Exporting Care

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.

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