The Moral State We’re In

Nursing Homes and Care Provision

The nearest we have seen to this kind of public anger was over the Royal Commission on Long-term Care, chaired by Sir Stuart (now Lord) Sutherland, which was set up when the Labour government came to office in 1997. Its members were chosen from a variety of areas, with a heavy weighting given to nurses. Its conclusions were, essentially, that the government, with restrictions according to nursing assessments, would have to pick up the cost of the long-term care of older people.

The Commission’s basic argument was that, in an NHS that was free at the point of use, there was no distinction to be drawn between the kind of long-term care a person needed when very old and frail and the kind of help and care they needed when acutely ill in hospital. This was the majority view, though the debate over the distinction between nursing care and social care demonstrated the impossibility of the position we had got ourselves into, historically speaking. There were two dissenters, the aforementioned Joel Joffe, now Lord Joffe, who was worried by the rising and unsustainable costs of long-term care for the elderly, and David (now Lord) Lipsey, who realized that the Commission was moving towards a conclusion that would be entirely untenable as far as the government was concerned. He did everything in his power to make the other members change their view. His final minority report made it clear that he believed that older people themselves would have to pay the costs of long-term care.* (#ulink_70f8730b-68d2-5e83-9fd0-f01955ce838d)

Both the government and the Royal Commission missed a trick here and caused deep resentment amongst older people and their families that has not gone away, at least in part because people feel a grave injustice has been done. Indeed, it is in this area that real political action by older people might still become a reality, in a society where grey power has been a long time in coming. The curious thing is that this was, and is, an entirely unnecessary outcome. The Royal Commission ended with a recommendation, essentially, that long-term care should be paid for by the statutory sector. The implication was that the tax rates would have to rise to pay for this. They never quite got to the bottom of what was nursing care and what was social care, a problem that has bedevilled the care of older people for all my working life and which has caused much unfairness.

The classic question is that of the bath. Is giving someone a bath because they smell a nursing or a social task? If they smell, it is argued, it is a social bath. If they have sores or the possibility of them, then it is a nursing bath. On those grounds, the same bath, given to the same person, could either be given for free, for medical reasons, or be paid for, for social reasons.

After the government decided to reject the Royal Commission’s recommendation of requiring statutory payment, it came up with the worst of all settlements. According to assessments made by nurses, older people would get a weekly payment according to need, but this was not enough to pay the cost of a care or nursing home.

This has led to some bizarre results and is a good example of the politics of unintended consequences. Relatively wealthy older people, already in nursing homes and deeply dependent on nursing and social care, are getting help with the fees for their homes, usually allowing the nursing homes to raise their fees. Poorly off older people, not quite so dependent but without the children and relatives who might provide a some care, do not get enough help to allow them to be in a nursing home or care home, unless their dependency becomes so severe that the reluctant local authority decides to pay. Meanwhile, for many nursing home owners the fees provided by local authorities are so low that they have decided the whole area is uneconomic. They can make more money by selling the properties, especially in the booming southeast, and pocketing the profits. Staff costs have been rising and the availability of staff generally declining. The government settlement of help with nursing care has done nothing except raise costs and give a bit of help, often to the better off who are already paying their way in nursing homes.

In Scotland, where the decision was made to go the other way and to pay the full cost of care, the nursing homes are now deluged with older people and the system is cracking under the strain. Despite the strong feeling within the Scottish Parliament that this was the right direction, the total subsidy of nursing home care makes it virtually impossible to choke off demand. And in parts of Scotland where there is low employment or where property prices have not risen very rapidly, there has been an epidemic of nursing and care homes opening, simply because the income–though not huge–is assured.

All of this has been horribly unfair and has disappointed older people, who greatly fear the need for nursing home care and the giving up of independence. And it was unnecessary. Few older people and their families feel that it is essential that the whole cost of long-term care should be borne by the state. Approximately one in four older people will need long-term care of some kind–a proportion so high that it might seem like the kind of risk we should expect people to take on for themselves. Supposing the settlement went rather differently. Supposing older people themselves were required to take on part of the risk–perhaps paying for up to two years of care, which is the average time older people spend in long-term care. Beyond that period the costs would be fully covered by the state. One major advantage of such a scheme is that it would deal with the issue of unfairness. Though there is still a one in four chance that long-term care will be needed, it is reasonable to ask people to plan ahead for such an eventuality. But the cost would not be open-ended and, if prepared for by saving or by taking out an insurance policy, would not require people to realize major assets, such as selling their house, which is currently a cause of huge resentment. Though many people might not like such a system, they could not say it was unfair. Nursing contributions could then be restricted to those who elect to stay in their own homes-a further discouragement, if one were needed, to going into a nursing home.

The reason for the anger on the part of older people was so predictable and so unnecessary. The government was trying to choke off the cost of long-term care to the statutory sector, which is what governments do. But to older people, as well as their carers and children, it seemed as if the government thought people were going into nursing homes for fun, as if it was some kind of luxury item, like going on exotic foreign holidays. But for most older people, going into a nursing home is the last stage on a journey to death, much resented, much feared, the last thing most of them want to do. It was completely unnecessary for older people to become distrustful of a new government that had come in promising to do something about a situation that was generally agreed to be appallingly unfair. All the accusations were thrown into the ring: older people had paid their taxes, older people had given service to King and country during the war, older people were being abandoned, older people were being neglected, older people were being badly treated by the NHS and were now not even being helped when they needed long-term care. But underneath all this there was genuine resentment. Older people had paid their taxes on the basis of care ‘from cradle to grave’ and this undertaking had been broken without any debate, without consent from those for whom it had, apparently, been made. Older people had trusted the new promises of the welfare state from 1948. And that trust was being betrayed.

People do not choose to go into long-term care, even though their relatives sometimes think it is the best option. People want to stay in their own homes and remain independent for as long as possible. Sometimes this is not possible. Did the government not understand what an awful decision it is to have to give up one’s home, to embark on a one-way journey into a care home, to surrender one’s privacy, to have no control over one’s own life? Did they not understand that care homes and nursing homes are a necessity, not a luxury? Could there not have been some sympathy, some generosity, here? Instead, there are cases, time after time, of the Ombudsman finding that guidance on NHS funded care has been misinterpreted to save the NHS money, with a particularly heavy judgment in April 2000 that lead to considerable payouts by the NHS. The scandals about payment are legion, with an excellent campaign being run sporadically by the Daily Mail, ‘Dignity for the Elderly’, about the perversity and unfairness of the system. Since the government has paid out over £180 million in compensation to people who should never have had to pay their fees at all, it has been argued that ‘this is just the tip of the iceberg…The system is failing the most vulnerable members of our society, many of whom fought for our freedom and paid taxes throughout a long and productive life…More than 70,000 are selling their homes every year to pay nursing home fees often amounting to hundreds of thousands of pounds.’* (#ulink_4c5a0831-8155-5ca6-98b4-6158b1d97bef) The Daily Mail has not been alone in taking up the cudgels on behalf of older people. No one wants to be in a care home, and this is where government has made such a huge mistake.

Grey Power

From the resentment caused by the government’s reaction to the Royal Commission on Long Term Care, after years of surprising political inactivity amongst older people, there has grown the beginnings of a grey-power movement. It does not yet have real political teeth, but they will come. Though the organisation of the grey vote is not in the league of similar movements in the USA, the voting figures, which show that older people vote more than younger people, make governments nervous. If older people voted more on self interest, then governments would be in trouble.

And there are signs that older people, who have not hitherto voted on sectional interests, are beginning to change. They see themselves as having to bear the risk of the costs of long-term care, and they cannot see how they can trust a government that has, in their view, reneged on a promise to remove the inequities of the present system. Worse than that, they are beginning to ask whether they can trust any government to treat them fairly. The 75p increase in the old age pension in 2000 met with a furious response. As Gary Younge pointed out, in a hard hitting article in The Guardian shortly after that famous increase, the government’s determination to keep the pension increase index linked ‘was more than a mathematical calculation. There was political arithmetic there too.’* (#ulink_a1ae0bcf-e79a-51c3-a399-d7c27cae9550) The assumption, as Younge makes clear, was that old people would complain but that they would not fight back.

