The state support is means tested and targeted. The Heath and Social Care Act 2001 introduced free nursing care and only apply to people in residential setting. The amount paid depends on the level of care required on a three flat rates: £35 for basic care, £70 for intermediate and £110 for high level need (). Nearly 250,00 older people live in nursing or residential care receive state support (White 2002). Most individuals will have an active old age supported pensions, personal savings, and benefits from the NHS, which will take care of their heath needs. However, a large proportionate of elderly people today are most likely to require special care and long term assistance as they grow frail. And how that care is funded is the most concerned questioned asked in public policy. The Royal Commission on Long Term care, suggests that the cost of long term care for elderly people (paid by both individuals and the state) could rise from £11.1 billion in 1995 to:
- £14.7 billion in 2010;
- £19.9 billion in 2021;
-
£28 billion in 2031 ( 2002)
There is increasing evidence such as in The Home Life (CPA, 1996) and the Wagner Report (see appendix 1), Townsend (1962 in Tinker 1992), Brearley, (1990:76) of the problems and concerns faced by elderly in residential care. Research suggests there is a lack of:
- Choice
- Power
- Security
- Control over personal decision-making
- Independence
- Autonomy
- Privacy
- Normality because of the institutionalised nature of setting and provision
- Rights
The institutionalised nature of residential care has many negative impacts on the user. The characteristics of institutionalised implies a loss of the above principles of human rights. This is can be demonstrated where regimes functioning in homes give residents limited opportunity to exercise choice over the way in which they spend their day; how they organise and make use of personal time; what and when they should eat; whom they should share room with. This kind of influence tends to be ‘’depersonalise individuals and undermine personal dignity’’ (Peace et al, 1997:46). The routines care delivery inside the home is delivered at the convenience of the provider, the care staff. This is should not be the case as that is not what the users want.
The study by Counsel and Care (1992) of the wishes and expectation of lives of residents demonstrated these points: ‘’most people (81 per cent) considering residential care wanted to be able to choose what time they would get up in the morning, but only 56 per cent thought this would be possible of those in homes only 52 per cent had choice on this matter. There could be no more damning statistics of inhumanity of institutionalisation’’ (Councel and Care 1992:17). Elderly people desire ‘normality’, they should not feel excluded from the normal life style from those living at own home.
Not only the routinalised delivery and the institutionalised setting of this form of care is at the preference of the users it’s more at the control of the provider and practices are usually undertaken with the notion that elderly people are no longer capable of thinking for themselves, therefore they require constant ‘support’. According to Peace et al (1997:47) this is rather a '' paternalistic and infantilising viewpoint’’. Provisions are often made on a service lead basis and what is needed is a user lead provision as this will take in account of individual needs rather than intuitional need – collective need.
Care staffs have a significant role to play in delivering the service, in many ways the life of residents is at the hands of the staffs. A report into a care home in Oxford revealed horrific abuse and neglect in many care homes. Visitors had to ring ahead when they came to see relatives in Oathurst Residential Care Home in Oxford, this was to give time to care workers to hide stench of urine with room freshener and scrap faeces off the curtains. A residents neck was so gnarled by age that it pressed her chin tightly into her chest only had head violently wrenched upwards to facilitate force-feeding when no guest were present. Another 89-year man died due to neglect of care by staff. The son of the latter resident reported, ‘’It quite literally had roses round the door (the weekly fee of the home was £315); inside it seemed just as perfect. We couldn’t have guessed the horrors that were going on: we were lied to and deceived until it was too late’’ (Hill 2001) Experts believe 10% of the 23,000 residential and nursing homes in Britain hide similar stories of cruelty and staff and management incompetence, see Annex C for care staff profile.
Despite standards in the Care Act, experts fear that thousands of residents in homes across the country could be suffering because of a glaring legal loophole. ‘’Unlike the laws available to the police to pursue those responsible for child abuse, there is no law available to protect vulnerable adults from exactly the same abuse, said John Meredith, Thames valley police who took a resident's case to court. ‘’Elderly people are forgotten section of society; we were at this stage with children years ago.27 percent residents reported they abused in care setting according to Action for Elder Abuse in the most I a survey, given that less then 5% live in care setting this is staggeringly high (Ibid).
