A specialist nurse who has worked with patients in both hospitals and care homes responds to our briefing on social care in Solidarity 544.
What’s happening at the moment in care homes has thrown a spotlight on how they operate. A lot of the problems now running wild were already problems, but with the pandemic everything is obviously more acute.
The thing I thought when I read the number of deaths is that staff must have been working very hard to keep people in care homes rather than sending them off to hospital. I think it’s generally the right thing, because most people living in care homes will not benefit from hospital treatment – it simply won’t work for them. For some vulnerable older people who contract the virus, particularly those already near the end of their lives, there may not be a lot you can do. You don’t want to take them from what is effectively their home into the chaos of a hospital, to have distressing medical interventions, when those interventions are not going to work. The only case is if you think something specific can be done. But these decisions should all be made on a case by case basis and not decided en masse.
For that reason reducing the infection rate is, or would have been, crucial, so you get back to the points about people needing to be able to work safely, or not work if necessary.
You need to get your head round what it means that care homes are independent private businesses. They can pretty much do what they want. Even if homes advertise themeslves as open to all and receive public funding, the companies that run them can pick and choose who they admit, and they will often choose not to admit people they think will pose a particular challenge. There is no right to care. I’ve had a patient who was turned down by twelve different nursing homes.
Care homes are also landlords and residents can be evicted, even if that basically means slashing their life expectancy. There are retaliatory evictions sometimes if someone complains. And of course many people in homes don’t have family to back them up, even before the difficulties caused by the pandemic.
Residential care homes have no qualified nurse on site; nursing homes have. But nurses in nursing homes usually don’t get proper training or support. It depends on what the company has put in place. They are cut off from the district nursing and other frameworks, from proper training, from being part of a collective team and getting peer support. At least with residential homes a district nurse who is properly trained and part of that wider framework will visit.
Care home staff of various kinds are held responsible but they get very little support, not just in terms of their terms and conditions but also in terms of doing their job.
Managers are accountable to the corporate body they work for, no one else really. Unless it’s something extreme safeguarding or failing an inspect badly, they’re generally left untouched. Recently I came across a case of workers making a complaint to the Care Quality Commission, and the CQC said you need to have PPE, and the manager said yes and that was it. And then the workers were targeted and treated even worse for having complained.
Without a union and collective organisation you can’t make an impact – that is what’s needed. You get exposes on Panorama and so on, but without staff being organised and having the support of the labour movement it is hard.
However the barriers to unionising are quite strong. The fragmentation of the system is the obvious one. Strong union organisation could overcome that but it’s chicken and egg. The same for the precarious terms and conditions workers are on and their vulnerability to management. The failure of unions to break out of the public sector and the large number of unions in health and care doesn’t help either.
I think if there was a wider, high-profile campaign to change social care it would lift workers’ spirit and maybe make them more confident to organise.
As well as all this, the profit motivate operates quite directly. You get homes shut down or expanded on the basis of what will make a profit. There was a spate of homes shut down a few years ago, and it seems staff are being laid off in this crisis – this is because care homes get paid per bed, so if lots of people die there will be empty beds, and less money coming in.
If you contrast care homes with the NHS, the health service is fragmented now but in terms of governance and people being held to account it’s on a different level. You have proper local structures, even though they’re not what we would want. The regulation you get in the care homes from the CQC is far more arms-length and last-resort. People’s families making a fuss is often the main mechanism for getting things changed.
There has to be a reorganisation to end the situation of totally fragmented units and of course public ownership would be the best way to do that.