But the government got it wrong. Older people did fight back. The National Pensioners’ Convention is growing. On the question of council tax, some older people have simply refused to pay. In March 2002, one old lady, 102-year-old Rose Cottle, furious at the prospective closure of her care home where she had lived happily for many years, took a petition to Downing Street and caused some embarrassment-but not enough. By the next week things had moved on, and she was forgotten. Some have gone on hunger strike, and others have been moved-against their will-and have died shortly afterwards. But grey power is coming. As The Economist made clear recently, the overall fall in voter turnout is largely a change in the voting patterns of the young.

(#ulink_45668836-f8e5-584b-95ee-26b3c790b4cc) The old vote as they always have done. So pensioners, who represent 24 per cent of the voting-age population, accounted for 35 per cent of votes at the last election. At the next one, the figure is more likely to be 40 per cent. So grey power will soon begin to bite.* (#ulink_ad3db308-91f9-5989-9c0d-37038ab6235f)

Long-term care has been one source of anger amongst older people. Another issue that has caused resentment is abuse.

Abuse

A survey conducted by Age Concern as far back as 1991 estimated that between 5 and 9 per cent of people aged over 65 had been abused-more than half a million people. The incidence of abuse is clearly likely to increase as the population ages: the greater the level of dependency, the greater the risk of abuse. In 2004 Jennie Potter, a district nurse who is a national officer of the Community and District Nursing Association, compiled a report on abuse of older people

(#ulink_7396ed24-4785-58e0-ab90-7d16cfce692d) that suggested the problem was widespread. The CDNA surveyed just over seven hundred nurses, and found that a staggering 88 per cent of them had encountered elder abuse at work, 12 per cent of them daily, weekly, or monthly. The most common form of abuse was verbal (67 per cent), followed by emotional (51 per cent), physical (49 per cent), financial (34 per cent), and sexual (8 per cent). The most likely perpetrators were partners (45 per cent), followed by sons (32 per cent), daughters or other family members (29 per cent), paid carers (26 per cent), nurses (5 per cent), or other persons (4 per cent).

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This suggests a huge incidence of abuse, one that until recently we did not take seriously. Though dramatic cases often make the local press, very few are reported in the national papers. The appalling case of 78-year-old Margaret Panting, for instance, who died after receiving huge physical abuse that included cigarette burns and cuts from razor blades is little known. Whilst there is a major inquiry over the death of Victoria Climbié, and over every other child who dies in appalling circumstances, abuse of older people, which may also lead to death, simply does not carry the same weight, or tug at the heart strings as much. Yet there is equally a serious problem here, and some older people, as well as their carers and nurses, are now speaking up about it in a brave and forthright way. For it is not a simple issue, which, to some extent, is why older people have been loathe to raise it. Though there is some violence against older people on the wards of hospitals, most abuse is not the stuff of headlines. Much of it is score settling-often by a wife who feels she has had a rough time at the hands of her husband-when one partner becomes physically dependent on another. This may be no more than rough handling, verbal abuse, and a general lack of care and kindness. But it can still make the last years, months, or weeks of a person’s life intolerable. Then there are some paid carers who take advantage of their position to steal from their employers. I well remember my own mother’s fear of us confronting one of her early carers (the majority were completely wonderful, with this one exception) who was stealing from her and forging stolen cheques. That fear, that loss of the normal ability to confront an issue, makes the abuse of older people truly dreadful.

Even more complicated is the amount of abuse received from partners and children, normally due to the considerable levels of stress experienced from trying to care for someone as well as carrying on with the normal things of life. Action on Elder Abuse, a charity set up in 1993, has been campaigning for urgent official action after demonstrating in a variety of ways, including an undercover TV programme in late 2003,* (#ulink_364cb3a4-c6e0-511d-baac-76308788813f) the seriousness of the situation. An analysis of the calls the charity received over a two-year period from 1997 to 1999 demonstrated that two-thirds of the calls came from older people themselves or their relatives. Most of the calls concerned abuse in people’s own homes, though a quarter were about abuse in nursing homes, residential care homes, and hospitals.* (#ulink_3162da44-9c78-52e2-b20c-a03e15f69caf) There were cases of near starvation in care homes, of helpless older people left to die because their buzzers had been placed out of reach, nurses sleeping through night shifts and dressing patients in incontinence pads so they would not be disturbed, and the attempted suicide of several people in nursing homes that were due to close. Some of the statistics are particularly concerning. For instance, abuse appears to increase with age, and therefore with vulnerability. Given that vulnerability makes it harder to complain, this is particularly terrifying. Three times as many calls to Action on Elder Abuse concern abuse of women: women live longer and are therefore likely to be amongst the very old.

