Can Gerry Robinson Fix Dementia Care?

Following the previous series, in which entrepreneur Gerry Robinson looked at the parlous state of the NHS, the BBC is now running another series in which he looks into the issue of dementia care homes - Can Gerry Robinson Fix Dementia Care?.

I’ve watched two programmes so far. The first thing that strikes me is the fact that he is the very opposite of the picture of the grasping Capitalist often used by Moral Socialists as an alternative to objective analysis of Capitalism. Far from it, he comes across as a very caring person, who relates with great empathy towards the poor souls he meets confined in these institutions. And, in fact, he also seems to show great empathy towards the ordinary workers within these homes, in contrast to his disdain for the bad management of many of them – bad management, which, in part, he seems to conclude, arises from a short term focus on penny-pinching measures of cost-cutting, intended to maximise profits, but which have the opposite effect. Of course, he’s not alone. Nineteenth century Britain, when the age of its grasping Capitalists was at its height, was also the age when Philanthropy in Britain was at its height, and when many of the well-known social reformers like Rowntree came from the ranks of the rich. Today it is the US, which tops the league for charitable giving. The world’s two richest men, Bill Gates and Warren Buffett, have both given nearly all of their vast fortunes over to the Gates Foundation, which spends vast sums on a range of charitable works in the poorest parts of the world. Of course, if you are very rich, then the pleasure of giving is just one of the many pleasures, which wealth enables you to enjoy, and which is largely denied to those without. Having said that, I had a walk along the lane to my Cousin’s house the other day. He’s as poor as a church mouse, and lives in conditions more appropriate to a Dickens novel, yet his cheque book is full of donations to every charity under the sun.

In the first programme I saw, Robinson visited two homes run by the same company. The first was almost like a good quality hotel. There was a good staff to resident ratio, conditions inside the home appeared excellent, and the residents were kept occupied and well-attended. It was fully-occupied, and very profitable. But, it charged £750 a week. On that basis it was quite selective in the residents there. If not all, then nearly all, were self-financing. If you go into a Nursing Home, you can if you qualify, get financing to cover the cost from the Local Authority. The Authority will pay up to a given amount, and the balance has to be found by the resident, or the resident’s family. If the resident’s or their family cannot meet the additional sum, the Local Authority will cover the difference within reason, but that is normally only up to around £400 a week. The second home was quite different. A large number of its residents were financed by the Local Authority, and its charges reflected that fact, being nearly half that of the former home. As a result, the quality of the home was much lower in terms of its facilities etc. Fewer staff were employed, due to the lower revenue, and what staff there were were badly paid and demoralised. The demoralisation not only stemmed from being poorly paid whilst doing an arduous job, but also from the fact that they were constantly short-staffed, and that management tried to cut costs even more by petty cost-cutting measures in relation to the workers meal breaks, perks etc. With the home way below full-occupancy, economies of scale kicked in, so that even with such cost-cutting, the home was still unprofitable. As Robinson pointed out, if the home had been full, the income would have covered more staff and facilities, and still have made a profit! This always tends to be the problems faced by small, under-capitalised businesses. The problem here being that the condition for the home being fully occupied was that it became a place that people would want to go. A classic chicken and egg situation.

At the same time he went to see another home that did not have lots of Capital standing behind it, but which was profitable. In fact, although this was a private company, it embodied some of the ideas I have spoken about in the past, in relation to how I would see local communities running their own Co-operative Care facilities. For one thing the management of the home made a point of breaking down the separation between carers and residents. Despite the fact that these residents were suffering from dementia, it was difficult sometimes to know who was carer, and who was a resident. The carers wore ordinary clothes, they sat and ate their meals with the residents as though they were all residents in a hotel, or members of a family. Rather than the residents being drugged up, and left to vegetate, sitting in a room with nothing to do, they were encouraged and assisted to continue caring for themselves, and carrying out all of the functions of maintaining the home alongside the carers. That had a noticeable effect in terms of the relationship between residents and carers, and on the behaviour, not to mention well-being, of the residents. Although, the home did not charge outlandish fees, the fact that it was fully occupied, and the fact of how it was run reducing some of the costs, the home was very profitable.

