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

People over the age of 85 needing 24-hour care is set to double


The number of people aged 85 and over needing 24-hour care is set to double, says a new study, as an expert warns the care system is “at breaking point”.

The study, published in the Lancet Public Health journal, analysed the projected health needs of the elderly in England between 2015 and 2035.

It found that the number of 65-year-olds and over needing round-the-clock care is also set to rise by a third.

The government says adult social care reforms will be set out in the autumn.

The modelling study, carried out by Newcastle University and the London School of Economics and Political Science, highlighted the fact that the fastest growing demographic in the UK is elderly people over 85, whose numbers are projected to more than double by 2035, increasing by 1.5 million.

Many of these elderly will develop multiple long-term health conditions, such as dementia and diabetes, leading to increasingly complex care needs.

The number of over-85s requiring help throughout the day with tasks such as dressing, bathing and going to the toilet is estimated to almost double to 446,000 by 2035.

By the same time, the experts predict that a million over-65s will need similar 24-hour care.

Prof Carol Jagger, from the Newcastle University Institute for Ageing and senior author of the study, said the number of unpaid carers is in decline. She warned that relying on unpaid family carers was not sustainable and said: “The challenge is considerable.

“Our study suggests that older spouse carers are increasingly likely to be living with disabilities themselves. “On top of that, extending the retirement age of the UK population is likely to further reduce the informal carer pool, who have traditionally provided for older family members.”

Investment

Nick Forbes, senior vice-chair of the Local Government Association, warned that more investment was needed to avoid a crisis. “Adult social care services face a £3.5bn funding gap by 2025, just to maintain existing standards of care,” he said.

“The system is at breaking point, ramping up pressures on unpaid carers. “There is an urgent need to plug the immediate funding gap and find a long-term solution to how we pay for adult social care.”

The study also noted that there were increasing numbers of adults aged over 65 living independently, with a rise of 60% forecast by 2035.

However, as they got older men were more likely to remain independent, whereas women will spend almost half of their remaining life with low dependency needs and more years needing intensive 24-hour care.

The researchers categorised elderly people’s care needs as high dependency if they need round-the-clock care, medium dependency if they need help at regular times daily, or low-dependency if they require support less than daily and are generally looked after in the community.

Focus on disabling conditions

Prof Jagger said this highlighted the importance of focusing on disabling long-term conditions, such as arthritis, that were more common in women than men.

“The rise in obesity is hitting women harder than men, and men have probably benefitted more from the reductions in cardiovascular disease.

“Women also suffer from a decline in muscle mass, and so I am stressing the importance of physical activity and maintaining strength and balance.”

She added: “This expanding group will have more complex care needs that are unlikely to be met adequately without improved co-ordination between different specialties.”

The report also predicts that the number of people aged over 65 with dementia and at least two other diseases will double by 2025 and treble by 2035.

Summary

This study published in the Lancet Public Health journal highlights the challenge faced by governments regardless of their political persuasion in meeting the future care needs of people in England. The study found that the fastest growing demographic in the UK is elderly people over 85, whose numbers are projected to more than double by 2035, increasing by 1.5 million. Many of these people will develop multiple long-term health conditions such as dementia and diabetes, leading to increasingly complex care needs.

Despite government platitudes claiming additional funding has been made to the social care sector, those who work in the industry know that this level of investment is no more than a sticking plaster measure. What is needed is real investment now and, in the future, along with a strategy that addresses the complex care needs of people who are living longer. To rely on the valuable contribution made by carers is unsustainable.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy