Feature

Homing in on what users want

Elderly people facing life in a residential home lower their expectations — but find reality is lower still. Jef Smith reports

My personal contribution to ‘political correctness’ this year has been to try never to contrast residential care with community care. Residential establishments must be seen to be a part of the community, and there is no point in continually bewailing their tendencies to institutionalism if we go on treating them as separate institutions.

The political attention given over recent years to ‘care in the community’ - and when using that phrase politicians often do seem to be restricting themselves to services delivered to people in their own homes - has not made it any easier to foster images of residential care which can counter the poor law’s terrible heritage. The shadow of the workhouse lies heavily over many homes, in the independent as well as in the statutory sector. Some families choose boarding schools for their children and some students choose to live in halls. Why should elderly people not positively choose life in a residential community?

Some of course do, braving the stigma. Life in a home offers security, companionship and services on hand at all hours - all for a relatively calculable financial outlay. By contrast, life at home for an elderly person with disabilities can be lonely, unsupported, and economically unpredictable, at the mercy of patchy services and sometimes unwilling family and friends.

Yet we know that the vast majority of older people given a choice would prefer to remain in their own homes. What can be done to make life in homes not just more attractive but closer to fulfilling its obvious potential?

Facing the question at Counsel and Care, it seemed sensible to ask the consumers themselves, residents in care and nursing homes. An immediate snag presented itself. In earlier work on privacy, we had talked to residents and recorded our surprise that they often appeared to accept intolerable invasions of their dignity and autonomy - a lack of locks on bedroom or lavatory doors, having to use commodes in shared rooms without screens or curtains, the absence of facilities for eating alone or making a private telephone call. Our conclusion was that elderly residents characteristically lack power, assertiveness and organisation, vital constituents of the capacity to protest. Accepting their apparent passivity is clearly no way forward.

The proposal we made in devising a wider study of users’ views was that we would talk with elderly people at the point of entering a home and re-interview them six months later, comparing pre-admission perceptions with their experience of the quality of life in a home. This design rapidly broke down. As an advice agency providing information to elderly people who are recognising their dependence, we encounter plenty of clients seeking advice on entering homes, but the sadness and trauma they are so often experiencing make it impossible to add to their burdens with a questionnaire.

We fell back on a plan to talk with two samples of elderly people in day centres. With the first group we discussed what they would like to experience in a residential setting, with the second what they expected. A third sample of current residents provided a snapshot of actual experience.

The views of the three groups, as recorded in our recent report From home to a home, make a revealing and often depressing contrast. By and large as regards quality, hopes were scaled down to expectations and the reality fell further still. For example 90% of elderly people would like an ensuite toilet; only half of that number expected such a facility; barely a quarter actually have it.

Nine out of 10 prospective residents would want a home at which they were resident to provide transport to enable them to go out on trips and visits; just over three-quarters expected this service; less than a quarter had it.

More than two-thirds of day centre respondents said they would like a choice of food at meal times, and only a few per cent less expected to have a choice; only just over a third of the residents we interviewed were able to choose what they ate. Sadly - from the point of view of advocates of more assertive consumerism - less than 30% of that group felt this an issue for complaint.

Providers of residential care clearly face a tough market over the coming years. The emphasis will shift increasingly to domiciliary care. Cash to pay clients in home will be limited by fresh public expenditure curbs. Both inspection units and care purchasers will be in a buyers’ market where they can press for higher standards and better value for money. In How to market care in homes, we address this sharper market and offer some advice. But the message of both of our documents is essentially the same - if producers are to survive, they must find new ways of listening to their consumers and acting on what they hear.

From home to a home and How to market care in homes, £5 each or £9 together, Counsel and Care, Twyman House, 16 Bonny Street, London NW1 9PG. Tel: 071-485 1550.