The plan to solve our care home crisis
When Johann Hari wrote a powerful account of the atrocious treatment his grandmother suffered during the last years of her life, a huge number of readers wrote in with similar stories of abuse, neglect and defeat. Here, he presents a 10-point strategy to protect the elderly
Wednesday 26 January 2011
My grandmother hated anybody making a fuss over her. The only time I ever tried to capture her on a home video, she dashed out of the room shouting "I dinnae want to be televised!" So she would have been bemused to discover that the story of the last 10 years of her life – in which she was treated atrociously by a series of care homes – caused such a reaction after I wrote about it 10 days ago. Since that article came out, I've been hit by a tsunami of emails from relatives and dissident care workers describing how they have seen elderly people being abused, neglected, drugged and defeated in residential homes across Britain. My grandmother went through a nightmare – but she was not the only one.
I have no doubt that if it was revealed tomorrow that the kennels across Britain were treating dogs this way, there would be mass protests on the streets. Do we really care about our grandparents less than our animals? I hope not. There is real pain in these emails – and there is a searing knowledge that this system will swallow us too in time, unless we radically reform it. So the emails have almost all ended with an insistent question: how can we stop this ever happening to another person? How do we stop it happening to us?
I'm glad the Care Services Minister Paul Burstow responded to the story by saying: "this shouldn't happen to anyone's grandmother". I'm sure he's sincere. But sympathy isn't a political program. If we are going to protect the 500,000 people currently in old people's homes – Ghosts of Christmas Future for all of us in an ageing society – we need a manifesto for transforming this system. Based on interviews with the best and bravest defenders of the elderly in Britain, I have drawn up a 10-point plan to do just that.
Act One Support elderly people to stay in their own homes wherever possible
Everyone would rather stay in their own home than be institutionalised. There is a whole range of services that make this possible – from Meals on Wheels to home helps who are there to help an old man to shower in the morning and get into bed at night. We should be stepping them up, to keep anybody who possibly can free and independent. Instead, we are ruthlessly stripping them away. The local councils who provide these services are facing the largest cuts of any part of this cut-hungry government. As a direct result, Which? magazine reports that councils are "tightening their eligibility criteria, cutting services and putting up prices" on help for the elderly. All the charities for the elderly are warning frantically that many won't be able to cope, and will end up falling over trying to shower themselves, or wasting away because they can't cook for themselves. The result? Huge numbers of people who could have stayed at home with a little help are about to get knocked into the care system.
Act Two They are better off with their families – so offer the care home funds to them first
It costs £450 a week on average to keep an old person in an institution. Almost all of these older people would rather be with their families, yet many families feel they can't cope. But what if you offered them the £450 a week, with which they could buy carers to come in every day to help? Many would be delighted to take up the offer. Alas, in my grandmother's case, it would have been impossible – her disability was too great, and she could only be moved by a large hoist – but for many people it would work. So make the funds transferable. Once an elderly person is judged to be in need of residential care, offer the same £450-a-week to her family first, with a home becoming a last resort. Many wards of old people's homes would empty overnight.
Act Three Make being a care worker a desirable profession
Today, our elderly are looked after by people who are paid the same amount as street-sweepers, and have the same level of training. The Care Quality Commission (CQC) says that 72 per cent of staff have no recorded relevant qualification. Many of the people looking after my grandmother had been given no training at all except for being shown a DVD about how to lift people for an afternoon, and then being left alone with 30 people with dementia. Some of the care workers for my grandmother responded with incredible sympathy and kindness. More reacted with irritation, anger and panic. They had no idea how to respond to the sudden paranoia and fear of a dementia patient: I often saw them telling my grandmother and others "not to be stupid," or snapping that she should "stop fooling around," which only made her more panicked and afraid.
Care workers are regarded here in many homes as, in effect, managers of cattle. One wrote to me this week saying: "Whenever I try to stop and have a conversation with a resident about how they are feeling, I am told off for wasting time by my manager. Lifting, washing and feeding are seen as work. Talking and caring are seen as luxuries." The turnover of staff is huge: within two years, 60 per cent have dropped out.
