Location, Location, Location
Yesterday I read this article in the Guardian. It reports that in Germany there is an increase in Germans being placed in residential, retirement and rehabilitation units in eastern Europe where the costs are lower.
As the article says
Germany’s chronic care crisis – the care industry suffers from lack of workers and soaring costs – has for years been mitigated by eastern Europeans migrating to Germany in growing numbers to care for the country’s elderly.
But the transfer of old people to eastern Europe is being seen as a new and desperate departure, indicating that even with imported, cheaper workers, the system is unworkable.
But before we are too quick to castigate Germany, I think it’s important that we look at what happens in this country.
Until one month ago, I was a local authority employed social worker, seconded into an NHS Trust (as I was a mental health social worker) working predominantly with older people. I made a lot of residential and nursing placements. I worked in an inner London borough.
The amount of local placements we had came nowhere near meeting the needs of the local community. Yes, there has been a push towards caring for people longer at home – perhaps it was a feature of central London, perhaps not, but many of the people I worked with did not have family around them. The cost of housing had pretty much seen to that in terms of ripping communities apart.
Still, there are pockets of close communities even amid the high towers of the financial centres of London. Among the office blocks and fancy shopping streets, there are communities that have evolved over the decades, centuries even and those tourist spots visitors see, they are ‘home’ to many people who might not wear the smartest suits or have the fanciest accessories.
We ‘converted’ some of the residential provision locally into ‘extra care sheltered’ provision – see, that would be good, that would ‘keep people at home’ for longer.
So where are we now?
The chances of getting a placement in the local area are very slim to zero. We had waiting lists months long for some of the residential provisions in the area. The wonderful ‘extra care sheltered’ housing provision realised soon that they could not manage the needs of those who needed 24 hour residential support or maybe the criteria for residential care moved higher but they have not truly become an alternative for someone who needs a residential placement. They have become a safer environment with a constant ‘warden’ for those who may otherwise have had sheltered accommodation.
So there are fewer residential and nursing placements for people who are local to the area. If a family shouts and hollers enough they may get someone on the ‘waiting list’ for a place. Who knows when that place will come up. We don’t like saying it explicitly but places in residential and nursing homes usually come up for one reason and that’s a death or a deterioration in physical health and noone wants to think about that.
What does a local authority do then?
It moves people out. It is more likely to move out people who have no family support and no ‘links’ to the area. You see, living somewhere for 70+ years isn’t seen as ‘link’ enough if your family and friends aren’t there. Anyway, even if they don’t want to move you out, if there are no beds, there are no beds.
So while we aren’t moving people to other countries, that’s only really by virtue of us being an island. We aren’t that much better than Germany in this respect. We are moving people to unfamiliar settings and localities on the basis of cost alone.
Commissioning Quality
How are these decisions made? Well, to absolve myself from responsibility, I’ll say it wasn’t my decision. I did and do rage against it. I raised it internally as the ways these decisions are made are purely on the basis of finances of local authorities to make placements.
Currently, in inner London we are placing frequently in outer London but soon it will be the Home Counties and further and further away from familiarity. I wonder how consistent this is with the Mental Capacity Act which demands previous preferences are taken into account. This can be ridden over roughshod if there aren’t any local placements at the right cost.
So we move to commissioning. There has been a race to the bottom in terms of providing services and placements at the lowest cost. Property is a massive cost in central London so cheaper land can push down general cost but at what price to autonomy and preference?
There has to be a way for commissioners to be accountable for the decisions they make. Families can push and make complaints on behalf of those who are not able to make decisions for themselves but there really needs to be, in my opinion, some external scrutiny of commissioning decisions made by people who really understand the social care sector. Yes, councillors can scrutinise but how many understand the needs of those who are not pounding on their doors making complaints about council services? Who understands that those who have the quietest voices or who have noone to advocate for them may be having their rights ripped away from them?
I’m not sure of the answers. All I know is that I wish the commissioners would have listened to their social workers. I wish there were a stronger, formal system of advocacy which would raise these issues with people who commission services and I wish there were an understanding in central government of the impact that geography makes on the cost of social care.
