Care crash - change course or face disaster

Northern Ireland is facing a crisis in care that could see our entire system collapse in the next few years.

Costs are going up while fees are being squeezed and this has left the independent sector – including both third- and private-sector operators – at breaking point, but they are so central to our care structures that any significant failure would be disastrous.

This week Four Seasons announced the closure of seven of its residential homes - prompting Health Minister Simon Hamilton to take emergency action over plans to reduce statutory provision. As things stand, such incidences are only going to become more frequent until the whole structure fails.

Independent providers receive much of their income from trusts, and are responsible for most provision both in the community and in residential homes.

There are around 16,000 care home beds in Northern Ireland, almost 15,000 of which are administered by the independent sector. At the same time, around 24,000 people receive care in their own homes every week, with two thirds of non-statutory.

The people who use these services are frequently older or have disabilities and can be utterly reliant on what they receive.

Therefore a catastrophe in independent care would be a catastrophe in care full stop – and it is a very real and imminent possibility.

For the past few years the sector has warned that many of its members risk withdrawing their services because they are no longer financially viable.

Independent Health & Care Providers (IHCP), an umbrella group representing many providers here in Northern Ireland, and the UK Home Care Association (UKHCA) worked together to produce a report in 2013, Can We Trust the Trusts?, which accused health trusts of “undermining government policy” by cutting payments for care, ultimately causing providers to see their finances stretch further and further.

As things stand, we remain on the same trajectory. It seems unfathomable that our senior health administrators – the minister, trust executives, and so on – will accept what is coming and just let it happen.

The bigger worry is not whether they will eventually address the issue, it is whether anything can be done about it at all.

The healthy context

The crisis in care mirrors wider problems in HSC, albeit on a more acute scale.

Since the creation of the National Health Service, the needs of the general public have changes dramatically and, in many ways, public health services are a victim of their own success.

We are living for far longer but this means many more people are living with chronic conditions or long-term requirements for support – and, factoring in the increased number of potential treatments due to medical advances, far more is expected of an NHS nowadays than was the case just after the Second World War.

Far more is expected, and far more is delivered – but that does not mean that demand cannot still outstrip supply, and that is happening as we speak. Current estimates suggest:

• By mid 2039 the number of people in Northern Ireland who are aged 85 and over will go up from 34,400 to 88,600 – an 157% increase
• Over the same period the number of people aged 65 and over will rise to 498,500
• One in 14 people aged over 65 have a form of dementia, this rises to one in six people amongst the over 80s and one in three over 85

If care services are at breaking point already, then the future is unsustainable under the current model.

The bright spot is that HSC in Northern Ireland already has a road map for restructuring to allow us to provide broader services.

Transforming Your Care – since backed up by the Donaldson report – needs to happen and needs to happen quickly. Current health minister Simon Hamilton has spoken firmly about his commitment to the reforms, but actions and not words are now required.

His problem – truthfully, all our problem – is that the public purse is empty, so while current services are unaffordable there is also no money for effective transition.

Signs showing

The fact is, warnings of disaster are not scaremongering - and the signs of trouble are already there, with closures recently announced by provider Four Seasons.

Evelyn Hoy, Chief Executive of The Commissioner for Older People, said this was disappointing, and that Health and Social Care Trusts must now make sure that residents are given alternative choices that are as good as, or better than, their current arrangements.

Four Seasons Health Care announced this week that they are to close seven care homes as they are ‘operating at a loss and no longer viable’. They also stated that a national shortage of nurses means they have had difficulty recruiting and retaining suitable staff and are having to rely on temporary agency nurses at a higher cost. Over 250 older people will be affected by the closures and are now faced with finding alternative accommodation before the closures commence in February next year.

Speaking about the closures, Evelyn Hoy, Chief Executive of The Commissioner for Older People for Northern Ireland said: “This is obviously disappointing news that seven care homes are closing, homes that people have lived in for years. Health and Social Care Trusts involved will need to work hard to ensure almost 250 residents are given alternative choices that are as good as, or better than, their current arrangements. Any alternative provision must be based on their individual need and preference whether this may be making sure they are close to the community to continue to partake in community life, or that they are moved to the same place as their friends who they have become accustomed to spending time with. 

“The issues raised by the provider around the unsustainability of the sector are of concern. The HSC Board and Health Minister must look critically at the regional tariff if it is the case that organisations can’t provide the required quality and level of care with the money available.

“It is welcome news that the Minister has announced the halt and review of the consultation on closing ten statutory residential care homes so that the impact of loss of provision in the independent sector can properly be considered. It is very fortunate that this was not later down the line when the statutory residential homes may have already been closed otherwise this may not have been possible. Government must plan and properly consider, through the commissioning of an expert health economist, the true cost of nursing, residential and domiciliary care. Older people deserve to have a range of sustainable choices for their care.”

No solution in sight

If this was just a problem for Northern Ireland then we could likely look elsewhere for a solution.

However, the same issues are being played out in Great Britain.

It hasn’t been a good week for Chancellor George Osborne and, amidst all the pressure he finds himself under, one of unpopular things he announced was cuts to care services in England and Wales.

To quote that article: “The Tory election manifesto commitments to protect the NHS, pensions, foreign aid, education and defence have put intense strain on the remaining unprotected budgets in Whitehall. Such is the reconfiguration of the state that nearly 43% of all public spending will be focused on health and pensioners by 2020, up from a third in 1997-98.”

That should sound familiar. Of course, Northern Ireland is in a rare position of advantage when compared with England and Wales, because our health and care systems are integrated, which allows for more potential efficiency.

However, our money is not our own, we may have devolved institutions but we still rely on heavily subsidised public finances – and although we can spend our funds with a degree of freedom, money put into care will have to be taken from elsewhere (in a wider context of tightening budgets).

So looking across the Irish Sea provides a reasonable indication of where our publicly-financed provision is headed.

Unsurprisingly, bosses in the care sector are not pleased with the Chancellor’s plans.

Barring some unforeseen and positive event, the best we can all hope for here in NI is a period of change that is extremely painful but which comes to an end, with a sustainable and publicly-funded health service the final outcome. But that is far from guaranteed.