It doesn't have to be this way. In Scandinavia, being a care worker is a desirable and well-paid job, with long-term career prospects – so the homes are far better. You get what you pay for. How do we afford it? If we imposed a windfall tax on the banker's £7bn in undeserved bonuses tomorrow, we could double the wage of every care home worker in Britain, and so demand much better standards of training and qualifications. It would transform the lives of elderly people in one step.
Act Four Make every home publish its staff-to-residents ratio
Every parent knows how many pupils there are per teacher in their child's school. Nobody knows how many carers there are per resident in their granny's home. I asked at every home I considered: nobody would tell me. But this can make the difference between a good home and a terrible one.
If a care worker is scrambling to look after 30 needy old people, they won't be able to talk, or show kindness, or listen, even when they have good intentions. Even people who seem to have mentally disintegrated can respond to sustained conversation. In my grandmother's second home, there was a woman who spent all day howling: "Moira! Moira! Where are you Moira?" She had an Irish accent, so one day I asked her what part of Ireland she was from. At first she ignored me. So I started talking about when I had last been to Ireland for about 10 minutes, and suddenly she said, "Oh, I haven't been to Dublin for a long time," and started asking about the sights, and how the city had changed. The staff were amazed. Nobody had ever tried to engage with her amid the constant scramble. So publish the ratios. Make the homes compete to show they have the best ability to stop and talk.
Act Five Impose minimum nutritional standards for the food
The food in every old people's home I have ever been to is horrible flavourless slop. "In the home where I work, they spend £8 a week per head on food," one distressed care worker told me. "I am serving tinned spaghetti as dinner, without vegetables, to hungry elderly people, day in, day out, because that's what they make. I feel ashamed." For many people lost off the farthest shores of dementia, food is the last pleasure they will have, and a delicious mouthful is the last thing that can make them smile – and we offer them leathery mash. In our schools, there are strict nutritional requirements on the food they serve. In our old people's homes, the only requirement is that the food should be "of sufficient quality" – left undefined and unenforced.
Act Six Change the attitude
In every home my grandmother lived in except the last, they had a "bedtime", when my grandmother and everybody else was wheeled off and covered up, whether they wanted it or not. "But what if she wants to sit up and watch television and talk?" I asked one care worker in that first week. "Tough," she said. "We have a home to run." The job of any care home should be to serve the will and desire of its residents to live their lives, their way. But too often their desires are seen as a hassle, getting in the way of the smooth running of the place. Once real training begins, respect for the resident's own desires should be at its heart.
Act Seven Stop the mass prescription of anti-psychotics to rebelling residents
Many elderly people are horrified to be dumped in this excruciatingly boring and loveless environment – and respond with an entirely rational rage. They are quickly drugged into submission. The Alzheimer's Society says 140,000 people are being subjected to a "chemical cosh" – a cocktail of anti-psychotic drugs that they don't need – that reduces them to drooling zombies. To his credit, Paul Burstow has issued a ministerial directive saying this should stop, but who is checking? Gary Fitzgerald, the director of Action on Elder Abuse, says: "It's still happening on a massive scale. It's an easy and cheap way to control somebody who is very distressed. It takes more time to figure out why they are so upset, and to change the environment. So they reach for the pills."
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Act Eight Restore proper inspections of care homes
Judy Downey is a former care home inspector who now runs the Relatives and Residents Association. She explains that, beginning in the last days of New Labour and intensifying under the Conservatives, "inspections of care homes are basically being abolished. It's the great untold story."
If you try to contact the official care home inspectors, the Care Quality Commission, to say you are worried about or have witnessed elder abuse, they tell you to go away. Their website declares: "We cannot investigate your individual complaint." They refuse to act on warnings from members of the public. Instead, they tell you to plead with the home itself, or to contact charities for the elderly, or the Citizens Advice Bureaux – neither of whom are equipped by law or enough financial support to deal with this problem.
