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Long term care and older people

By Tom Dening

Suddenly care homes are hot news. As I drove to work this week, the two leading national stories were both on this topic. First was the shocking care provided to the residents of Winterbourne View in Bristol. As one scene of abuse was followed by another, the whole effect was increasingly distressing and I could only watch to the end in order to ensure that action was going to follow. ‘Call the police’ was going through my head throughout. The second story was about Southern Cross, the care home provider that expanded rapidly but has now run into trouble as its income can no longer finance the rents for the homes. The debate continues as to whether Southern Cross should be allowed to reduce its rent payments and whether (or when) the government will need to step in to protect the 30 000 residents.

Everyone knows that society is getting older. Many more people live beyond the age of 80 than has ever been the case and there may at the moment be more centenarians alive than have ever previously existed in the whole history of the world. Along with the increasing numbers of very old people, it is estimated that the numbers of people with dementia will rise dramatically, approximately doubling to about 1.5 million in the UK by 2050. And although most older people live most of their lives in their own homes, nonetheless, despite all the community care that is available, a large proportion require 24 hour care eventually, which in practice means moving into a care home. There are about 500 000 people in care homes across the UK. The number of long term care places fell slightly for about 10 years from the mid 1990s – this was the result of changing provision, with fewer long stay hospital beds and local authorities ceasing to provide their own homes, instead commissioning care from independent care home providers. The fall probably reflected investment in community services. However, we are now probably reaching another phase where more care home places will be required.

There are plenty of indications of public concern. For example, the National Dementia Strategy, which has successfully highlighted that dementia is a massive health and social care issue, supported for example by recent evidence that people with dementia fare badly in acute hospitals. The Law Commission has just published its proposals on the future of social care and the Government will need to respond in the next year or so with new plans for affordable services. Age UK has in the last month issued a report describing care for older people as ‘in crisis’. Many of those of us who are not yet of retirement age will be carers for older people or relatives with other needs and, even if we are not, we will still be wondering about what the future holds and who is going to pay for it.

As an old age psychiatrist, I see a lot of older people in care homes. There are about ten of them in my part of the city. Over the years, the homes themselves have changed. They are no longer eccentric conversions of Victorian houses run as family businesses by nurses who used to work at the psychiatric or geriatric hospitals. They are now mainly larger, purpose built and run either by not-for-profit organisations or private companies. They still vary a lot in terms of whether you could imagine living in the place yourself! The ambience varies as does the extent to which the home feels ‘homely’ or ‘institutional’. Some smell more fragrant than others. The managers have a huge influence on the atmosphere and on the staff group working there. Personally, I have long been impressed by just how many people in care homes have dementia. The proportion is about two-thirds, even in homes that do not purport to care for dementia. Therefore, I have argued for over 10 years now, dementia is really the main business of most care homes and dementia is the main reason why most people enter institutional care. I think that this message is staring to get through and be more widely recognised. It has profound implications for the skills required of care staff.

My passion for this subject is shared with my colleague Alisoun Milne, from the University of Kent. We have often discussed these issues from our slightly different viewpoints – me as an NHS psychiatrist, Alisoun as a researcher in social sciences – and it was this complementarity which led us to write our book. We have aimed to provide a text that not only describes common mental health issues in homes and their management but also sets out the legal, policy and regulatory framework, and then describes good practice, research and future trends. We have had great support from our wonderful contributors, including a resident in her 90s. We have discussed many of the issues that underpin the Winterbourne View and Southern Cross stories. Although our book focuses on older people, we have also discussed residential care for people with intellectual disabilities. We include a chapter on safeguarding and abuse; and another on funding of care homes. The final section of the book is firmly looking forward to the future, trying to anticipate the needs of the older population and the skills that will be needed to care for them.

Perhaps because we are optimists, our conclusions are cautiously positive. Of course, there is no shortage of stories of terrible, abusive care. These are often criminal acts and should be dealt with as such. There are the current demographic trends and the present recession and curbs on public spending, which are hitting local authorities very hard right now. Providing care is not an easy business and for care workers it is hard and demanding work. And living in a care home is not like being independent in your own house. Nonetheless, there are welcome developments that we should not lose sight of:

–  the quality of homes and the care they provide is, overall, better than it was
–  the importance of dementia is better recognised and there is far more knowledge about how to care for people with it
–  it isn’t inconceivable that future medical advances may delay the onset or advance of dementia – even slight gains could make a difference
–  most of the need for residential or nursing care is at the end of people’s lives, so the fact they are living longer doesn’t necessarily mean they will need longer periods in care homes
–  there is more training available for staff with more opportunities to gain qualifications such as NVQs
–  the current debate is welcome and a good antidote to the traditional neglect of older people in care homes.

Tom Dening studied Medicine at Newcastle University and trained in Psychiatry in Cambridge and Oxford. Since 1991 he has been Consultant Psychiatrist in Old Age Psychiatry in Cambridge. From 1999 to 2002 he was seconded part-time to the Department of Health as a Senior Professional Adviser, including work on the National Service Framework for Older People. He is now is the Medical Director of Cambridgeshire and Peterborough NHS Foundation Trust. He is the co-author (with Alisoun Milne) of Mental Health and Care Homes.

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