Robinson attempted to get the managers of the second home to learn from the managers of this last one. But, their was clear resentment at the idea that there management style was being criticised, and nothing came of it. Similarly, this week Robinson brought in the same managers to another home to try to see if he could bring about a change. This case demonstrates what I was talking about the other week in my blog Warning – State capitalism Can Seriously Damage Your Health. The home had originally been assessed as “poor”, but after a change of management a more recent assessment had raised it to “adequate”. Yet, as Robinson noted as he first visited the home if this was “adequate” how bad do you have to be to be “poor”. Once again the residents were sitting around lethargic, unmotivated and understandably reacting with bad behaviour and resentment. The staff were also demoralised, and badly motivated with similar problems of absence leading to short-staffing and so on. At least one resident who was immobile had his emergency cord, by which to call for assistance, tied up out of his reach! Its important, however, not to be too critical of the workers who had resorted to such measures, as you’d know if you spent much time in one of these homes.

My Mother was in a Nursing home for four years, so I got plenty of opportunity to see some of what goes on, though clearly nothing like all. The picture painted by Robinson of poorly paid, poorly motivated staff, rushed off their feet doing an arduous, and often quite unpleasant job is typical. They have a tight schedule of jobs to do – going out in a morning to get bed-ridden residents like my Mother, washed and dressed, which in itself is difficult when the person has wasted away like my Mother to around six stone, and when you have to be careful not to tear the skin, or break a bone just in moving them; changing often badly soiled beds, organising breakfast; taking out and dispensing medicines to pretty much every resident; and before you know it, organising dinner and so on. In the midst of that, the alarms from certain patients will be going off constantly trying to draw you away from the resident to whom you were trying to give attention. Sometimes, it will be for a genuine reason, often it will simply be because the particular resident wants constant companionship and attention from a carer. So, the buzzers tend to drone on endlessly until a carer has the time to attend to it, or as my sister and I used to do, a visitor goes to deal with it.

The response of workers at the home to the suggestions and methods put to them by the Managers Robinson brought in was extremely positive. The attitude of management also seemed quite positive compared to that of the home he tried to improve the previous week. Many of the changes were brought in quickly and had a notable effect on both patients and staff. Yet you got the feeling that the staff were more committed to this approach than the management, a feeling born out by the comments of staff, including asking the outside Managers if they’d like a job! Symptomatic of that was the fact that in the middle of all this, the Manager, and one of the owners of the home, went away on holiday together. During that time the outside Managers from, I think the home is called Merryvale, came in and brought in even more drastic, but rapid changes, that appeared to cost very little, but which had a dramatic effect. The resident who had had his cord tied up, was an ex-paint sprayer, and was given a job painting a shed outside, and which he set to with gusto. However, during the week, it also came out that this home, which had only recently been inspected, and raised from “poor” to “adequate”, had even more severe problems relating to incidents of sexual abuse between residents. The home was closed down.

Robinson himself has asked the question whether the profit motive is itself incompatible with the needs of providing such care. Of course, the simple answer is yes. The profit motive is incompatible, overall, with the need to provide anything on the basis of need, precisely because those in most need, will frequently be the ones least able to pay the price required to meet that need by suppliers out to make a profit! For many things we can simply choose not to buy them if we can’t afford them, but if you need healthcare, if you need social care, such a choice does not exist, or at least if it does, then the consequences of not being able to buy it are severe. Of course, we should not be too dogmatic about that either. Lenin, following Marx, wrote that although Capitalism is a system driven by profit, Capitalists cannot divorce the drive for profit from the need to meet the needs of consumers. In the end any commodity is only profitable if enough people are prepared to buy it, and as Mandel correctly states, again following Marx’s comments about the “Civilising Mission” of Capital, the history of Capitalism fort he last few centuries has been the history of making commodities once only available to a very few, very rich people, available to the masses. Part of the problem with private Social Care, and with Nursing Care in particular, is that it has been a very, very profitable business. According to Robinson, profit margins can be as high as 30%.