That is only one symptom of how the inspections have collapsed. In 2005, there were 50,000 physical inspections of care homes. This year, there will be a quarter of that number. David Cameron has called for "light touch regulation" of this sector, so homes are increasingly being asked to engage in "self-assessment". That means they will be asked to fill in a few forms. "But no home will admit on a form that it's gone wrong," says Downey. "You need people to actually go there and see it." Does anybody think that Parkside House in Nottingham, where five people died from rotting pressure sores caused by neglect, would have admitted on a form what they were doing?
The few inspectors that remain aren't even specialists in old people's homes. They could find themselves from one day to the next inspecting a plastic surgery clinic, a drug rehab unit, dental services, blood transfusion units, an abortion clinic, or prison facilities. The dedicated inspector of old people's homes no longer exists.
The fewer eyes there are on these homes, the more abuse there will be. So in addition to restoring frequent official inspections, we need to restore financial support for the network of charities that stand up for the elderly and make sure they are visited. For example, the Relatives and Residents Association is a brilliant group that helps confined old people who are screaming for help. From 1992 to this year, they received £40,000 a year to keep going. Now their funds have been stripped away. Others are facing similar cuts. But the opposite should be happening. These charities need to be expanded. They want to co-ordinate networks of volunteers with old people who have nobody to visit them, to make sure there's a constant flow of outsiders going into homes. The people who work there need to know there are eyes on them all the time. That takes official inspections, and even more frequent unofficial inspections from volunteers, friends and relatives letting the sunlight in.
Act Nine Make sure care homes that are shut down stay shut down
Every home that my grandmother lived in was rated as "good" by the inspectors, including the one where they forced her to walk on broken legs. So I can't even imagine what the homes they rate as so bad they have to be shut down must be like. Yet the brilliant investigative journalist Fran Abrams discovered something startling in a recent report for the BBC's File on Four. At least a dozen homes that were shut down for appalling standards last year simply reopened the next day in the same building with the same management, under a new name – and were allowed to "look after" elderly people. Indeed, they are then listed on the official inspectors' website as a new home, with no critical reports. That is how farcical and toothless our inspection regime currently is.
Act Ten Impose serious criminal consequences for elder abuse
At the moment, people who are caught committing crimes against elderly people in homes are almost never sent to prison. Last week, a couple in a care home in Cardiff were convicted of sadistically terrorising the elderly people in their care, including flicking their ears until they were "red raw". They were given a few hundred hours community service. A 17-year-old who raped an 86-year-old woman in a care home was sentenced to only three years and will serve much less. Gary FitzGerald says: "The message from so many verdicts like this is that you can attack elderly people and get away with it. We need a crime against an elderly person to be taken as seriously as a crime against the rest of us."
If the Government is serious in its sympathy for my grandmother and all the other people like her, they will offer more than honeyed words. They will follow these 10 steps. At the moment, they are moving in the opposite direction. They are cutting funds for the elderly and stepping down the few remaining inspectors. The horror that happened to my grandmother will happen to even more people.
But the Government will only act if we make this one of our priorities and demand it. At the moment, we turn away from care homes with an embarrassed shudder. We don't want to see. We don't want to hear. We want to jab some more Botox into our face and pretend that our youth is a permanent truth. It is revealing that the only time that care for the elderly ever enters the mainstream political debate is when they have to sell their empty homes to pay for their care. In other words, you only get angry when granny has to sell your inheritance, not when she is being shut away and abused.
The neglect of this issue by the Government is a reflection of our neglect. They are not acting because we are not acting. I feel ashamed enough that I only saw my grandmother twice a week. But every time I did, I would stare out at rows of elderly people who nobody ever came to see. Where were their families? What did they tell themselves? "Moira! Moira!" that woman would scream all day, but Moira never came. The generation of old people currently confined to homes saved us from the Nazis. Will we save them from our own indifference?
For updates on this issue and others, follow Johann on Twitter at www.twitter.com/johannhari101
To join the fight against Elder Abuse, you can join, volunteer for or donate to the excellent Relatives and Residents Association. Click here
To read Johann's article about his grandmother from last week click here
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