The covid pandemic has put Scotland’s care homes under the spotlight in an unprecedented way.

Much of the attention has been devoted to private care home providers, with politicians and commentators now asking what role – if any – they should play in the future.

One manager told healthandcare.scot he felt care homes were routinely “vilified”.

Others say politicians and the government have, until now, undervalued the sector, overlooking problems that stretch back for years.

Figures released last week reveal the role of private companies in the care home sector in Scotland has increased over the last decade as charitable and public organisations exit the market.

Scottish Labour described the statistics as “a wake-up call to the creeping privatisation of public services”.

Monica Lennon MSP, the party’s health and care spokeswoman, said it was now “more important than ever to take profiteering out of care homes”.

Last week Public Health Scotland published its annual care home census, which reveals that private care homes for older people account for three quarters of the total, up from 67% in 2009.

From March 2009 to March 2019 the total number of care homes for adults fell by 22% from 1,416 to 1,102.

Closures were concentrated among not-for-profit homes and those run by the public sector, where numbers fell by around a third, meaning the private sector grew in importance.

Annie Gunner Logan, head of the Coalition of Care and Support Providers, which represents third sector providers, says part of the problem is a lack of funding through the national care home contract, which sets the rate that local authorities pay for residential care.

She told healthandcare.scot the proportion of care homes run by the third sector has “been shrinking for some time.”

The last major withdrawal was Bield, which in 2017 announced it would be closing the 12 care homes it operated.

At the time the charity said it was losing a “significant amount of money” on the homes and was running out of cash to plug the gap.  

Ms Gunner Logan said: “Essentially, the position for third sector organisations is that if you want to invest in staff training, uphold the principles of fair work and deliver the quality of care that your charitable mission and objectives require of you, then the rates agreed under the national care home contract will not support you to do that.

“In general, third sector providers aren’t prepared to make the sacrifices on any of these fronts in an attempt to make the numbers add up, which is why those who are still doing it are struggling, financially, and others, like Bield, have exited.”

One option would be to seek out more people who pay for their own care, to balance out the lower rate paid by local authorities publicly-funded spaces.

Currently anyone with assets of more than £27,250 is expected to pay their own home fees. Below this level the council steps in.

Self-funders pay an average of £977 a week for nursing care while the charge for council-funded residents is £739, a gap that has widened over the last decade.

Ms Gunner Logan says many charities oppose seeking out higher numbers of self-funders as it conflicts with the principles they operate on.

Meanwhile there is “strong resistance” to the idea of charities using their own reserves to “shore up basic services”.

She added: “The national care home contract rate is a particular problem for smaller care homes where the third sector tends to focus – with honourable exceptions, and even then, the larger ones in our sector tend to cluster into smaller ‘units’ in order to present a more homely feel – because the ‘economies of scale’ available to larger homes are not available.”

Professor June Andrews, a former Scottish government advisor who has sat on care home design panels, believes the decline is “due to unsuitable and unviable homes” dropping out of the market.

This can often be due to demands for facilities like ensuite wet rooms, which Professor Andrews says are essential for residents’ dignity.

Professor Andrews, a former director of nursing at NHS Forth Valley and author of books on care homes and dementia, says non-private operators can struggle to find the cash to upgrade facilities.

“The pattern of change in sectors is partly due to older less suitable buildings being more common in the local authority and not-for-profit sector.

“They do not in general have the capital or the permission to raise capital that would be needed for a new build in most cases.”

This week a Scottish-government-commissioned analysis of discharges from hospitals to care homes suggested that a premise’s size – not a lack of testing – was the key driver behind outbreaks.

Health Secretary Jeane Freeman has also said smaller institutions appear to have handled the virus better.

However, conditions in the care home sector – with the main funding levels set by government – appear to have encouraged the growth of large institutions with more residents.

Over the last decade places available across Scotland fell by just 5% as the number of residential care institutions fell by 22%.

Professor Andrews draws attention to the business benefits of larger sites with more people.

“Big companies do not get much sympathy in the press, but they offer economies of scale in back office and head office support, such as HR, payroll, staff training and supervision,” she said.

“They also have capacity to maintain compliance levels by centralised monitoring of issues such as untoward incidents, and requirements for standards. They can cross subsidise a home that has a temporary financial problem.

“Of course, any business can have a local problem when a local manager fails, but the whole company should not be damned by one failing unit.

“We do not say that the whole NHS is untrustworthy when one hospital is in trouble, but sweeping statements are made about the care sector.”

 

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