COVID-19 and care homes in England: What happened and why?

In the context of very high mortality and infection rates, this article examines the policy response to COVID-19 in care homes for older people in the UK, with particular focus on England in the first 10 weeks of the pandemic. The timing and content of the policy response as well as different possible explanations for what happened are considered. Undertaking a forensic analysis of policy in regard to the overall plan, monitoring and protection as well as funding and resources, the first part lays bare the slow, late and inadequate response to the risk and reality of COVID-19 in care homes as against that in the National Health Service (NHS). A two-pronged, multidimensional explanation is offered: structural, sectoral specificities; political and socio-cultural factors. Amongst the relevant structural factors are the institutionalised separation from the health system, the complex system of provision and policy for adult social care, widespread market dependence. There is also the fact that logistical difficulties were exacerbated by years of austerity and resource cutting and a weak regulatory tradition of the care home sector. The effects of a series of political and cultural factors are also highlighted. As well as little mobilisation of the sector and low public commitment to and knowledge of social care, there is a pattern of Conservative government trying to divest the state of responsibilities in social care. This would support an interpretation in terms of policy avoidance as well as a possible political calculation by government that its policies towards the care sector and care homes would be less important and politically damaging than those for the NHS.     

The Effect of Financial Incentives and Access to Services on Self-funded Admissions to Long-term Care

With the growth in the numbers and proportion of older people in the population the funding and incentive structures around long‐term care are of international concern. A study of the circumstances of self‐funded admissions to care homes allowed the comparison of self‐funders with publicly funded admissions to care homes in the UK, the influences on self‐funders in their decision to move into a care home and resources on which they were able to draw. These findings contribute to our understanding of the impact of current policy on self‐funders and our thinking about the way that future policy and practice changes could improve the way we use society's resources in the provision of long‐term care.     

Developments in home help for elderly people in Denmark: the changing concept of home and institution

The official figures on provision of home help in Denmark are compromised in that they include figures for help delivered to people living in assisted-living dwellings, facilities that were formerly considered nursing homes. Furthermore, many municipalities have integrated home help and nursing-home care and report this as home help. This article examines the effect of these administrative arrangements on the provision of home help and the distribution of home help in terms of hours per week. There has been a polarisation in size of care packages: a smaller group of recipients composed largely of people residing in assisted-living dwellings receive larger care packages, whereas the care packages to people living in their own dwellings have decreased in size. However, a sleight of hand of definitions regarding the concept of home has made the official figures on provision of home help look even more generous than they are.     

Human Motivation and Professional Practice: of Knights, Knaves and Social Workers

Efforts to improve the efficiency and responsiveness of public services by harnessing the self‐interest of professionals in state agencies have been widely debated in the recent literature on welfare state reform. In the context of social services, one way in which British policy‐makers have sought to effect such changes has been through the “new community care” of the 1990 NHS and Community Care Act. Key to this is the concept of care management, in which the identification of needs and the provision of services are separated, purportedly with a view to improving advocacy, choice and quality for service users. This paper uses data from a wide‐ranging qualitative study of access to social care for older people to examine the success of the policy in these terms, with specific reference to its attempts to harness the rational self‐interest of professionals. While care management removes one potential conflict of interests by separating commissioning and provision, the responsibility of social care professionals to comply with organizational priorities conflicts with their role of advocacy for their clients, a tension rendered all the more problematic by the perceived inadequacy of funding. Moreover, the bureaucracy of the care management process itself further negates the approach's supposedly client‐centred ethos.     

Settling In and Moving On: Transience and Older People in Care Homes

This paper reports on a study which examined the experiences of 46 older people who moved into nursing and residential care homes, interviewing them at four points, from before the move to up to six months afterwards. A key finding was that older people were actively involved in the process of settling into homes and forming new friendships. Participant data also indicated that these older people had often experienced many moves in recent years, as their need for care had changed, and following them through after their inclusion in the study indicated that, for some, there were more moves to come. These data place the debates about assessment, and the identified problem of "misplacement" in a different light. The problem is not simply one of improving assessment techniques so that needs and provision can be matched more accurately, but it may mean accepting that the needs of older people are likely to change over time. The question then is whether we can develop services and forms of provision which ensure that care moves to older people, rather than older people having to move to care.     