Why is this a problem? Most new industries see a few firms enter them, and make similar large profits – what is known as first mover advantage. In many industries, those who enter first tend to be pioneers, they tend to be set up by people who have specialist knowledge – the computer industry is a classic example. But, other firms then seeing these large profits jump in. The large profits mean that some who jump in will not have a good business model, product or whatever. Again we saw that with the Internet Bubble, in the 19th century it was seen in the Railway Mania. Sooner or later, these firms go bust, there is rationalisation, and only the efficient firms are left to compete it out. But, with Social Care, and Nursing Care in particular its not quite like that. In Healthcare, the NHS takes care, albeit badly and inefficiently, with the needs of the vast majority of the population for “free”. Only if you are rich, or desperate will you resort to private healthcare. Demand is limited, and so the Supply from the Private sector faces intense competition. Only those providing good quality, efficient healthcare can make a profit in the mass market. But, the number of people requiring Social Care and Nursing Care is vast and growing as the population ages. There is no free Social Care or Nursing Care for many, if they have savings or assets. Although, Local Authorities can run Residential Care homes – though the number is reducing, and many are being outsourced – they cannot run Nursing Homes. With the NHS, now handing over responsibility for Nursing Care to such homes, there is a vast demand. Its that demand which makes it so profitable. But, the level of profitability also means that those who have entered this market, and who enjoy first mover advantage, do not necessarily represent those most suited to running such businesses. That is certainly, the impression I get from watching Robinson’s programmes so far. In many ways they are more like the old Merchant Capitalists who were adventurers and opportunists, seeing an opportunity to make a quick buck, get rich quick and get out with their winnings. Many I suspect are former nurses, or social workers who saw an opportunity to make money and took it. With that kind of short term vision, its no wonder that many want to maximise profits by cutting costs rather than maximising revenue. If private social care is to provide any kind of solution, it will only come about when the big professional companies like BUPA and others begin to dominate provision, and who will maximise profits by taking a longer-term, revenue maximising approach based on utilising the benefits of economies of scale, by maximising utilisation. As with private healthcare, that will only happen if they can provide good quality care, efficiently, and at a price that the majority can pay either from their own funds, or from Public Funds.

The more Capital moves from being based on manufacturing and becomes based on services, the more such a possibility becomes likely. But, there are other problems. When consumers make choices, they always try to make informed choices. But, despite the claims of orthodox economics, that is never such an easy thing to achieve. If you buy a Snickers, and decide it was the wrong choice, and you should have bought a Mars Bar, nothing much is lost. Make the wrong decision about which Care Home to move into or to move your parents into, and the consequences are more serious. And, however, much we might want to make the right choices for our parents or dependents we will tend not to take everything into consideration. For one thing, we’ll tend to take our own needs into consideration. And, I know that several times my Mother asked if she could be taken out of the home she was in, and I ignored her, basically because I believed that there was nowhere better for her to go, and that she would have wanted to be taken out of wherever she was. If we go into a hospital we can decide for ourselves whether we’d want to go there again, and we can pass that information on to others, but unless we are ourselves in a Care Home, we can never see exactly what happens when we are not there, and never make the same kind of choice.

In addition, if the problem of the “alienation of labour” can affect us badly as consumers of products, it can affect us even more badly as consumers of Social Care. I wouldn’t really want to be a passenger on a BA flight over Xmas, given the fact that the Cabin Crew on whom I could depend in a life and death situation, have been really pissed off by a bad management that has once again shown the partiality of the bosses State and its Courts. Less still would I want to be a totally dependent resident dependent on workers who have been badly treated by a Dickensian Management. But, of course, none of that is solved either by Lassallean and Fabian calls for the bosses state to take over. As I’ve said in recent weeks, and as recent reports have shown, State Capitalism is just as guilty in providing appalling care for the working class as private Capitalism. Badly paid, over-worked workers employed by the bosses state will be just as alienated as those in the private sector.

Only, if local working class communities have ownership and control of social care within their midst, providing care for themselves as a community as one big family, can we begin to break down that alienation. That after all is one of the arguments we put forward for Socialism, and what better means could there be of convincing vast numbers of workers of its superiority over Capitalism, than showing in practice how that could work here and now. All of the methods used at Merryvale that broke down that alienation, that broke down the division between worker and consumer, carer and resident, could be fully achieved in a Co-operative Social Care Home, owned and controlled jointly by the workers and residents and their families. All of the economic efficiencies that flow from Co-operative as opposed to private Capitalist firms could be directed towards providing a high level of care and comfort, that would ensure full occupancy, and the advantages of economies of scale that flow from that. Socialism is not something we should put off until the indefinite future after some hoped for revolution. It is something we have to build ourselves now, and on that basis the revolution will be brought that much closer.