Caring for Life - a dream of fixing the care home crisis in the UK

The Challenge: 

The Question: 

What to do about care homes in the UK?

The Problem: 

High asset prices, distant managers, disempowered staff.

The Solution: 

Innovative legal and financial structuring, combined with participatory management approaches.

Channels: 

What if we could create a network of independent, highly connected, care homes? They would be innovative, fairly priced and an integral part of their local community. They would be great places to work, and run for the benefit of all, not to maximize profit or subject to the whims of governments. That’s our dream. 

A bit of background: The care industry in the UK is in crisis (the BBC recently called it the problem no one can fix).  It is a familiar story.  The demand for care is growing rapidly due mainly to an ageing population, with increasingly complex conditions, a breaking down of traditional community-provided care, and higher expectations amongst the elderly.

At the same time, the ability of government-funded institutions to meet those needs is diminishing. They lack the resources, the responsiveness and the political will to deal with the population’s increasingly complex care needs.

At the same, escalating asset prices are putting pressure on traditional providers, and attracting hedge funds and private equity looking for the "growth opportunities”.  The result is that many care home are being run as a businesses more than as a service, meaning that profit and shareholder value is prioritised over the needs and well-being of residents or staff.

Caring for Life is a diverse team has come together to seek a better solution. We are inspired by:

  • open source communities, that harness collective intelligence to find new solutions to old problems;
  • networked organisations, notably Buurtzorg, the community care provider in the Netherlands, that combine the benefits of being small with the benefits of being part of something large.
  • traditional community-based approaches to care-giving that are human-centred and sustainable.

We intend to will achieve this in particular by taking over existing care home businesses and creating, one-by-one, a network of homes modelling the type of care we want to see.  Once we have established a small number of our own homes, we will reach out to other like-minded operators to create a broader community of homes around the UK.

A key operating principle will be to involve all "stakeholders".  Buurtzorg (mentioned above) has an excellent model, illustrating the various levels of involvement, and whilst this is primarily looking at home care as opposed to care homes, it is a useful way of viewing the bigger picture.

Care home residents come into care with social networks, habits, routines and pastimes, which are normally stripped away on entering care. As far as possible these should be maintained because these are part of the person's "support system". Involving the family and friends as well as the wider community will, whilst it may add to the complexity, lighten the burden of care and increase quality of life for all affected.

Legal structure:  Our intention is to separate out the capital assets from the business of caring. The precise legal structure remains to be worked out but may be similar to a so-called community land trust (see http://www.communitylandtrusts.org.uk/what-is-a-clt/about-clts) where one organisation (maybe a charity) owns the freehold of the land and a social enterprise runs the care home.  There would be some element of employee ownership, which has been shown in many businesses to encourage higher than average levels of productivity and profitability.

Getting started:  Our intent is to start by acquiring control of one care home.  In order to keep capital needs as low as possible in the early stages, the intention is to lease premises on a long-term lease rather than buying a home. An opportunity has been identified near the south coast of England and conversations have started with the owners.  This is an interesting opportunity, in particular because there is an chance to acquire the property and business for a low price.  The home is currently subject to "special measures”, imposed by the Care Quality Commission.

Comments

Separate assets from activities

Alberto's picture

This sounds very sensible. I am curious about the separation of assets from care activities. Could you say more about why you think that's necessary?

Separating assets from activities

Patrick Andrews's picture

We have a particular problem in the UK, which is rising asset prices and particularly land and building prices. This is partly because we are a small crowded island and could do with more houses but it is also because we have an excess of money, and it tends to accumulate in the hands of a minority.

In care, the result is that individuals and even the state find it increasingly hard to acquire care homes and they attract private equity and hedge funds who treat staff as human "resources" and patients as "consumers" of health care services, squeezing the system to extract wealth.

This is, arguably, an extreme way of presenting the situation (after all, even hedge funds have to employ managers, many of whom are very professional and caring). However the fact is that having "owners" who have different drivers and values from the care-givers causes a tension that too often results in quality of care taking second place to "delivery of health services", which is quite a different thing.

