Care homes and domiciliary care are key parts of British society, but are usually viewed as the poor relation of the NHS.

There are more than 457,000 beds in the care home sector, and a similar number of people are cared for by home care workers. The sector employs about the same number as the NHS, nearly 1.5 million.

The misunderstanding, and poor treatment of care homes by government and the NHS, has been illustrated in the Covid-19 pandemic when the NHS was prioritised in terms of capacity – involving the movement of tens of thousands of hospital patients into care homes, without being tested for coronavirus – and personal protective equipment for care workers, resulting in at least 30,000 excess deaths.

Despite this, care homes and the domiciliary care sector has become expert in: dementia care, continuous care planning, palliative care (end of life care), ‘hands-on’ caring and nursing and monitoring technology.

We need to make sure that we: 

1. Give responsibility to the CQC for the financial regulation of the care home and domiciliary market:  The CQC (Care Quality Commission) needs to take on responsibility not just for regulating quality, but also for system sustainability in terms of making sure that the rates paid to care home and domiciliary care providers are appropriate to keep both current services open, and to invest in upgrading the physical stock of care homes. Clearly, those rates are not even achieving the first of these objectives. In terms of what capacity is required, in future these should be provided by the Integrated Care Systems (ICSs) and submitted to the CQC as the regulator responsible for system sustainability.
2. Raise fee rates and invest in the  care sector:  Another requirement, following on the utility ROI regulation, is to raise fee rates so that companies can invest in their workforce, in building their capital stock, in establishing an intermediate care sector, and in leveraging technology.
3. Provide clear executive authority: Currently, no single person is in charge of the many ‘moving parts’ that comprise safe discharge of patients from hospital and their ‘re-entry’ into a care home or their own home, and the diffusion of responsibility engenders confusion, misinformation, delay and blame-shifting. The answer is to have one person, inside the hospital, in charge and – by ‘in charge’ – that means the power to mandate that care packages are available, and that care home places are available. That means the authority over the total discharge and community resources and the process. In turn, this requires that the current budgets and commissioning responsibilities are absorbed into this discharge function from the local authority and the CCG.
4. Include hospital discharge responsibility for the CEO of community-based care:  Hospital bed blocking is very expensive. Addressing this alone could potentially save billions of pounds over a few years. Moreover the patient could receive the same or better quality of nursing care in more appropriate care surroundings, delivered by staff with experience in specialist older and dementia care, and with less risk to them of hospital-acquired infections.

Clearly, the UK is not the only country with an ageing population, and other European countries are trying to wean themselves off an economic system that allowed high spending in the short term together with lower taxes, all to be paid for by a demographic quirk that meant the working age population was much larger than the retired, pensioned population.

This demographic quirk has now unwound, and it is now no longer possible ‘to kick the can down the road’.

It’s not easy. But there are lessons to be learnt from other countries. Neither the German nor the Dutch systems are perfect and both face difficult choices.

Yet they have managed to develop a system of social care that both raises more money for a better funded social care system (as described in the earlier Book 4 of this series) and one that is more stable and agile in serving the needs of the vulnerable adult population.

Stephen was introducing Book No. 6 of his series The Best NHS?