There may be cheaper and more available placements in South Yorkshire but that doesn’t mean the answer is placing Londoners there. I fear it may well be in the future.
We can’t become too complacent. Germany today may well be Britain tomorrow.
Unsafe Spaces 
Brilliant piece as ever Ermintrude – thankyou. I read the same piece with dread – as you say we aren’t far behind.
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The usual crisp clear analysis that I associate with your postings.
Some years ago Kent County Council began exploring the prospect of placing older people in homes in northern France; they were embarassed out of it by ‘questions being asked’…. but meanwhile even outer London boroughs began the business of scanning the horizon for cheap answers, such as arranging for people to move from say Romford to north Kent – not too far away on paper, but completely out of the question for relatives (spouse/partner) to visit. No public transport, and possibly no longer able to drive, the relatives of the 10% of care homes residents in a long term relationship were destined to become strangers!
Given that “we ain’t seen nothing yet” so far as the impact of austerity there are likely to be plenty of people – either ‘far sighted’ providers, or canny commissioners – who will begin flying kites, citing progressive Germany as a role model.
Such alot of red tape and hassle yet it will always be the front line sw or carers that bare the brunt of the downfall displacing people it’s a shame those forcing the cut price care are often those who have afew spare rooms and funds that could probably help more
In mind of not being politically correct in so noting, you have not noticed that a very great proportion of ‘care workers’ , in the metropolis certainly and in large cities in the UK, are from overseas, often with limited/ poor spoken and written English, (I have experience of this). They accept the minimum wage because it is a job they cannot get in their own country. Many of these come on student visas. It is easy to get a clear CRB because there is ‘no history’ here and the work is ‘level entry’.
My concern is not just with sending elders to other countries to be cared for, but the fact that there is no doubt that care will be inappropriate or inadequate across cultural and linguistic barriers even here.
With many elders with dementia living alone, some of the harm / poor care to these most vulnerable will arise from inadequate and inappropriate care packages from care agencies recruiting people with inadequate / inappropriate linguistic skills.
The inability of care staff to communicate properly has been raised many times in reports but is ignored by local authority purchasers and social workers, even Ed Milliband is ‘mouthing’ this matter now.
But an additional issue for the very old now is regarding knowledge and attitudes to behaviours common in dementia unfamiliar to many ethnic groups. The care workers here are often from other countries where they may not even have seen, let alone worked with, very old people, or seen someone with dementia, because the majority do not yet live long enough in their countries to develop it or are hidden and looked after in family environments for shorter life spans).
We are putting the care of vulnerable people into hands we should not in the UK. Why worry about Germany?
I really don’t think that’s likely to be the case.
As it happens, I once worked (before qualifying as a nurse) alongside a care assistant from Zimbabwe. Her concern wasn’t the stunning realisation that elderly people exist. She was more disgusted by the way we Brits farm out our parents and grandparents to care homes instead of taking the time and trouble to care for them within our own families – for someone in Zimbabwe to do the same would have been deeply shaming.
My post was not anecdotal, nor based on experience of a single care worker. Apparently life expectancy in Zimbabwe is 51.82 years. No doubt they marry in the teens and are grandparents very young.
I accept that in many countries elders are not farmed out. But it is naive in the extreme to think all are well cared for any more than here, although I expect they would not wish to have interference (from the state) that distances them from their children, as in many of these countries elders expect to be looked after in old age too.
Not always good to compare anecdotally, because we are not often looking at like for like situations in other cultures, where state interference in family life may be low and the ‘services’ minimal.
In mental health care people have been farmed out for years in the UK. Many people are moved so far away from their home albeit still in the UK just, that their family can no longer visit and eventually lose touch. We have been doing this to people for a long time so why are we suddenly concerned when it is the elderly?
I don’t think it’s ‘sudden’. I was just responding to what I have been seeing. I think we should be concerned wherever it happens. With older people I’ve worked with, it has often meant spouses who are also older cannot have access as easily and often the moves are for the rest of someone’s life but compassion shouldn’t be an either/or. We can care about both, surely?