A useful parallel is the struggle many communities have to create affordable housing. An interesting and succesful innovation has been the community land trust, where land is acquired by or on behalf of the community and held in trust over the long term. They make the land available for affordable housing. Separating out the ownership of the land from the occupation of the land allows people who couldn't otherwise afford to occupy the land to come in and use it, subject to the conditions set down by the trust. We imagine a similar type of structure.

To put it another way, using financial language, owning land has a different time horizon and a different risk profile  from owning a business. A care home that separates the two can attract different sorts of capital for the two different needs, and thus more closely match the interests of the investors with the interests of the stakeholders. That's the theory anyhow.  

Reshuffling the cards

Alberto's picture

Wow, @Patrick Andrews , I had missed your answer. This is really interesting.

The way I understand it, managing real estate in an overheated real estate market like the UK's makes more money than producing care services. Hence the tension of these hedge funds that, as a result of being bottom-line oriented, focus on the buildings and not on the people. 

The separation of assets from activities makes a ton of sense. I looked up community land trusts on Wikipedia (https://en.wikipedia.org/wiki/Community_land_trust), and I think I now understand how that might work. It seems to me there is an "upstream" problem: finding the money to take a valuable piece of real estate off the market forever, damn the capital gain. I don't see how this can be completely solved. The advantage of the CLT model is that you only have to do that ONCE. Once you have done it, the land is secure (except if the CLT goes bust, but I imagine CLTs are supposed to be very risk-averse). Am I getting this right?

CLTs might be of interest to @Nadia in view of The Reef. 

yes, you're right Alberto

Patrick Andrews's picture

yes, you have understood it well Alberto. Taking land out of private ownership into community ownership is a challenge. In Scotland there is some governent support for this (inspired by the population of the island of Eigg, who bought the whole island from the owner). In time I hope the UK government will become equally enlightened. 

Independent care home?

Noemi's picture

@Patrick Andrews hello, I was reminded of this post as we are having a conversation on care homes which run on intergenerational care. You might want to have a look here (mentions of other Dutch and American well run facilities too).

What do you mean by independent care homes? From the very little I know about the UK care system, many times services are provided by both NHS and affiliated trust foundations whose status is formally semi-autonomous. Also, many times services are signposted to third sector/ independent organisations, which makes me wonder if you see your new organisation working in similar partnerships? Do  you want to be independent in status or also in your practice - meaning little or no collaboration with the existing system as it is now? I'm curious about the positioning, and it can also be relevant for our research. Also ping @Tino_Sanandaji for possible interest in this.

Inter-dependent care homes!

Patrick Andrews's picture

Hi Noemi, in response  to your post, I would say we want to be inter- dependent,  not independent!    I guess I wrote the original post in rather a hurry, in response to the Open&Change  call, so  it probably didn't get it quite right.   I see our project as forging some third way between state or charity  ownership on the one hand, and private for-profit ownership on the other.  it anyway will succeed is to partner up with caregivers, doctors groups, and other independent care homes.  I envisage a movement of care homes,  highly networked,  helping and supporting each other and yet deeply rooted in their own community. It is a big vision and so we are  starting slowly :-)

Autonomous, but connected

Noemi's picture

I see, it's almost like they could be the care home version of the Reef!

You probably need one great test case and then others in the current system can learn and be modelled on it. 

Very excited about this, keep close..

 

Care Home structure

zazie's picture

Definitely suggest a test case and liaising with local CGCs / councils... The sector is very heavily regulated by CQC (Care Quality Commission), and the mandatory requirements are quite intense in terms of staff training & numbers, facilities, type of care offered, activities, care planning, health & safety (including prevention of infection - limiting doing "funky" things with premises, unless one works really hard), etc.

The idea of making endless profits by shoving people in a care home and doing nothing for them is a myth, as is the idea of private equity jumping in to the sector to clean up... (Look at the spate of the disposals and failures in the sector.) Trust me, as someone with knowledge and experience in the sector, there are a LOT easier ways to make money, especially by pure property plays. WHY would a new corporate go in to such a demanding area, unless they had experience or size advantages / consolidation to bring to it?

Not sure how you'd bring in clients; if council funded, you'd definitely need to comply with regulations, equally if private you'd need to comply and attract customers. (Remember the market is competitive and low return, and council-funded clients will barely cover your minimum staffing and food costs.) Perhaps voluntarily attending such an entity would work?

