Care as necessity or choice

Looking 20 years into the future we know there will be many more older people in the UK, and more of us will be living with multiple physical and mental health conditions, something which goes hand in hand with being “older” old. In such a world, specialist housing with care delivered on site (whether we call this extra care housing, residential care, nursing care, and so on) will play a bigger part in our country’s care market. The specialist environment and round the clock support it offers will be a necessity for more and more older people.

And perhaps that is the problem – it is still viewed as a “necessity”, rather than a positive choice. Moving into residential care is viewed with dread, even fear, with people seeking to avoid it at all costs. In polling1 Demos carried out as part of our Commission on Residential Care a few years ago, three quarters of the public said they wouldn’t consider moving into a care home in old age. 54% of these said this was because they feared the risk of neglect or being abused, significantly higher than the percentage who didn’t want to have to sell their house to cover the costs (33%).

Innovative care models around the world

Of course it needn’t be this way – and in many places around the world it isn’t. During our research into innovative care models, we visited places in the US, the Netherlands and elsewhere where residential care emulated small community and village life, and where local services (everything from the local post office, to cafes and swimming pools – even a university where the vast majority of residents were also mature students) were co-located on site. People living in residential care mixed more readily with their neighbours, and where they in turn were far more visible to the local community. The perceived fear of being institutionalised was far less present, and understanding of what residential care entailed was better: a far cry from our traditional image of foreboding places closed off to all but relatives during visiting hours.

But innovation isn’t the preserve of other countries – many care setting in the UK are pioneering similar approaches – in JulyBBC news2 featured the imminent opening of a nursery in a care home in South London as a move towards genuine intergenerational sharing of community resources. Movements such as My Home Life3, the Evermore4 project and so on all prove there are ways to ensure residential care can offer not just a real home for those who live there, but also a new lease of life and sense of identity and autonomy in sociable surroundings.

What does ‘good’ look like?

The variety of approaches adopted – often at a relatively small scale – around the UK underlines the fact there is no single “ideal” care home model to emulate, but rather many interpretations of what makes a good life for older people in residential settings. And this is how it should be for an increasingly heterogeneous cohort of older people. Nonetheless we can point to features some of the best care homes offer older people, such as:

  • gaining and maintaining independence and autonomy (including being able to progress to greater independence) – this can be achieved by “homes within homes” (e.g. creating specialist dementia units within a care home) and “mixed models” of residential care, including self-contained flats and care homes sharing the same site, to allow people to move between different settings according to their needs without having to move and lose continuity with surroundings, friends and carers.
  • taking control and having a sense of ownership over one’s life and one’s environment – this includes democratic processes which allow for powerful “resident voice” to make decisions about day to day aspects of living – from décor to activities, to helping to interview new staff.
  • having personalised and relationship-centred support – including designated teams of staff supporting small groups of older people, encouraging better relationships through continuity and familiarity; and more radically the “green house5” model, where small-scale “house” living with non-uniformed staff trained in hospitality is the norm.
  • being an active and visible part of one’s community – through the “porous” care home concept and co-locating with community services (from libraries to gyms, GP surgeries and nurseries) to bring residential care into the centre of a community as a visible asset.
  • engaging in meaningful activity and a sense of purpose – where older people can return to education or help maintain their home through gardening and decorating, alongside social activities which take an ambitious “can do” approach to risk management (not risk minimisation).

Of course, sometimes these are being achieved in purpose built environments, and modern facilities. But fundamentally, people want comfortable, home like environments underpinned by meaningful relationships (with people they live with and the staff who work there), in a culture which promotes independence and personal autonomy.

An art or a science?

How do we achieve this? Getting residential care right is an art, but at its heart it is based on human relationships. It is it starts with the staff. We must have a living wage sector, licences to practice, and recognised and transferable accreditation to allow great staff to move around the system. Great care needn’t cost the earth, but we cannot ignore basic truths – that carers need to be trained and get paid fairly, like any other profession.

The political will to provide adequate funding remains in question, and yet we need more than that – we need the will to fundamentally challenge public perceptions of what care homes are, and are not, by celebrating good practice with the same dedication as we weed out instances of neglect and abuse. We need to defend the care sector as a positive choice – but we can only do this when it is given the financial recognition it deserves.

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Social care