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There is the additional likelihood that cases of abuse will rise as the population grows older and the number of people with Alzheimer’s disease increases. Though we may not be ill for any longer than previous generations, the nature of our illnesses is changing. The increase of Alzheimer’s disease has huge implications for the kind of care we will need, and the amount of patience that will be required to deal with often very difficult, irrational, older people. Ironically, it will be even harder to detect abuse, for often the complainers will not be believed, even if they are telling the truth, simply because of the nature of the disease. Caring for those with dementia requires such a degree of patience and skill, and can lead to such frustration, that the chances of abuse increase and the levels of care needed will be much greater-for instance, more and more lengthy home visits will be required. Present provision is patchy at best, and often simply unsatisfactory, as Tony Robinson reported in his story in the Daily Mail about the care his parents received:* (#ulink_b8f8eacc-cab7-5abd-8608-a6343b39474c) ‘The NHS still fails to recognize the special needs of people with dementia, and won’t pay for their long term care…If we want a dignified old age for ourselves and our parents, it’s up to us to do something about it.’ Meanwhile, research suggests that some 22,000 old people are being given drugs to sedate them, to make it easier for care staff to manage them, according to Paul Burstow, the Liberal Democrat spokesman.

(#ulink_f666bec6-f5ce-56c5-9387-26947fcd98fa) If anything, this figure seems on the low side.

Yet on this whole question of abuse of older people there are detectable signs of change-most notably in the fact that considerable numbers of older people have raised the issue themselves. They have told district nurses, social workers and others, including friends, that they are being abused-despite the difficulties involved for those who may not have access to a telephone and the fact that those committing abuse may be close family members, as well as professional carers. Action on Elder Abuse suggests that there is a category of carers who hop from one agency to another as soon as suspicions about their abusive behaviour become known, with the result that they are able to move to another care home, to another group of vulnerable older people, and perpetrate their abuse all over again. To compound the problem it will be a long time before the National Care Standards Commission will be able to register all care workers. Action on Elder Abuse:

(#ulink_64c5abf1-0ef4-5e87-b1fa-cb47d2070dfc) argues that it may take anything between ten and eighteen years before care assistants and home helps are registered by the General Social Care Council; yet, as Gary FitzGerald, Chief Executive of Action on Elder Abuse, argues: ‘Less than three per cent of the identified abusers are social workers, whilst 36 per cent are home helps. There is clear evidence that we need to look at the other end of the scale.’ Despite this, the General Social Care Council is starting with the registration of social workers. Even when it reaches all care workers, registration will not give us all the answers because there will always be staff shortages and employers may well believe-understandably-that it is better to have some staff, even if a bit dubious, than none. Whilst the government wants half of all care home staff to have achieved NVQ level 2 by 2005, it must be questionable whether care home owners will pursue that goal as hard as they might, given how hard it is to get staff at all. It must be equally in doubt whether individuals who might have thought about becoming care staff will bother to go all out to be recognized as capable and reliable in these circumstances, given the numbers of hoops they will now have to go through.

Only the worst cases of abuse make the news, such as the attack in 2000 on Lillian Mackenzie, who was kicked and beaten by two teenage girls who were befriended by her. Jean Lyons and her sister Kelly had run errands for Mrs Mackenzie, who lived in the same block on an estate in Manor House, north London. Wearing balaclavas, they kicked her, beat her with an iron bar, and robbed her of about £800, as well as stealing her handbag and some documents. They then visited friends and bragged about what they had done. Yet Kelly was able to tell the jury that Mrs Mackenzie had been ‘like a nan’ to her and had taken her for meals at a local cafe. This was, as one reporter put it, ‘as mean and despicable offence as can be imagined’.* (#ulink_bd8fc337-a6ff-5075-a78a-acb3f7811b2b)

Yet if one scans the local papers, there are hundreds upon hundreds of cases. In June 2003, the Yorkshire papers took serious issue with a nurse who took away an older person’s buzzer because he was using it too much. He had to be fed by tube, as his stroke had left him unable to speak and partially paralysed. Yet he was perceived as being too much of a nuisance. As a result, he was overfed by five times the correct amount, could not let staff know things had gone wrong, and died unnecessarily.* (#ulink_076e878c-ec03-5776-8930-8f13e8907985) Another nurse in Yorkshire strapped up her patients in incontinence pads so she could sleep the night shift through, resulting in blisters, sores, and burns.