Yes - to the idea of intergenerational interaction and care, yes to more community involvement and interaction for residents; but also yes to actually researching the practicalities involved...

Have seen good examples of "care villages" elsewhere, especially designed to deal with dementia and Alzheimer's cases - shops but no money needed, good levels of interaction, residents free to roam and be independent with staff around to monitor and care but not impose... Such things sound excellent, as do the existing experiments elsewhere with intergenerational care (e.g. students living in care premises and assisting, in return for free accomodation). There is a lot of knowledge and experience we are losing or wasting with our youth-orientated / advertising and spending power-focused society.

(I'd suggest looking up CQC documentation - available online, together with detailed requirements for various levels of care e.g. residential without nursing, residential with nursing, dementia care, etc.)

Good reality check!

Noemi's picture

Hi @zazie and welcome to edgeryders and thanks for jumping in! I think @Patrick Andrews above was onto something when specifying their aim is to be inter-dependent, since going in as an outsider could (unintendently) add to the list of things that are not going as one would hope. Are you working in the British care system..?

So if you're a corporate actor and play by the wrong incentives the market is looking up, but if you're driven by wanting to improve care there's only so far you can go in a competitive system? This is quite a straightforward way of putting it, but this is what I understand from your comment. What is your preffered setup then, from those successful "care villages" you mention? Social enterprising of sorts? Relying heavily on community goodwill and basically volunteerism? 

First do no harm...

Patrick Andrews's picture

Thanks Zazie, I appreciate your note of caution. I have heard this from others I have spoken to, and am not about to leap into something blindly. On the other hand, it is clear that a radical shake up will be needed over the coming years so thinking creatively will be desperatley needed. This may include, among other thnigs, challenging the way the CQC thinks and operates.

At the moment, we are proceeding slowly and cautiously. I think the principle of "First do no harm" applies - we are not about to go out and buy a load of care homes and think we can instantly transform them. We are working with people in the field and looking for existing homes with open-minded owners  we can work with.

If you want to stay informed, let me know your email address and I can add you onto our list. It sounds like you could add a lot of useful knowledge and experience so I may well want to get in touch at some stage and tap into that. Would that be OK?

Alternatives in care for the elderly

zazie's picture

Hi!

(Just as background - have been handling compliance / regulatory issues in a small institution for a while now, in the UK.)

Hopefully, we will see more innovative ways of care develop, especially with the idea of co-living / caring, that can benefit both parties, not just be an act of charity or goodwill / volunteering...

The UK Government (and others) are looking at the issue as a major priority, given our aging population as the baby boom generation feed through and medical advances mean longer lives... Meeting the cost is a big debate here, especially in a time of "austerity" and widescale removal of central government funding.

There is good reason for the regulatory framework, but the overhead for both parties (regulatory body and care institution) has become increasingly high and ever-changing, as with many top-down bureaucratic systems. (In the UK the body has gone through some changes after criticism regarding its efficacy , but it was formed from good intentions to stop care providers simply taking the money and "housing" the elderly or needy. There have been issues with maltreatment, theft, poor care, etc., just as there has in other social care areas, so some standards need to be set and monitoring carried out by a third party.

Part of the issue is funding. Larger premises or chains do lead to economies of scale and can help with staffing (whereas a single, small institution may need to resort to agency staff on occasion - which can be very expensive). The other side of this is that large operators can seem to get away with things that a small or single premises operator would not, simply as to rebuke them or suspend their activities would result in chaos for service users, never mind the relationships that develop with a large care provider and a local council or clinical commissioning group. (I've seen examples of large corporates who provide home care services being inspected and noises being made by staff who complain they are not alloted time to travel between appointments, etc., yet nothing seems to be done, despite the obvious failings. I suspect some in Government aren't in a position or of a mind to focus on the service users at the moment, but rather see some dubious measures as essential cost-cutting / profit maximisation on the part of the corporate body. Another point to bear in mind is the connections between certain politicians, financiers, and industry - as with many sectors!)

