Residents rule - OK?

Dr David Chapman

The media have revealed the neglect, bad conditions and even serious abuse and violence, suffered by residents in at least some of the privately owned homes for the elderly. The government is providing L500 million a year for this private care, and is clearly not getting good value for the money. Various suggestions have been made to remedy this, such as: more effective inspection; an independent complaints procedure for residents; better selection and training of managers of homes; and greater firmness by local authorities in shutting down homes where abuse occurs.

But helpful though these suggestions may be, they do not get to the root of the problem, which is that the home receives from the DHSS an unconditional L130 per week per resident, however well or badly the residents are treated. The home thus has little incentive to provide better conditions than that minimum (evidently very low) which would avoid getting the home closed down.

'A bonus fund, to be divided between the different homes according to how well they were rated by their respective residents'

I therefore propose that the home should unconditionally receive only part of the payment - let us say L100. The remaining L30 should go into a 'bonus fund', to be divided between the different homes according to how well they were rated by their respective residents. Thus while the average home would still get L130, an unsatisfactory home would get less, and a good one more.

The residents of a home would be given (perhaps once a month or once a quarter) the opportunity of recording a rating, between zero and 100, reflecting the satisfaction of the resident with the running of the home. It would be given in a secret ballot, run by some impartial outside body (perhaps Age Concern), to avoid any chance of pressure on residents from the management of the home. In giving his/her rating, a resident may be assisted by another person, who could be a relative or friend, or another resident, but must not, of course, be one of the home staff.

For each home, its average rating would be calculated. The home would then receive a share of the bonus fund in proportion to its number of residents, multiplied by its average rating.

Persons should be allowed to choose at which home they should live and they should be allowed to change from one home to another without difficulty. To help them in this choice, the average rating of each home should be made publicly known and a Consumers' Guide could be published. Thus dissatisfied residents would tend to move from homes with a low rating to homes with a high rating. An unsatisfactory home would not only get a lower payment per resident, but would also tend actually to lose its residents, and this would put added pressure on it to improve its conditions.

But, it has been objected, would not the scheme deter the management from taking measures which were good for the residents, even though against their wishes? This seems a somewhat paternalistic objection. If the staff think they know what is best, they should seek as far as possible to convince the residents before taking action.

Again, it has been objected that a confused elderly person might be incapable of making a sensible rating. But in this situation, the rating could be made by a relative or friend, according to their judgement of how well the person was being treated. In any case, there is no reason to deny the non-confused majority the opportunity to affect the conditions under which they have to live.

The case for the scheme is that it would give each home a strong incentive to provide conditions agreeable to its residents. It would seek a higher rating, not only to get higher payments, but also to get public recognition of its good work. This scheme seems likely to bring about a great increase in the welfare of our old people, in return for increasing public spending only by the small amount needed to conduct the ratings ballot.

David Chapman, Democracy Design Forum, Coles Centre, Buxhall, Stowmarket, Suffolk IP14 3EB (tel 0449 736 223).

Alternative suggestions by David Scott

David Scott argues that Dr Chapman's scheme would be 'costly to administer, with increased bureaucracy and serious reduction in cash flow' for needy 'poor' homes; and that there would also be the danger of residents voting in favour of mediocre accommodation without having other institutions to compare with. He makes a number of alternative proposals:

- An award for homes which meet high standards. Inspections by a panel coupled to a controlled questionnaire to residents and staff. Also a certificate of good residential care, and a Queen's Award for services to the elderly or handicapped.

'A certificate of good residential care, and a Queen's Award for services to the elderly'

- Regular inspection of all residential homes by an independent panel of local people to include Age Concern, local nurses, and other elderly people. Include local authority residential homes and provide the panel of visitors with the power to close all unsatisfactory accommodation, or to take over the management.
- Training for managers and staff to be compulsory and only certificated persons to be allowed to manage (after a reasonable transition period).
- Define standards of food, hygiene, laundry, bedding and so on, and appoint a senior executive of Trust House Forte to administer the programme of basic standards in the manner adopted by franchise holders such as 'Little Chef'.
- Encourage WRVS, Red Cross and St John Ambulance to participate in the day to day management of all local residential homes in order to harness local experience and skills for the benefit of the community.
- All residential homes in receipt of public funds to be fully accountable by annual budget, and audited quarterly out-turn figures to an independent local committee for residential homes drawn from local caring agencies, including representation by residents or their next of kin.

David Scott, National Association of Almshouses, Billingbear Lodge, Wokingham, Berkshire RG11 5RU tel 0344 52922).

Response by David Chapman

David Scott objects that my proposals would be costly and bureaucratic, and then goes on to propose a raft of highly expensive measures whereby some external bureaucracy could inspect homes, impose training, define and administer standards of food and materials, audit the accounts and so on. The fundamental problem is the utter powerlessness of old people in these homes under the present structure. Scott's proposals, if we could afford them, would do nothing to correct this.

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