(#ulink_5cffbe10-cff4-51bf-8479-ef3aff665155) In Leicester a care worker was given a caution for slapping a frail older person. Again in Yorkshire, a nurse was accused of running a military style ‘boot camp’ in a care home for mentally ill older people: she had sworn at a 90-year-old wheelchair-bound man, as well as instructing care assistants not to lift up a 78-year-old man with dementia after he had fallen on the floor with his trousers round his ankles.

(#ulink_2e10999e-a966-504a-87c9-6c0fed3323f5) A woman of 69, a psychiatric patient, had her bed moved away from an alarm button because she was constantly pressing it. Mrs Wootton had a long history of mental health problems, and had set herself on fire whilst in hospital. But her death was the result falling from her bed whilst trying to reach the buzzer. She sustained a broken hip and, later, bronchial pneumonia.

(#ulink_8f9d0e8f-431e-5069-919c-2415d446b4dd) And these examples are quite apart from the murder investigations and the major cases of neglect.

The truth is that we know about this in our hearts. We see it ourselves with our own eyes. Look at the fear, the terror, in the eyes of some older people in hospital wards, in care homes, in nursing homes. Listen to what they say in code. Listen to how their carers speak about them. It is not universal, by any means, but it is common. And one of the terrifying things is that we have known about it, subliminally perhaps, for many years.

The redoubtable campaigner Erin Pizzey, famous for her action on domestic violence, has now taken up the cudgels. She argues that abuse of the elderly has a terrible habit of being kept quiet: ‘It is a bit like domestic violence amongst the middle classes–no one ever talked about it, although people knew it was going on…If baby-boomers don’t start kicking ass now about elder abuse, this will be their future–and they are a generation who are used to their freedoms. Tackling elder abuse requires a revolution–a grey revolution.’* (#ulink_85433279-4bb6-5baf-b642-5dae4dc698d9)

We know human beings are often very abusive to people who are in their care. We understand that there is a risk, but our way of dealing with it is to add layer upon layer of regulation and inspection rather than to encourage the opening up of institutions such as care homes and nursing homes so that ordinary people can come and go frequently, as part of daily life. Whether those in care are children, older people, people with enduring mental illness or learning disabilities, or even prisoners, cruelty can often well up from the depths of the human personality. We know it well enough from all the inquiries into abuse in large institutions. Abuse occurs wherever vulnerability exists. If we have strong legislation to protect the vulnerability of animals, why not for older people also? But legislation needs to go hand in hand with opening up institutions, for openness is far more likely to breed an atmosphere of trust than any system of regulation and inspection.

Fear of abuse has been further exacerbated by the chaos surrounding care and nursing homes, particularly, though not exclusively, in the south and west of England. With the rise in property prices nursing home and care home owners find it difficult to maintain standards and get staff. One by one, homes have been closing. The result is that older people who moved–often unwillingly–into nursing and residential care find themselves with nowhere to go when they are at their frailest and most desperate. Though this is not abuse as such, it is a form of mistreatment that beggars belief. Many professionals suspect that many old people attempt suicide because their future in such circumstances is so bleak.

Abuse exists in the NHS sector as well, as the CHI (Commission for Health Improvement) report into conditions in Rowan Ward of the Manchester Mental Health and Social Care Trust made clear. There was abuse, an inward-looking culture, low staffing levels, high use of agency staff, poor supervision and appalling management.* (#ulink_85b59d6f-2120-5139-ad1a-332dc13d213e) The report, which came after complaints of abuse of older patients by staff, found amongst other things: a ward left physically isolated when other services were moved to more modern premises elsewhere; poor reporting and clinical governance procedures that failed to pick up early warnings of abuse; regimented care; ‘Patients’ clothing was changed and their hygiene needs addressed according to a schedule rather than when the need arose.’ They also found sickness rates of 9.8 per cent during 2002 among nursing staff; widespread use of mixed sex wards in the Trust’s older-age mental health services; ‘rudimentary’ performance management of staff; an aimless service; and a lack of management attention to quality of care caused by transition to care trust status.