What I have seen from my exposure to a small institution is caring staff who are doing a good job and have good, close relationships with their service users. However, they are often distracted or overwhelmed by an ever-changing regulatory framework, as happens in other sectors such as teaching. Ultimately I would like to see the funding from lcoal councils topped up by central government, and this be accepted as the only way to provide decent care. More flexibility from the regulatory body would also help - allowing for more differences in care provision, especially in smaller, more intimate homes; as I've mentioned this does seem to be unlikely given the current standardised, bureaucratic, regulation and inspection by checklist...

(Equally mixed communities and inter-generational interaction would help, but this is increasingly rare. Housing seems to be led by developers keen to focus on young families who have income to buy new-builds on new estates, and marketing focuses on the younger age groups that go our and spend their disposable income, hence society focuses around such people. What would help is a societal background that valued the more elderly or mature, for their experience, wisdom and human stories.)

Perhaps a graduated move towards care premises would be good, whereby a suitable one could be found in the local community and the potential resident spends some time there to build connections and tie them to existing links in the community outside, rather than that person going through an instant switch involving the sale of their own house and them being suddenly moved in to a care premises. Ideally, children and other family would be near enough to visit and spend time there too, but again we need societal change in this area. We seem to be more keen on housing our elderly relatives in care homes in the UK than say, South East Asia or Southern Europe. More interaction should be encouraged. (I've seen some families who barely see their parents once they've been moved in to a care home!)

I do feel interaction with local community institutions would also help - retaining an existing GP, interacting with local schools and even nurseries, community gardens, parks and the like - though obviously this would depend on the mental and physical fitness of the person concerned. Fundamentally we still see care homes as a last resort, rather than a good place to be, and a large part of that is due to the lack of community interaction. I see some sheltered or assisted housing, where there are good communal facilities and assistance available if needed, but the person is otherwise living in their own flat or rooms... Such premises could be combined with a more typical care home, so there is a mix of people within the institution, though this could present issues handling medical needs.

Sizes of residential housing is also an issue. Many people now buy new-build houses with small rooms and little extra space compared to older homes, hence there isn't always the capacity to bring in an elderly relative. Again this comes back to the issue of housebuilding, supply and demand, selling off of social housing, developers maximising profits by building small homes on greenfield sites whilst ignoring the many brownfield sites or old, disused homes that could be brought up to standard... Nothing in this world is disconnected! :-)

To return to the main points - I do think small care institutions can bring advantages, good personal care and rewarding relationships, but we do need to look at funding in this country. We also need to look at how we consider and treat the elderly in this country. These are big issues, but it is a matter of priority. I don't wish to turn this in to a political comment, but the current thinking seems to be aimed at small government, austerity and cutting services and council funding. Sooner or later we will have to accept more taxes if we want good social services.

I do like the ideas initially expressed at the top of this thread, but it would seem to get these accepted and off-the-ground one would have to push for acceptance from the council, government or regulatory body concerned. I am sure there would be interest in alternative care provision, given the struggles in the sector at the moment, and I'm sure families of those needing care would be interested in such alternatives too.

Very helpful

Alberto's picture

Wow, @zazie , thanks a lot – this is really interesting stuff. Ping @Rossana Torri – I think she will resonate with what you are saying (you from the care home side, she from the local policy maker side), and also can probably offer some of her own experience. Likewise, @WinniePoncelet and @Yannick and @Lakomaa had expressed interest in the policy/care intersection and could be interested in catching up.

Inspiring read

WinniePoncelet's picture

Thanks for the headsup @Alberto . Insightful words from @zazie .

I have a question. There are some practical examples of other possible ways (like the cohousing of elderly and students) that were succesful. How do these lessons find the ears of policy makers? If they do, how often does it get incorporated in policy?

It is often the ambition of projects to serve as an example for others to be inspired. Do we need to move up a level; is the example a government needs, one of another government trying a new way of governing, rather than an example of people doing something differently (eg. elderly care). The latter would be 'just a policy decision', the former would be 'the way in which policy decisions are made' and perhaps more relatable to a government?

Deeper than you'd think

Alberto's picture

@WinniePoncelet you have a knack for asking really great question. This one runs deeper than it would seem on first sight. 

Thanks

WinniePoncelet's picture

Thanks @Alberto . To return the compliment, I have the feeling answers are already scattered across posts on the forum and your work as a team.

What are your thoughts on the subject?

Difficult...

