How do we greet the news in a recent press release that the Care Quality Commission plans to get tougher with the regulation of care homes? A few years ago, I would have said “about time”, but now standing back from the problem I am not so sure this is the right way forward.
Older people and their relatives almost everywhere would confirm that residential care is very much seen as a choice of last resort. Their own eyes and noses are the only quality assessment tool they need to know that most residential care is not up to a standard they would choose if there were a better and more importantly, affordable alternative. For the lucky few there are some exceptionally good residential care homes with high standards of accommodation and qualified staff but this usually comes at premium fee rates. New models of provision, such as extracare housing, are still relatively new and not available in most areas nor to the majority of people.
So we are left with most residential care homes acting as warehouses for older people – they keep people warm and fed but have no aspiration to give people any kind of quality of life. Not surprisingly, even very frail older people are not keen to move in but nonetheless there are still queues at the door. This is driven by the weight of demographics and the inability of individuals, their relatives and Social Services to cope with people at home, especially those with dementia.
So why don’t things change for the better, given that the customers certainly want better quality, the staff much prefer to work in a positive environment and Social Services and the Regulators want to see improvement?
At the heart of the problems is the fact that the financial model of residential care is flawed and the social care model is based on dependency.
In financial terms, since 1991 when the rules were changed and means tested assessment was introduced, Central Government has progressively starved Social Services of funding for social care. Having been handed this poison chalice, Social Services have used their near monopoly purchasing power to dictate low fee levels, while simultaneously pushing up the care levels. In fairness to them they have little alternative.
Small homes became less able to spend money on property upgrading or staff training and have been progressively squeezed out of the market.
In the meantime, corporate providers using the economies of scale, provided larger homes and grew rapidly in the decades between 1985 and 2005. They were funded by bank borrowing “secured” by the promise of Government revenue and an endless supply of customers. They also had impossible-to-achieve revenue returns, as debt was leveraged up to build more and more homes.
Now, many of the big residential care companies are on the verge of insolvency due to the combination of high gearing and artificially low fee income. It is probably only the current low interest rates that keep them afloat. Quite what the emergency rescue package would be for a large residential care provider going bust – nobody knows. Hopefully the CQC have a contingency plan for this possibility. I suppose theoretically they would be refinanced by further extending their debt. This has already happened in several cases where “forced” mergers/acquisitions have taken place, but this cannot go on indefinitely.
It is this background of inadequate (but unlikely to improve) Government funding and a highly leveraged, financially precarious residential care provision that no doubt stays the hand of tougher regulation. To close over 70 residential homes in the last 12 months sounds dramatic and indeed may well lead to an early death for many of the 700 residents who have been forced to move as a consequence. However, closure of 0.3% of the 24,000 residential care homes will make very little impact on the quality of life of the hundreds of thousands of older people living in residential care.
I am not against tougher regulation nor arguing these few homes should not have been closed. It is just that it fails to address the real issue which is the appalling quality of life which is offered to most elderly people living in residential care. If CQC wish to have a substantial, strategic and long term impact on quality outcomes, it can’t be through increased regulation and more home closures. Tighter regulation in itself only puts homes on the defensive and sets experienced regulatory staff on the opposite side of the quality debate to hard working and generally well intentioned care staff. CQC in its own press release acknowledges that the final sanction of home closure inevitably hastens the deaths of many of the residents who are forced to move out.
So the Care Quality Commission sits on the horns of a great dilemma – in one open hand it has the aspiration to improve quality of life, and the other hand is a closed fist which holds the hammer of regulation.
The Department of Health needs to acknowledge that regulation has done very little to improve residential care in the last thirty years. I was told by the Head of Regulation some years ago that their role was about compliance – well the evidence suggests that, that blinkered view hasn’t worked. The brief of the Care Quality Commission needs to be re-focused.
The way ahead lies in the opposite direction to tougher regulation. The CQC should champion good practice and facilitate learning and skills improvement throughout the residential and domiciliary care sector. This approach is about preventative health care and support to encourage an active later life. There is no shortage of residents, relatives and staff who would wish to travel this route. The alternative only leads to dissatisfaction and distress.
If we do nothing, the tougher regulation road can only lead to crisis. So enable the CQC turn around and walk the other way – take the high road of aspiration.
Don’t you agree inspiration is better than regulation?