Guest blog by Clive Bowman

Frustration regarding current social care policy is understandable, the headline issue is of funding, but it is much more than that and fresh thinking on the “who and how” is needed.

Dependent older people are at the heart of the matter. At the inception of the NHS, the number of older people with dementia and/or medical complexity and care dependency was relatively small. Put simply, people with complex health needs had shortened lives and those needing refuge from poverty were offered little more than food and shelter. The present and future looks different with a burgeoning older population. Whilst the majority may be fitter and more able, there is a decreasing proportion, but growing absolute number of care-dependent people with complex and often unpredictable needs (presently most commonly related to dementia) who are unable to live independently and frequently require the 24 hour care of a care home.

Care homes and their residents have fared badly through the pandemic; confused leadership resulting in often conflicting guidance from local and national bodies none of whom are primarily designed to support care homes through such an emergency. This leadership issue is a serious concern and with more than 400,000 beds in the sector (over four times the entire NHS estate) and if there was any doubt the pandemic demonstrated this is not a marginal population.

Care homes really don’t fit the NHS paradigms of prevention/diagnosis/cure and management of long-term conditions nor those of social care (enabling and protecting through assistance to maximise autonomy). As anyone who has tried to negotiate “the system” for a relative or friend will attest, it can be immensely difficult. Processes vary considerably from area to area and too much professional time is spent determining entitlement to health and care resources and not enough directly supporting individuals. Repeated inconsistencies and failures of needs assessment and variable NHS support beg the question whether just allocating more money without major reform will bring the necessary benefits.

Recent policy initiatives have centred on integrating health and care services, but just as oil and water don’t easily mix neither does mixing services that are means tested with those that are free at the point of delivery. Inevitably, budget-led pressures on cost ownership and local arrangements make consistent standards difficult to achieve however committed integrated health and care systems are.

New thinking is needed, starting with a national service model aligned to the needs of the people requiring care. The present multiplicity of local authorities and health services involved in assessing eligibility (and the varying interpretations) consume huge amounts of professional time and are unfit for purpose and add little or no value to “customer” well-being. Furthermore, many care home providers are national concerns so satisfying complex locality commissioning requirements unnecessarily complicates and adds to service management costs.

Care homes with nursing struggle to fill professional nursing posts and providers scour the globe for nurses who can achieve registration in the UK often competing with the NHS. Many come from emerging economies and are often highly trained hospital nurses, but all too often with little experience in older persons care. Maintaining regulatory approval drives care homes often to become dependent on agency staff, the cost burden becoming a factor in the trend for care homes with nursing to re-register as residential homes, losing their need to employ nurses. This of course leads to increasing reliance on district nursing services. It is difficult not to conclude that the organisation and use of professional skills is a complete mess. Be clear, this is not to denigrate individual practitioners, but is emblematic of a broken system.

Assessment, care planning and surveillance should and could be provided as a public service aligned to support the individual. A starting point could be the establishment of a National Care Home Commission (NCHC) as an executive agency within the Department of Health and Social Care with regional and district structures consolidating and repurposing the resources of the various NHS, local authority and regulatory bodies into a new organisation whose mission would be aligned to the assessment of individual needs, care planning and the coordination and surveillance of care. Imagine, just one service to contact!

Designating professional time to assessment, case management and surveillance would allow a new ability to calculate the number of professional nurses required. Case managers typically have a caseload of 60-90 (in proven systems internationally), depending on their experience and the complexity of their caseload (suggesting some 6,000 case managers for 400,000 residents).

Care homes be they public, charitable or private of any scale could be licensed by the NCHC. Home managers would similarly be licensed professionally by the NCHC. Providers’ responsibilities would centre on personal care in keeping with the care plan and maintaining close liaison with an individual’s case manager, establishing a proactive approach to changing needs. Having remodelled the commitment of professional nursing time, the opportunity exists to enhance care staff terms and conditions and to introduce a requirement for continuing training support from the national commission and, crucially, roadmaps for career development.

Regulation could become a combination of ensuring a range of statutory standards and crucially, the satisfactory delivery of individual care plans and residents’ experience. Much present regulation would be replaced by modern governance systems of tracking individual residents’ care, quality indicators and risk measures. Such information with the adoption of AI could indicate potential “at risk” services at an individual, home or district level enabling a shift to pro-active intervention rather than reactive investigation.

Many further details that would need resolving but one thing should be clear – in the event of a future national situation, the NCHC could actively manage the “protection” of care homes and their residents in parallel with the NHS safeguarding capacity.

The proposals here have parallels with the government’s recent approach to reforming the railways. Structuring ownership, leadership, skills utilisation and processes promise a more clearly aligned care system to the needs of individuals now and for the future and a much better use of precious professional skills. It also offers a landscape where clarity on personal and state funding liability could unblock resistance to new funding commitments by the Treasury and perhaps open a new door for insurers.