Alberto's picture

The question is so great because it made me realize I do not know. Not really. I have been to many a conference where high-ranking civil servants are exposed to the trends and buzzes of the month. But does this information really trickle down to a City Hall's office? 

Maybe @Rossana Torri can answer this...

Care Homes - The Bottom Line

zazie's picture

For those in the UK, this programme was excellent! (A VPN may help those elsewhere...)

http://www.bbc.co.uk/programmes/b08c2mlk

Shows how tight things are in the sector, and the difficulty of engaging with CCGs, local authorities, healthcare trusts in all their public / private permutations, budgets, etc.

The issue of addressing bed-blocking, specifically elderly patients in expensive hospital beds not being able to be released due to cuts in necessary social care provision (e.g. home visits to check on the former patient, giving medication, or even just checking the patient has all they need in terms of feeding and other basic care essentials) is mentioned, along with the practical difficulty of addressing it using the common-sense idea of utilising much cheaper spare capacity in care homes.

Another issue mentioned is the fact that people are often going in to care homes later in life, and when they need more care. (It's mentioned that residents used to arrive driving themselves to a residential care home!) It does seem the last resort now, with people hanging on as long as possible in their own homes, even if that means being on their own and struggling with shopping, cooking, etc.; less onus seems to be placed on the positives of being in a shared establishment with other people (company and activities, good facilties, cooking and cleaning taken care of, assistance on hand whenever needed, etc.) Is this reflective of our focus on youth and the "invisibility" of the elderly, our fear of aging and death nowadays, marketing, the cult of the self and independence, or somesuch?

Programme description -: "Care Homes - The care home business is heading for a crisis according to Evan Davis's guests in this edition of The Bottom Line.

The cost of providing care in this labour-intensive business has increased significantly because of the introduction of the National Living Wage. The fees paid by local authorities on behalf of poorer residents no longer cover the cost of providing accommodation, food and staffing. Care homes make up the shortfall by charging higher fees to privately funded residents. Social care analyst William Laing tells Evan Davis that private payers subsidise publicly funded residents by, on average, £8000 per annum. But this is not an option in less affluent areas with a shortage of fee paying clients.

John Ransford of the HC-One group provides care for mainly publicly funded residents. He tells Evan that 24 hour care for the elderly has to be provided for less than the cost of a night in a Travelodge.

Evan's guests believe that the care sector's business model is unsustainable. Find out what they think will happen next.

Dr. Jane Townson. Chief Executive Officer, Somerset Care Group

John Ransford, Non-Executive Director, HC-One

William Laing, Founder and a Director of Laing Buisson, Healthcare Intelligence Company"

 

Cohousing

zazie's picture

@WinniePoncelet -: There are starting to be some cohousing projects in the UK, but these seem to be focused around shared living for those who do not yet need care (aimed at the over 50s, rather than the more senior). It seems people in such projects envisage sharing a carer as they get to the point of needing help. I'm not sure of the viability of staying in such a place when serious dementia  or physical ailments start to occur; equally regular medication may require a qualified nurse and preventative care may require qualified staff on hand 24/7.

Again, I do think we need to start thinking about things in terms of the housing we are building. We can't just keep building homes for young families or "trendy" flats for young single people. We need to seriously consider social housing, mixed communities, purpose-built homes for the elderly, etc. Mixed housing should be mandatory for large-scale new build schemes, and not just a tiny number of "affordable flats" that the developer can negotiate to build in a completely different city (as is happening now in the UK!). Also social attitudes and culture need to move on; young people and families need to see a mixed community as an asset, that can bring wisdom and care for their own children within easy reach, rather than seeing it as something they wouldn't really be interested in.

I'd listen to my previous post above on the actual issues of budgets, who pays for what when interacting with the powers-that-be, etc. What I can say from these initial cohousing projects is that they're a start, but don't yet seem to consider serious (legally covered) nursing care.

(Are you aware of companies like McCarthy and Stone who build retirement homes, by the way? Perhaps schemes like that could be a way to progress the idea of cohousing and start people living together, with care facilities and good environments provided on top of their existing model.)

