Care homes: Now is the right time to rethink what we want from our care sector

Derek Feeley, the Scottish Government’s former director general of Health and Social Care, has been tasked with reviewing “how adult social care can be most effectively reformed”, including "consideration of a national care service”.

He will report his conclusions to the Scottish Government in January.

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It is an opportunity to ask what we want from a care service: what are we willing to pay, and what difference would a new model really make?

On Tuesday, Public Health Scotland published its annual census of the adult care home sector.

As always, the costs are eye-watering.

At present, anyone with savings or assets (such as property) worth in excess of £27,250 is required to pay the full cost of their care home place. In 2018/19, 34 per cent of care home residents were “self-funders”.

Only once this is whittled down to £17,000 does the full bill fall to taxpayers; if the resident has capital between £17,000 and £27,250, they pay some of the cost and the local authority pays the rest.

Self-funders are also charged more than council-funded residents - a gap that has widened over the past decade as self-funders have been hit with above inflation fee hikes.

The gross charge for a resident who needs nursing care and is required to pay their own costs has gone from an average of £635 a week in March 2009 to £977 by March 2019.

Meanwhile, the charge for council-funded residents has gone from £544 to £739.

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The costs vary hugely though, depending on where you live.

A self-funded care home resident in Aberdeen is paying £1,203 a week on average compared to £782 in North Ayrshire.

Residents in Moray have faced the biggest increase in fees, with costs up 79% from £606 to £1087 per week.

This far outstrips any reduction in supply: since 2009, the number of care home registered places for older people in Moray per 1000 people aged over 65 in the region has only reduced by 7%.

However, it may reflect the struggle homes in rural areas face recruiting staff (in some cases having to pay employees’ accommodation as an incentive) and those overheads being passed on through increased fees.

This could explain why Argyll and Bute, despite having one of the oldest populations in Scotland, has seen its number of registered care home places for older adults reduce by 24% in the past decade.

In comparison, the number of places is up 70% in East Dunbartonshire.

The problem is something of a vicious circle: care homes are required to meet certain staffing thresholds to be considered safe, and if rural homes tend to struggle more than Central Belt premises to attract staff then they are more likely to be forced to close if staffing levels are inadequate, or simply fold because the high staffing costs make the business unsustainable.

As a result, families end up with heartbreaking decisions to relocate loved ones tens of miles away to the nearest available, suitable care home.

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Private business dominates the care sector: 74% of care homes in Scotland are privately-owned, up from 67% in 2009.

In some ways, it makes sense to want to remove the profit motive from care. We know that some major operators have taken huge sums from the public purse only to siphon profits out of the UK into tax havens.

But we also know that simply nationalising a service doesn’t mean taxpayers money isn’t wasted or misspent.

It is unlikely to solve rural care's recruitment problems as these also trouble NHS services.

And would a nationalised care service have been less prone to the devastating Covid outbreaks? Not necessarily if PPE supplies were still prioritised to hospitals and decisions were still taken to transfer infected patients into care homes.

We could look to other countries for inspiration.

In the Netherlands, university students get free accommodation in exchange for sharing accommodation blocks with elderly residents who they help out for 30 hours a week.

In Belgium, the 30-year-old ‘kangaroo housing’ initiative houses older people with immigrant families in the same property but on separate floors. The elderly person gets live-in assistance while the immigrants are helped to assimilate into the community.

One priority, however, should be to iron out the postcode lottery in costs. It is unfair that someone in Moray should have to pay £400 more per week than someone in Ayrshire.

But good quality care is expensive, whether you pay for it through life savings and assets or through a lifetime of higher taxation.