Part of the Problem or Part of the Solution? The Role of Care Homes in Tackling Delayed Hospital Discharges

As part of current UK policies to reduce the number of delayedhospital discharges, a number of commentators have identifiedan alleged crisis in the care home market as one of key contributingfactors. With local authorities under pressure to cut costs,it is argued, the number of care homes is reducing, and delaysin hospital can often result. Behind this diagnosis is a seriesof assumptions about the role and nature of care home provision,the appropriateness of this form of service for many older people,and the need for more care homes to reduce the number of hospitaldelays. In order to explore and critique these assumptions,this paper reviews the role of care homes in tackling delayeddischarges, and argues the need for fewer and different carehome placements rather than more of this type of provision.     

Health informatics for older people: a review of ICT facilitated integrated care for older people

Growing demands on welfare services, arising from expanding populations of older people in many countries, has led policy makers to consider the use of information and communications technologies (ICTs) as a means to transform the cost-effective delivery of health and social care. The evidence for these claims is examined by reporting the main findings of a review of worldwide published literature documenting the adoption of health informatics applications to improve health and social care for older people. It focuses around two dimensions of the UK government's programme for 'modernising' public services, which emphasise the use of ICTs to facilitate the sharing of health and social services information and its potential to foster person-centred approaches to independent living. Findings suggest that there is little evidence that these dimensions have been realised in practice and the perceived incompatibility between them is more likely to produce expensive and ineffective health informatics outcomes.     

“A game of two halves?” Understanding the process and outcomes of English care home closures: Qualitative and quantitative perspectives

With care services increasingly delivered via a market there is always a risk that care homes could fail financially or struggle in terms of quality, ultimately having to close. When this happens, the received wisdom is that subsequent relocation can be detrimental to the health and well‐being of older residents (possibly even culminating in increased mortality). However, there is very little formal evidence in the United Kingdom (UK) or beyond to guide policymakers and local leaders when undertaking such sensitive work. Against this background, this article reports findings from an independent evaluation of what is believed to be the largest care home closure program in the UK (and possibly beyond). This consisted of qualitative interviews with older people, families, care staff, and social work assessors during the closure process in one case study care home and one linked day center, as well as self‐reported health and quality of life data for older people from 13 homes/linked day centers at initial assessment, 28 days after moving and at 12‐month follow up. The study is significant in presenting public data about such a contested topic from such a large‐scale closure process, in its focus on both process and outcomes, in its mixed‐methods approach, and in its engagement with older people, families, and care staff alongside the use of more formal outcome measures. Despite significant distress part‐way through the process, the article suggests that outcomes either stayed the same or improved for most of our sample up to a year after moving to new services. Care homes closures may thus be a “tale of two halves”, with inevitable distress during the closure but, if done well, with scope for improved outcomes for some people in the longer term. These findings are crucial for current policy and practice given that the risk of major closures seems to be growing and given that there is virtually no prior research on which to base local or national closure processes. While some of this research is specific to England, the underlying issue of care home closures and lessons learned around good practice will also apply to other countries.     

Older People and the Health–Social Care Boundary in the UK: Half a Century of Hidden Policy Conflict

The boundary between health and social care services has been an important focus of both social research and policy reform in many western and northern European countries. In the UK there is a history of particularly sharp divisions between the centrally funded NHS and locally run social services. A consequence for older people, especially those with less acute or "intermediate" needs, is that they may be rationed out, ignored, or treated inappropriately on either side of the boundary. This paper seeks to go beyond explanations in terms of financial, administrative and professional divisions by using now-available public records to show how the boundary between health and social care was set in stone in the immediate postwar years and resulted in a constant battle between the two services over the needs they would meet. The first part of the paper examines a largely hidden history of health and social care policy. The second part examines the new NHS Plan and the extent to which it is likely to resolve the problem of the boundary.     

Professional Perspectives on Decision Making about the Long-term Care of Older People

With the increasing pressure on social and health care resources,professionals have to be more explicit in their decision makingregarding the long-term care of older people. This groundedtheory study used 19 focus groups and nine semi-structured interviews(99 staff in total) to explore professional perspectives onthis decision making. Focus group participants and intervieweescomprised care managers, social workers, consultant geriatricians,general medical practitioners, community nurses, home care managers,occupational therapists and hospital discharge support staff.The emerging themes spanned context, clients, families and services.Decisions were often prompted by a crisis, hindering professionalsseeking to make a measured assessment. Fear of burglary andassault, and the willingness and availability of family to helpwere major factors in decisions about living at home. Serviceavailability in terms of public funding for community care,the availability of home care workers and workload pressureson primary care services influenced decision ‘thresholds’regarding admission to institutional care. Assessment toolsdesigned to assist decision making about the long-term careof older people need to take into account the critical aspectsof individual fears and motivation, family support and the availabilityof publicly funded services as well as functional and medicalneeds.     