(Final thought - have done some volunteer work in a day care centre for adults with learning difficulties before... Perhaps a similar model, with day facilities and night care facilities built separately, or being more intermingled than just nursing home residents gathered in their particular nursing homes 24/7, would be a good idea. Those who were more capable could use cooking facilities, make and create, etc. whilst in their "day environment," and other age groups or people living in the local area could also come and use such facilities / interact / assist? Again, funding would be an issue, especially in our current environment of service cuts and the loss of community centres and other such facilities. However, in the long run, I do think such things could prove to save money by keeping people active and involved. (Been reading something else today on the fact that inadequate checks on the elderly costs the NHS £2bn per annum due to resultant falls! So even a weekly visit to a local centre, or some interaction / activity, could prevent such things and incorporate some very simple checks - asking how they are balance-wise, quick check on visual acuity...)

Again - the major issue is the fact that we don't have joined up thinking, but increasing fragmentation in health and social care. Each individual element is asked to cut costs and reduce facilities, even if that results in massive costs elsewhere...

I better stop at this point, or I'll get political again :-)

Very happy to converse more on this area / subject of health, care for the elderly, cohousing, mixed housing, etc. @WinniePoncelet ,  @Rossana Torri , @Lakomaa @Yannick ,  and @Alberto 

Have copied some links on cohousing in the post below...

 

The elements are in favour

WinniePoncelet's picture

It seems to me the elements to change this up are in place: financial urgency, social urgency, large crowd of people, successful examples, ...

It's interesting then to wonder what still needs to happen for a large scale shift. And who will lead it: citizens, government, private sector, ...? The potential is there and many (business or other) models are possible to tap into it. This calls for a catalyst I think: a party that is relatively uninvolved to help accelerate things in the right way, whatever that is, preferrably by facilitating implementation.

File under "prevention"?

Alberto's picture

@zazie , co-housing for people that are not (yet) in need of personal, direct care makes sense to me. Because:

  1. It is prevention. Healthier, more connected lives make for fewer years in care homes. People who retain a degree of self-sufficiency might be able to stay at home longer is their home is social and intergenerational. Prevention has great ROI; but our health care systems spend almost all of their resources on response instead. My feeling is that, to reduce the costs of health care, you should start running and climbing clubs rather than hospital wards.
  2. It is something that communities can do very well. Comparative advantage kicks in: it makes more sense for smart communities to focus on the relatively health and help them stay healthy, and for professional, capital-intensive orgs to dealt with acute conditions and non-self sufficient individuals. 

The catalyst

zazie's picture

@WinniePoncelet - perhaps it could be taken forward by a group of like-minded individuals pursuing the relevant parties... But seems to need research, making contacts (in local govt., CCGs, financers, etc.) first.

Given the way things are going, perhaps we'll see this happening sooner rather than later; as you say there is a huge need out there!

Co-housing

zazie's picture

@Alberto @WinniePoncelet

Definitely agree with the idea of addressing preventative measures as a priority - and across healthcare too. (Drives me mad that the public purse is spending billions on obesity, whilst big food corporates are profiting from cheap, sugary, snack sales...)

The preventative works with mental health and capacity too - keeping active and interacting with others helps no end.

There's been a lot of mention of finding new ways of addressing the issues with caring for the elderly in recent weeks, especially with the problems of capacity in A&E and more general hospital wards due to the lack of the necessary social care. Heard of a scheme in Wakefield the other day, where triage is used between various branches of care (hospital, local GP / nurses, local or community facilities such as care homes) which was proving very effective at managing need and ensuring "efficient" (for want of a better word) addressing of peoples' needs. (Some volunteer services, such as Help the Aged and the like were involved to help with transport and checking on a patient when they were ready to go home, rather than them waiting for ambulance services and staff from social care services to check on their immediate needs once back - but this did seem better than the individual concerned waiting unnecessarily in hospital, at huge cost.)

Another benefit found was that building such local links ensured the elderly were "monitored" as in an eye was kept on their health and quality of life, and people could be referred to locally available facilities that they may not have been aware of or may have been reluctant to request or attend.

Definitely think the time is ripe for new approaches, and also that a new willingness to try these is developing on the part of CCGs, healthcare trusts and local councils. Hopefully this will extend to national government, and they will allow local solutions to develop from the ground up. They are doing so in other health sectors, so there is hope. The CQC - given its very specific mandate and structure - may be another issue! But we can but try!

 

 

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