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Residential care for the 21st Century

Des Kelly brings his personal insight into the recent Demos Commission on Residential Care report.

In the beginning…

At the beginning of my working life (as a care home manager) I had the privilege to be appointed to the Wagner Committee review of residential care. The group which was established by Norman Fowler MP, the then Secretary of State for Health, was chaired by Dame Gillian Wagner OBE and met for almost two years before publishing the now seminal report Residential Care: A Positive Choice in March 1988.

When the work of the Wagner Committee was reviewed after 20 years (in a book jointly published by Care Management Matters and the Residential Forum – Residential Care: A Positive Future all the recommendations of the original report were revisited to determine the progress that had been made. The level of success in implementing the report recommendations was surprisingly high. I make these comments as part of my introduction not to draw attention to how long I have been around but simply as a reminder that really big change takes time.

Revisiting the positive contribution of residential care

The Demos Commission on Residential Care was formed with the aim of developing a vision of residential care that is fit for the 21st Century. Chaired by Paul Burstow MP, it had its first meeting in July 2013 and published its final report in September 2014. Between the meetings of Commissioners there was a literature review, a call for evidence, polling, interviews with experts and a series of visits by the chairman. There is a link between these two major reports Residential Care: A Positive Future and the Commission’s report as they both have at their heart the intention to improve the quality of care and support services in residential care settings.

The Demos report The Commission on Residential Care is substantial, running to some 271 pages. I can’t, therefore, do justice to all the recommendations made in the report which are grouped under the following headings:

  • Leading from the front;
  • Working in housing with care;
  • Commissioning and assessment;
  • Providing housing with care;
  • Building housing with care;
  • Regulation, registration, inspection;
  • Funding.

Any one of these themes would quite easily provide material for an article in the space available here. However, the headings give something of an indication of the comprehensiveness of the recommendations and the inter-related nature of them. They are best seen, I think, as a package of measures. Without adequate funding, for example, the ambitious recommendations on the rewards for the workforce and the investment in qualifications and training will not happen. Without changing the relationship between commissioning and providers we won’t develop a shared vision for residential care for the future. Without changes in the approach to regulation and inspection the recommendations on continually improving quality of services will be undermined.

Embedding good practice

There are a total of 32 recommendations addressed to Government, policymakers and planners, local authorities and commissioners, the Care Quality Commission as the regulator, and to providers of residential care services.

The report argues that there is a strong case for rebranding residential care services as ‘housing with care’ because there are such negative associations, particularly in the media, with the term ‘residential care’. This is not about semantics; not intended to be simply an exercise in creating a new label. ‘Housing with care’ is a better description of the way in which care and support services have developed. It enables the blurring of the boundaries of care with the emergence of ‘extra care’ to be included in the definition. More importantly it makes it possible to reconsider the separation of the accommodation from care and from services. By separating accommodation from care and from services each can be more clearly defined, costed and funded. It will make it easier for the public to understand why this separation is important.

A shared vision and measures for change

The Commission recommends that providers and people using their services, local commissioners, regulators and Government work together to develop a shared vision for housing and care services. This recommendation is underpinned by calls for:

  • Promoting a shared evidence-based vision of what works;
  • The care sector to be a living-wage sector;
  • Minimum levels of training and the introduction of a license to practice;
  • Integrated commissioning models;
  • Sponsoring innovative redesign and enabling technology;
  • Exploring a tenancy framework for care home settings;
  • Greater use of planning incentives and measures to relax change of use measures to develop care facilities more easily;
  • CQC to conduct an annual survey of people using housing with care services and a workforce survey;
  • Extending CQC’s role to inspection of local authority commissioning practices;
  • Open book accounting and a fair funding formula.

Taken together these recommendations offer a step-change in thinking about the future of housing and care provision for adults and older people.

The report acknowledges other work to improve care settings and is a positive account of the potential of housing with care to be truly transformative. Case studies are used to illustrate the best practice ideas in the UK and abroad. Demos has reviewed a wide range of literature and interviewed a number of experts, including Dame Gillian Wagner, to build a better understanding of what good care and support actually looks like.

Recognition is given to the My Home Life (MHL) initiative within the report. MHL has developed into a significant UK-wide movement (in partnership with City University, Age UK and national care provider bodies), highlighting the importance of relationship-centred working underpinning best practice. The report reaffirms the value that MHL has brought to the housing with care sector and its contribution to promoting service improvement and supporting registered managers.

The Commission also makes a strong case for the care sector facing a very significant dilemma.

The report says, ‘In some ways, the future of social care is balancing on an axis. On the one hand, the Care Act 2014 promises to be revolutionary – bringing in a new duty of wellbeing, carers’ rights and commitment to preventative action – measures which have been long-awaited and much-welcomed by practitioners and representatives of disabled and older people’s groups alike. On the other hand the funding crisis looms large.’

Clearly the future of all care and support services, including housing with care, will be determined by our ability to resolve the problems associated with the persistent under-funding. The report makes clear that adequate funding is vital, ‘It is the foundation stone on which the wider vision…must be built.’

From assets to action

Housing with care must be seen as an asset which has a future as an essential part of the health and care system. The report argues for a new vision and new offerings of housing with care to deliver the outcomes people both want and value with four steps. Firstly by building on the community potential of services to support rehabilitation, re-ablement and outreach; secondly, stimulating greater choice, flexibility and diversity in market provision; thirdly, separating care from services and accommodation (for commissioning and regulating) in order to alter attitudes and the mindset typically associated with housing with care; and finally, the fourth step is to decide how we fund care and avoid the emergence of a two-tier system.

The Demos Commission report concludes, ‘Much has been said and written, but much less has been done…we want to create a powerful action plan for change…’

Here is the rub – any report can only ever be the starting point for action. The real test of the success of a report is in its ability to create enough influence to stimulate change. This will only be achieved through joint efforts that gain the active engagement of all those identified earlier – a partnership between commissioners, care providers and those receiving services and their families (in other words, the public). The purpose of housing with care, the way it is funded and delivered, its potential to support people and improve their quality of life needs to be debated with the public and not just with professionals.

The Demos Commission was struck by the seemingly unrelenting nature of negative public perceptions of residential care. Despite the positive experiences of people reflected in reports by the regulators, the public tend to see such settings as places of illness and frailty – the proverbial ‘last resort’. The demographic changes alone will mean that more and more people will come into contact with care and support services. People need to be involved in the debate about a shared vision for 21st Century housing and care. After all, all our futures are at stake.

Des Kelly is Executive Director of the National Care Forum.

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