Dianthus Medical Blog Archive

Care for the elderly

The top story I woke up to on the radio this morning was of allegations of mistreatment of elderly patients at a care home. This seems to be part of a disturbing pattern: mistreatment of the elderly (and other vulnerable people) in care homes is far more common than it should be.

No doubt the care workers responsible will be disciplined (one has already been sacked in this latest case) and some may face criminal charges. That is as it should be.

But it is not enough.

I would be very surprised if abuses like this happened purely as a result of wicked people managing to somehow slip through the care home's vetting procedures for their staff. Repeated abuses like this suggest to me that the whole culture in care homes is at fault. Blaming the front-line workers who actually deliver the abuse misses the point. While those people are undoubtedly culpable, the real blame must lie further up the food chain.

It is the job of the directors of care homes to create an appropriate culture in which their staff work. If that culture is one of caring, compassion, and a desire to do the right thing, then I suspect abuses will be very rare. If the culture is one of getting the job done as best you can with inadequate resources, then corners will be cut.

Inadequate resources in care homes is of course a real problem. The cost of care for the elderly is constantly increasing. Care for the elderly is a classic case of Baumol's cost disease: it's a labour intensive process with little scope for productivity improvements to reduce costs, so costs must rise in line with wages, which in the long run (though not so much in recent years) tend to outstrip inflation.

As a society, we don't seem willing to accept that caring for the elderly is expensive, and I feel we need to do that if we want to see improvements, at least in the short to medium term. Perhaps in the long term, improvements in robotics will mean that we can care for the elderly more efficiently, though I suspect it will be quite a few years yet before that becomes realistic and widespread.

In general terms, there are 2 ways in which inadequate services can be improved: through regulation, or through free-market competition.

Regulation is a very clumsy and blunt way to improve services. It is simply not possible for regulators to be present at every interaction between care home staff and residents. Regulation tends to create a box-ticking culture: the things that regulators measure get attention, but equally important things that are not measured get neglected. It is hardly possible for a simple set of regulations to capture all the subtleties and complexities of care home life.

And we can see that despite the fact that care homes are regulated, abuses still happen on a regular basis.

So what of free-market competition? Can we expect competition to drive out the poor care homes and ensure that only the best ones prosper?

In a word, no.

One of the most important assumptions behind free-market competition is that both buyers and sellers have perfect information. That's a very strong assumption in many cases, and in the case of elderly care, it is completely unrealistic, both for care home providers and for residents. An elderly person choosing a care home cannot possibly know with any certainty what the quality of care will be like until they have already been resident in the home for some time. And a care home provider will not know in advance just how much care any given person will need.

Another assumption of a free market is that barriers for consumers to switch between providers should be low. Again, that assumption fails spectacularly in the case of care homes. Once an elderly person is already resident in a care home, switching to another home is an extremely difficult and potentially traumatic process that few will willingly attempt.

I fear there are no simple solutions here. However, I do think it would help if boards of directors were held personally accountable for abuses in their institutions. Clearly no system is perfect, and a care worker with criminal intent will always be able to abuse residents even in the very best systems. But it should be up to directors to prove that their systems were as good as they could reasonably have been if they want to avoid jail terms when abuses occur. I suspect that would focus minds in the boardroom a little more on creating a more caring culture.

But we as a society also need to accept that if we want to be cared for with dignity and compassion in our twilight years, then we are going to have to pay for it.

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