Currently the Registered Homes Act 1984 and it regulations do not set out much detail in terms of the standards that care homes must meet. Although local discretion allow flexibility, it means that there is inconsistency between authorities, leaving providers uncertain about what they need to be registered, and leaving service users unclear about what standards they can expect as a national minimum standards. The current government has introduced the Care Standard Act in 2000 set promising regulation to enhance standard but however, like any other legislation and policy initiatives for improving care service the public will be sceptical as whether it be implemented effectively ( >2003)
A case for change
The current government is trying to improve the quality and has introduced a number of policy and initiatives to regulate standard and monitor consistency and coherence. The long term care charter ‘Better Care, Higher Standards’ 1999 and the Care Standard Act 2000 was brought to improve the quality and efficiency of the service. The remit of this report is to suggest a particular case for change, however, as the last section have shown there are numerous number of problems and concerns in the service thus it is difficult to pick out one particular aspect of the service as many concerns and causes of the problems are interlinked such as insufficient resources, inadequate care, lack of accommodation, untrained staff are indictment of lack of funding. Abuse and neglect could occur by untrained staff or staff shortage if there is more demand than workers can cope with. The concerns with regard to principles of human rights such as autonomy and independence are to do with a lack of user empowerment. There are a number policies and programmes from the past the and present government to improve care service tough Labour is doing more than the Tories but problems and crisis still persist.
It is not lack of legislation, regulation, supporting bodies or providers of service, it is the issue of funding that needs to be addressed and challenged. Despite the Labour government’s attempt to modernise social services and giving extra £3b for SSD up to 2002 an annual increase of 3.1%, the debate over funding for elderly care is highly controversial, should old age be the responsibility of the state, family or individuals? The issue of funding is complex given the mixed economy thus here we present a general case for why more fund is needed than rules and regulation.
Lack of funding and staff shortage is often blamed at the poor level of service in residential services. Sheila Scott, of the National Care Homes Association, blames a chronic under funding of care for a fall in quality. ‘A consistent downwards pressure by the government on the tariffs set by care homes means some owners have as little as 71p an hour to spend on residents’’. (Ibid). Local authorities are under pressure to limit and means test spending on users but elderly users’ needs are complex and much more greater than other groups in the society as they grow frail. The Audit Commission (1997 in Poxton 1998)) published important analysis of care needs of older people. Three basic components are identified for quality of life in old age: adequate finances, fitness and good heath. If there is adequate finance than other needs are easily meet.
In a report from Joseph Rowntree Foundation revealed £1bn black hole in the public spending of care homes. The study found that fee paid by local authorities from social services are longer enough to allow the homes to provide a good service and make a reasonable profit this leads hundreds of home owners quitting the business and leaving local authorities short of accommodations. Report conducted by Mr William Laing said ‘’For better or worse, the delivery of nursing and residential care was largely privatised during 1980s and 1990s.Our ability to offer quality and choice to older people now depends on providing a stable and competitive care home sector’’. (Carvel 2002).
This issue must be addressed at the central level as the councils cannot spend what they dot not have thus it is important to examine and review local government spending before doing the Comprehensive Spending Review so such issues can be addressed. This raised another issue, associated with local authority spending. It is better if budget is planned and delivered according to local priorities and needs rather than calculating at the central level. On the local level there is a great variability of needs and priorities. Some boroughs spend more or less than their allocated budget, Haringey spent 23% less than its assessed budget of £184 per head, Kinston upon Thames spent 30% more than it allocated £156 and tower hamlets spent all of its allocated £407 (May 2002). This rises inconsistency in service, some elderly might get a better home when the borough’s budget is within the limit and in other borough where overspent they would have limited choices and poor quality homes. Demands for residential care outruns provision and may be increased by demographic trends and stress on carers (Tinker: 1992:161). With the increasing aging population there is more demand than the supply.
There has been a significant increase in the number of older people, especially those over 75 years and, more especially, those 85 years: 18% and 80% respectively, from 1981 to 1997 (Poxton 1998). Rising tax might not be a feasible recommendation as the proportion of tax paying workers is relatively smaller than the proportion of retiring people, and that is a burden too great for the economy and in terms of the willingness of the working population to shoulder such high tax levels (Pratt: 219).