So can the NHS do better? Its record in this area is not all that reassuring. An inquiry by the Health Advisory Service in 2000

(#ulink_7867b3ac-9834-598c-8785-866e4203d4c9) demonstrated that older people were less satisfied with the care they received than younger people-which is surprising given that older people complain less than younger people. They experienced unacceptably long delays in admission, problems with feeding and with the physical environment, staff shortages, privacy and dignity, communication with staff, and, most profoundly, with staff attitudes towards older people. The recommendations were lengthy, but the most significant was that everyone-patients, relatives, and staff-has to take on responsibility for challenging negative attitudes about old age, about prospects for recovery, and about worth. So if the NHS has problems of this sort, will voluntary organizations take on the provision of care homes? Many already do, particularly those that are religiously or ethnically based. The mess in care home provision has come about as a result of inadequate planning and a cross-party agreement to shift the burden of care to the private sector. But the position is untenable. The risks of abuse would not be not hugely improved, and feelings of insecurity would remain.

An inquiry into the care market in London currently being carried out by the King’s Fund shows that there are still concerns about a number of familiar issues. For example, there is a very limited choice of care and support for older people. While there is no evidence of insufficient care home places for older Londoners, these may not always be where people want them; and there certainly is a shortage of services for older people with mental health problems such as dementia. The King’s Fund has also found that throughout London there are difficulties in recruiting and retaining nurses, social workers, therapists, and care workers. Older people’s views of services have been shown to be varied; some are very appreciative of a wide range of services, but there are widespread concerns about the quality of home care and residential care services. All of this is compounded by financial pressures, for in spite of increased government spending councils have to juggle the needs of older people with other priorities.

Though inspection of care homes has led to the uncovering of some abuse, inspection in itself is not enough: in fact the burden of inspection and regulation on an already precarious nursing and care home sector may make even more owners give up. Part of the answer lies in allowing ordinary people to visit older people in nursing or care homes, as part of a daily or weekly routine. However, the Better Regulation Task Force, a government body, warned that vital care services were being withdrawn precisely because of inflexible ‘no touch’ rules stopping volunteers taking older and disabled people to the bathroom or feeding them.* (#ulink_7f6d01c0-2a8e-5102-895c-808f715e744e) Indeed, volunteers, often in their sixties or seventies themselves, the so-called Third Agers, are now often subjected to the same training requirements for a few hours of help as professional care workers. The report was the work of a committee chaired by Sukhvinder Stubbs, who argued that small local agencies who work with volunteers are being affected by ‘silly regulation, bonkers regulation’. But the issue is really about the level of risk service users want to accept-for instance, the extent to which they want to be able to choose the temperature of their own bath water.

In the present climate we are automatically suspicious of people wanting to visit nursing homes and care homes on a casual, uninvited basis. Who are they? Are they would-be abusers? Are they after the older people’s money? Yet this attitude of mistrust, and the now ubiquitous fear of risk, may well be leading to a greater degree of isolation for residents. The more we close off institutions, the less we know what is going on within them, the easier it is for abuse to take place and for the residents to feel isolated, hopeless, and forgotten. Some system whereby lonely older people get visited on a regular basis needs to be taken up by a whole variety of organizations, from schools and colleges to churches and mosques, from Townswomen’s Guilds to Working Men’s Clubs. This sense of isolation, and the fear that taking an interest in older people will be seen as perverse, must stop.

A few schemes exist, such as the excellent British Red Cross’s Home from Hospital scheme, which has some 55 initiatives operating nationwide, but many more are needed. The Red Cross model gets round the issue of strangers coming in to people’s homes because the volunteers are trained and supported and the service is paid for by local social service departments. This model of supported, trained volunteers who do it because they love it, supported by professional volunteer co-ordinators and a serious, respected organization like the Red Cross, gives older people the confidence to use the service, gives volunteers the feeling that they will not be rejected by the people they visit, since the Red Cross badge will be seen as a mark of quality and safety, and makes the system run as a truly voluntary service with rigorous quality and safety checks.* (#ulink_006242bc-d316-5bd9-9885-a86e46685a6c) It is this kind of service that we need to see nationwide, with an expectation that most of us, if not in need of such support ourselves, should be taking part in providing it under the auspices of a respected, sensible organization. Such a model of practical help combined with care and companionship would make all the difference to the isolation and fear felt by many older people.