Mental Health Problems and Behavioral Disruptions in Nursing Homes:

This paper describes a study that examines knowledge of mental health problems and management of behavioral disruptions by social workers in nursing homes. Since a significant number of nursing home patients have mental health problems (estimates range from 50 to 80 percent) which present behavioral disruptions, this knowledge is critical. Results indicate that social workers are not prepared to provide needed services because they do not have adequate knowledge about the management of behavioral disruptions or the identification of mental health problems of nursing home patients. Recommendations are that social workers employed in nursing homes should have gerontological training and that national policy changes are needed to develop guidelines for qualifications of nursing home social workers. Nursing homes are not meeting the needs of older adults with mental health problems when social workers do not have the knowledge needed to provide nursing home services.     

Distribution of home help services in an elderly urban population: data from the Kungsholmen Project

Data from the total urban population 75 years and older in Kungsholmen, Stockholm were used to calculate the distribution of home help services. A structured questionnaire was used to collect information about education, occupation, living conditions, Katz Activities of Daily Living Scale, contact with the family, medical treatment and also questions about help needed and functional ability. Home help was considered to be provided when the subjects reported receiving home help service from the municipality. The number of hours of home help and the services received were registered. The results show that 86% of the elderly population in the Municipality of Kungsholmen live in their own homes, even when they are very old. Twenty-seven percent of those over 74 years and 33% of those over 80 years received home help services. The people receiving help were mostly women, single living, older and with disability detected by the Katz Activities of Daily Living Scale. The predicting factors of hours of home help are older age, condition of single living, disability detected by the Katz Activities of Daily Living Scale and less years of education. Our results also show that, among those who receive home help service, those with disability in the activities of daily living get more hours of help. However, a considerable group of elderly people are disabled but do not receive any home help. Our data stress the need for more attention by health care planners of domiciliary and intensive care and residential facilities for the high risk population (very old, living alone and with disability).     

Resilience among older caregivers in rural Namibia: The role of financial status,social support and health

Background: Namibia has one of the highest human immunodeficiency virus (HIV) prevalence rates and one of the highest rates of orphanhood in the world, and older caregivers provide much of the care to Namibians living with HIV and acquired immune deficiency syndrome (AIDS) (UNAIDS, 2014). In this study, the authors explore how financial status, social support, and health were related to the resilience of caregivers caring for people affected by HIV and AIDS in rural northern Namibia, Africa. Method: Data were collected through a structured interview from (N = 147) caregivers from the Zambezi region. Results: Findings from this study show that employment and physical health were significantly associated with increased resilience in older caregivers. Discussion: Our findings point to the need for employment assistance and health services to improve the resilience of caregivers caring for people living with HIV and AIDS. We conclude that there is a need for more vigorous concerted efforts from public and private sector practitioners and policy makers to create more sustained formal employment opportunities and intervention programs aimed at improving the overall health of older HIV caregivers, especially those residing in rural HIV endemic communities in developing countries.     

Return of the Nanny: Public Policy towards In‐home Childcare in the UK,Canada and Australia

Research on early childhood education and care (ECEC) policy focuses overwhelmingly on formal, centre‐based provision and, to a lesser extent, on family day care (or childminding) provided in the homes of registered carers. Comparatively little research addresses the policy treatment of care provided in the child's home by nannies and au pairs. This article examines the position of in‐home childcare in Australia, the UK and Canada, and the varied nature and extent of public funding and regulation. Introducing a new dimension into comparative studies of ECEC, it also explores how shifts in migration policy in each country have intersected with ECEC funding and regulation to reshape the recruitment and employment of in‐home child carers. Australia, the UK and Canada are all liberal, market‐oriented countries, but there is considerable diversity in the way governments support and regulate in‐home childcare, their rationales for so doing, and in the connections between childcare and migration. We argue that connecting the analysis of in‐home childcare to migration policies raises new questions about the classification and comparison of ECEC policies.     