The central government needs to look at spending on elderly people in residential care as a national priority as their lives are dependent on the care system and not up to individuals. Older people feel they are treated as third class citizens and the less valuable members of the society. There is some ambivalence about the value of older people in this country:
‘’…We are taking up too much trouble for them, causing too much trouble because we are living too long. There are several things that happen that make you feel that you are not wanted anyway. To be honest I often wish I was already gone’’ (Poxton: 14).
Elderly people should not be forced to sell their homes, it should be entirely at the discretion of individual to decide, some people may wish to pass on their assets onto their children and this should be their right as they have worked hard all their life for it especially in the case of property when one has paid mortgage. The state should not see older people as a burden as they contributed to the economy all their working lives. With out more funding in adult care service the elderly will not enjoy a quality life at old age.
Synopsis of involving users in planning and delivery
The last section presented the case for the need for the central government to reform spending on the elderly, however, with out involving the users in the planning and delivery of the service we cannot improve and can never know what people need and want. There are various ways of consulting users; the current situation suggests there is a greater need for involving users.
Elderly people in residential care want attention and support. They want to participate in the development of the service and want their voices to reach decision-making. Elderly users can be represented as part of ‘user involvement’ campaigns; this is where local councils may support their opinions, and possible progression in ‘getting heard’ (Our voice our future: Services and Support).
However according to the 1998 ‘Modernising Social Services’ white paper many users and carers report that they have not been asked how things are going once they are receiving services. This indicates that there is little involvement of users and their families. Furthermore, genuine consultation cannot only make services more responsive but also increase the opportunities available to all users (HMSO, 1998). For the first time children in care are being consulted, and having read some of the comments in the questionnaire carried out by the Who Cares Trust? for the Social Exclusion Unit it provides an insight into what it’s like being at the receiving end and what is wrong with the system ( >2002).
Informal regular meetings in the homes between residents, care staff and management would give residents the opportunity to listen to their providers and express any concerns. Some residents may not be able to attend meetings due their heath condition then management and staff must find alternative ways of discussing any issues to do with the home service. In preparation to the meeting staff can collect items of agenda from residents and encourage them to talk in the meetings. Some residents may be reluctant to talk about problems in the presence of managers and staff thus there should be a system to deal with complaints from residents. Residents under no circumstance should be ignored.
Others ways of involving and consulting elderly people in residential homes, would be by means of:
- Annual consultation to be conducted by local authorities with users, cares and their communities with regard to community care plans.
- Involvement of users and cares as the central component of assessment and care management process
- Accessible and comprehensive complaints procedures to be produced by all social services departments in order to enable users and cares to challenge the decisions and actions of service provider.
The central government departments, DoH would be the most important one, should always consult and include voluntary organisation such as Age Concern, Helped the Aged in steering groups of projects to do with elderly provision. Also DoH or any other government department carrying out task involving advising on elderly provision must have representatives from homes such as staff and managers. Advisory forums and steering groups are a very effective way of hearing voices across a range of representatives. Decisions are more likely to result in more coherency and consistency if local initiatives are first taken into account and then devise national policy and programmes to fit around the local needs and priorities.
Care management process should adopt person-centred planning involving the users assessments of needs. The tendency of planning care around a perceived ‘quota requirements’ cannot effectively meet the needs of all residents, some may require specific responses not just a standard allocation of beds, served food and so on. Going back a case in section 2 of an elderly being forced feed despite the woman’s inability to move her neck. Issues like these cannot be ignored under any circumstances.
Conclusion
This report has highlighted residential care is perceived negatively by the users due to the institutional nature of the service. However, it is important to note that this form of provision is very important for those who do not have alternative accommodations. The impacts of institutionalised nature of provision are not often addressed in service planning and delivery otherwise residents would not be so reluctant to go into residential care. Care staff, play a vital role in the life of residents and it is equally important for them to be trained and qualified to meet the needs of the residents.
The Modernisation programme and the Care Standard Act 2000 should bring some improvements to the care but however, to improve the quality of life of elderly living in residential care more funding is needed. More money into residential care service would solve many of its problems and enhance the life residents such having facilities and clubs for leisure activities, promoting independence and normality. The quality of homes is also determined by how much the LA can afford to pay to private and independent sectors.
Involving users in planning and delivery is equally important as the service itself. Elderly people in residential homes want to be heard and seen. Person-centred planning and self- assessment of elderly must be at the centre stage of care planning and delivery in order to meet individual needs. Consultation with users and voluntary agencies working to represent old people is a must in planning care at all levels.
