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27th September 2016

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Matthew Syed - author of 'Black Box Thinking'

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In conversation with Roy Lilley

25th October 2016 - King's Fund - tickets here.

What good looks like

News and Comment from Roy Lilley

I'm pretty sure there will be a clever person reading this who will put me straight. In the back of my mind, lurking, there is a little factoid...

Am I right to say; 70% of A&E admissions, of the over eighties come from care homes... or is it 80% of the over seventies admissions come from care homes.

Either way around it's a lot of elderly frail people who should be living in the last place from where A&E admissions come from.

You spend hours visiting and comparing and deciding the best place for yer granny and before you know it you get a call; she's got a UTI, giddy, fallen over, banged her bonce and she's in A&E.

Really?

Do we have a problem with care homes? Apparently, nearly one a week is closing. One fifth thought to be trading at the margins of solvency.

The nutcrackers of CQC regulatory palaver, minimum wage, Brexit threats to staff, stupidly low rates of care-fees and the impossibility of recruiting, never mind no-money-4-training and you're stuffed.

But, there is a greater subtlety at work here. The difference between a residential home and a nursing home.

A nursing home, broadly, does what it says on the tin. Nurses. And, that means, by and large, nursing and that means the NHS and that means it could be free at the point of use. Looking after 'needs'.

Residential homes means care and that means social services and that means eligibility thresholds, financial assessments and means tests. More to do with entitlement than 'needs'.

Let's think about a simple scenario. Mrs Lovely gets to the point where she can't cope and the relatives spend a lot of time finding and residential home for her.

They like the gravel drive, the flowers in reception and the charming lady who shows them around. The day room, the laundry. They have coffee and biscuits... the catering seems all right.

Mrs Lovely is moved into a room and her life is in a box on top of the wardrobe and half a dozen pictures on the wall. Private but lonely. A few sticks of furniture and a lifetime of memories... slipping away.

Lack of responsibility, activity, human contact, visits and challenge sees Mrs Lovely's acuity go down the pan. You can be lonely in a room full of people. Depressed and smiling at the same time.

No lack of goodwill but lack of skills, training and management means care is earnest but at the margins of love, warmth and affection.

Frailty scores start to go in the wrong direction and three or four A&E admissions later and we are all sitting in a cold crematorium; relatives who hardly know each other and a communicant who has no idea what Mrs Lovely was all about.

As the nation gets older the boundary between residential care and nursing care is eroding and becoming pointless. The contractual division of care plays no part in the lives of people who circumstances are continuous, the boundaries porous, with the ebb and flow of getting from older, to old, to frail and very frail.

We need continuous, seamless, silver services.

It is obvious; people who make arrangements to spend their silver days in a residential home are very likely to slip into needing nursing care... or be up-ended and moved.

The classification is redundant. Few residential homes can deliver step-up care.

If the CQC was going to do something useful it might insist, as a requirement for registration, that a residential home would have, as a minimum, twice weekly visits from a community matron and a weekly visit from a community pharmacist.

Ongoing training for staff and a rotation link with the local Trust might mean the quality of care would improve, job prospects be more attractive and some sort of career progression established.

There are any number of examples at the Academy, NELFT have a good example, that could be adapted and there are lots of other ideas here, where local systems work to reduce admissions from care homes and the Vanguards are making real progress.

Residential care homes 'care' can't be caring enough. It is wrong to expect that it could be. Residents move in with independence and before you know it; their needs change beyond the scope of the home, as they would if they remained in their own home.

The evidence and practical reality demands a national rethink and a close look at what good looks like.

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roy.lilley@nhsmanagers.net

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