The future for Meals on Wheels? Reviewing innovative approaches to meal provision for ageing populations

Winterton R, Warburton J, Oppenheimer M. The future for Meals on Wheels? Reviewing innovative approaches to meal provision for ageing populations The global phenomenon of population ageing is impacting on how community care is delivered, and a key component of health and social care services for the frail elderly is Meals on Wheels (MOW), a service that has traditionally encompassed delivering meals to older people in their homes. However, aspects of this conceptualisation of MOW are being redefined in order to address challenges posed by tightening global financial contexts, a reliance on volunteers and increasing social isolation among ageing populations. Through a review of the literature and websites from selected countries (UK, USA, Canada, Australia), this article explores and critically evaluates models of MOW delivery addressing these challenges. Findings suggest that MOW services are utilising a marketised approach, moving outside of the home and incorporating diverse volunteer roles. These findings demonstrate how services such as MOW can develop sustainable approaches to service delivery in a contemporary context. Key Practitioner Message: ?A review of innovative MOW highlights service models of broader applicability;?Varied delivery models and more diverse volunteer roles appeal to new sources of volunteers;?Research into the development of sustainable models with positive client social outcomes is now required.     

Autonomy,Choice and Control for Older Users of Home Care Services: Current Developments in Swedish Eldercare

In Sweden, a policy shift towards more individualized eldercare, with an emphasis on consumer choice, has taken place. The aim of this study was to analyze the processes and practices of individualized eldercare, focusing on preconditions for older peoples’ choice and control. Data consist of qualitative interviews with users of home care services (n – 12) and staff (n – 12) and participant observations (n – 7) of meetings between staff and older people. The choice and control available to older users emerged as decisions about ‘what’ care and services, ‘who’ should provide the care and services, and ‘how’ the care and services should be performed. Three approaches to enable older people choice and control over their home care services were revealed: test and revise, services elaborated in close collaboration between users, care managers and home care staff; choices in the moment, users could choose services at each occasion; and quality improvement through competition, competing providers develop attractive services. The findings could guide policy makers in combining the strengths of these approaches to enable older people in need of support to become co-producers in designing, managing, as well as consuming, care and services. Future quantitative research is needed to achieve generalizable knowledge about the strengths and weaknesses of different ways to organize eldercare services.     

Prioritising care services: Do the oldest users lose out?

Population ageing is a major concern in most European countries. Demands for health‐ and care services will increase, as older people typically have a higher need for such services. What is often overlooked, however, is that older users increasingly compete with younger users for the same limited care resources. We ask: How do employees in the Norwegian care sector make decisions regarding the allocation of services to younger and older users? To answer this question, we interviewed decision‐makers in Norwegian municipalities. Despite providing for equal rights to services, laws allow for an interpretation of needs and this can result in the unequal distribution of services. Our study indicates that needs are defined differently for younger and older users, which affects the amount, type and content of the services allocated to younger and older people. When resources are scarce and priorities must be established, the services to the oldest suffer. Key Practitioner Message: ● The article lays the groundwork for an open debate about the allocation of resources to users in different life phases; ● The analysis conceptualises and makes explicit important normative decisions made by practitioners.     

‘Someone's Decision: That is How I Got Here’

In the gerontological literature, the family has been characterised as either a party that has pushed the aged person into nursing homes or one which has assisted them to remain at home. But few studies have systematically examined the role the family plays in placing the older person in a nursing home. As part of a study that is reconstructing the pathway of 90 aged persons moving to nursing homes, this paper identifies the main actors in the institutionalisation decision, as well as the role the aged person, her family and health professionals play in decisions to obtain nursing home care.     

Using Private Social Care Services in Finland: Free or Forced Choices for Older People?

ABSTRACT

Use of private social care services among older people is increasing in Finland. This study aims to understand why older people choose private care in a comprehensive tax-subsidized social care system and examines whether people choose private service as a free choice or a forced choice as well as what factors contribute toward making these choices. Data for this study (N = 1,436) were gathered in 2010 from people aged 75 and above living independently at home in two Finnish cities: Tampere and Jyväskylä. Data were analyzed with several quantitative tests: chi-squared tests, multinomial regression analysis, and qualitative content analysis (for the open-ended responses from the survey questionnaire). Findings reveal that people chose private services mostly because of the effortlessness involved in its use and of the need for additional services that are unavailable through municipality; for example, cleaning. Majority of the respondents performed a free choice to use private services. People who lived in a city center with a higher level of income and who needed more services were more likely to be constrained toward using private support. Major concern, due to diminishing public service provision, is about service accessibility of economically disadvantaged groups; therefore, more research is required to understand the effects of the growing care market in Finland.