The Future of Residential Care for Older People in Scotland - Full Report

Context

Why people move into care homes

The decision to move into a care home or supported living arrangement is by no means an easy one, either for the person making (or accepting) the decision, or for the family member(s) or advocate making that decision for them. It can be an emotional and stressful time for all involved, not least because it is often taking place in response to a considerable increase in frailty and accompanying loss in ability and independence.

There are various triggers that can see someone move into a care home, some relating to the person's condition (e.g. requirement for more intensive levels of support), and other 'external' factors such as family members no longer being able to provide care. Generally, the majority of care home residents enter the home not through choice but necessity, and are there for the final months of their lives.

Residential Care in Scotland - The Journey So Far

In the late 19^th century, for those who could afford to pay, the nursing reform movement led to the development of institutions which cared for people who were unable to continue to live within their own homes. These arrangements developed without significant regulatory oversight until the Nursing Homes Registration Act 1927; but real reform only came with the creation of the NHS and 1948 National Assistance Act, which placed a duty on local authorities to provide residential care for people who were unable to care for themselves for reasons of 'age or infirmity'. While this duty was generally enacted through the provision of council-operated services during the 1950s through to the 1970s, the 1980s brought a new era of private provision and outsourcing, the greatest shift being from NHS continuing care provision to independent nursing homes and the development of the current care home market.

This historical context speaks to a shift over time from state-run services to a market based model. However, unlike other areas of social care, a commissioning relationship did not develop between the local authority and the external provider. Rather, local authorities have largely limited their role to the facilitation of placements, contract management and to a lesser extent, care management and review. In reality, then, the local authority tends not commission residential care - it merely buys and consumes.

Within this context, a mixed economy of care has emerged - but with private sector predominance. While some councils have retained greater levels of in-house provision, and while the voluntary sector continues to play a small but important role in most local authority areas, almost all councils in Scotland are now highly dependent on care homes that are provided by private sector organisations.

Since the development of the National Care Home Contract in 2006, we have witnessed standardised contracts and more transparent and consistent approaches to funding care. This has largely overcome the variation and complexity in the contractual relationship between the individual, the provider and the council, which the Office of Fair Trading^[1] was particularly critical of prior to the establishment of the National Care Home Contract. We have therefore made considerable progress on the procurement of care in care homes over the last decade. The current mix of provision demonstrates general value for money, especially when private and voluntary sector providers are compared with the cost of in-house provision.

We can also be generally satisfied that work undertaken since 2006 has improved outcomes for individual services users. The introduction of national care standards http://www.nationalcarestandards.org/ and a strong and effective regulatory regime, along with a payment for quality agenda that has been devised to reward the best performing care homes, has delivered a general improvement in the overall quality of care provided. However, the current mix of services within the care home market is not producing optimum outcomes, when viewed from a whole systems perspective. That is to say, there has been limited innovation in the Care Home market in terms of new models of care - for example, in the use of care homes as a means of providing intermediate care (to avoid hospital admission or facilitate discharge). Generic care provision has been variable, with growing numbers of providers operating at higher levels of quality but with a significant minority continuing to provide care at undesirable quality levels.

Equally, it has not been possible for commissioners at a local level to fully shape market behaviour, with the speculative development of residential facilities in some areas unbalancing supply and demand relationships; and, by contrast, supply issues in rural areas or where local property markets have inhibited investment in care facilities. Providers, for their part, argue that in the absence of clear commissioning strategies at local and national levels, they have had to speculate about future need and commissioning requirements.

Furthermore, isolated instances of instability and poor performance have contributed to calls for increased levels of scrutiny within the sector. Most notably, the demise of Southern Cross has raised questions about the financing and financial sustainability of the sector, its regulation and its capacity to deliver against the expectations of service users and commissioners.