Care Workers

Another enormous issue is one that will run throughout this book: the low status, low pay, and generally poor conditions and training of those who provide care for the elderly and other vulnerable groups. Over the last thirty years or more we have seen the professionalization of nursing. Nurses are now university graduates whose training has made them technically very proficient. At the same time, they are often unskilled in basic hands-on procedures, which are increasingly undertaken by care assistants whose training is often minimal and whose security of tenure, and relationship with other members of staff, tends to be poor.

This is a complex issue. Originally, health professionals–particularly nurses–had their hierarchy modelled on the military. After the Second World War nurses came to see themselves as being on an equal footing with doctors. The result has been that nurses’ status has risen. The former slave labour demanded of student nurses has, by and large, disappeared, and student nurses are now spending a great deal more time actually studying. There has, however, been a downside to this. Nurses no longer provide the discipline and structure of a ward or a hospital in the way that they used to do; in addition, routine tasks such as emptying bed pans, giving patients their meals, or turning them and making them comfortable in bed has been handed ‘down’ to care assistants. Nurses are now too expensive a resource to be allowed to feed patients, make beds, or plump up pillows and are too busy giving drugs and injections to empty bedpans. Nor have they been trained to talk to patients and find out what is really worrying or concerning them.

All this is a cause for deep concern, because so many patients will be older people whose recovery rate will be slower than that of younger people and who will inevitably be worried about what will happen to them when they leave hospital. Many will not be fit to go home. Many will be classed as ‘bed blockers’, as if it were their fault that they have nowhere to go and not that of the system that has failed them by not supplying enough nursing home and care home beds. Nurses could be the ones who listen to the fears of elderly patients, who reassure and comfort, who try to speed up social services, who use their position to get things done–and often they are. But because they have so much less hands-on experience than in former times, because they have not been routinely talking to their older patients as they help them eat, or change, or wash, or make their beds, they often do not have the closeness, the intimacy–in its true sense–with their patients that could be used to allay some of these fears.

The people who are currently performing the most intimate tasks for the patients, most of whom are old, are the care assistants. However, they do not have the status to allow them to tell relatives and social workers what is worrying a patient. It used to be said that the people who knew most about what patients were really feeling were not the nurses at all but the cleaning staff, who would chat to patients while they mopped round their beds. The gradual contracting-out of cleaning services has removed even this degree of contact. The people who are left to hear the patients’ stories are very often the care assistants. Yet many of them are largely untrained. National Vocational Qualifications are increasingly common, and many hospitals, care homes, and nursing homes encourage their care assistants to take those exams. But not all hospitals pay for the training or allow staff time off, and many do not offer more pay when a qualification has been gained. If care assistants were actively encouraged to study for NVQs and then, where appropriate, to move on to more advanced qualifications, the whole atmosphere might change. Care assistants would then be seen as embryonic nurses rather than skivvies. Though this happens to some extent with the skills ladder the NHS has in place, there seems to be a remarkable amount of resistance to letting people through the various ‘glass ceilings’ and allowing them to move from care assistant to nurse, and from nurse to manager.

Transferring such a scenario into the main care sector for older people, nursing homes and care homes, where there will probably be only one qualified nurse on duty, would similarly have a transformative effect on care assistants. They would no longer be seen as short-term employees doing dirty work for little money and no emotional and ‘respect’ reward, but people who may go into nursing eventually or who may choose to remain as care assistants, at the top of that particular tree, with all its attendant qualifications and respect. The government has set itself the target of half of all care home staff having reached NVQ level 2 by the year 2005. It is pretty unlikely that the target will be reached, but the government’s intentions are good, and grants given to care home owners to help them pay for courses and study leave would speed up the process. It is, after all, well attested that training care home staff can reduce the amount of abuse, both intentional and unintentional, quite considerably.