The two meanings of personalisation in residential care and why they matter for the future of care homes
The situation of older people in care homes and the difficulty of protecting them during the current coronavirus pandemic attracts much attention these days, and rightly so. The devastating effect of the pandemic on care home populations highlights a number of shortcomings in residential care in England, which for years has neither received adequate levels of funding nor much policy attention. Yet over 350,000 older people currently live in care homes, because they require high levels of care during most of the day and night. By ‘care home’ we mean organisations that provide long-term accommodation and services to people who need 24-hour care and attention, including help with personal care (in a residential care home) and medical care (in a nursing home). A care home is usually a person’s last home, but it is nonetheless their ‘home’. So it is important that they are able to live their lives as fully and as independently as possible.
In England, consecutive governments have emphasised the importance of personalisation for people receiving long-term care services. Personalisation refers to the process of tailoring care services to the specific needs and preferences of service users. In the past, this has mostly involved community care for individuals who receive care in their own homes, with policy-makers giving less attention to personalisation in care homes. This is regrettable, as it reflects the way many people associate a care home with an ‘institution’ or ‘place of last resort’, rather than a destination of choice in later life. Most initiatives to make care more personalised have been driven by the charitable sector (e.g. through initiatives such as ‘My Home Life’) or by care homes themselves.
Our study has sought to investigate how personalisation in residential care is conceptualised, which approaches are likely to succeed in promoting personalised care, and which barriers need to be overcome to provide an effective service to people living in a care home.
There is a difference of view of what personalisation means in the context of a care home. Essentially there are two sets of ideas, pulling in different directions. The first emphasises residents’ choice and control over the services they receive. This idea was influenced by attempts to promote ‘voice and choice’ among patients receiving health services in the NHS. Choice and control have been given prominence in domiciliary services for service users eligible for local authority support, who are given a choice between accepting care services organised by the local authority, and accepting a budget to organise their own care in the form of a direct payment. In this context, choice and control are often used interchangeably with ‘self-directed support’, which has been a key aim first set out by the disability movement. This movement has sought to increase the inclusion of people with disabilities in society, and to improve the services they receive. Its success has led to a major shift in awareness of what people with disabilities are able to achieve and the quality of the care and support received. It has been argued that this is due to the effects of individuals holding the purse strings for their care on the balance of power between them and the service provider. However, research has shown that many older people in residential care are less likely to benefit from choice and control in this way, given the extent of their care needs and the nature of how care homes are financed.
The second set of ideas developed out of concern for the quality of care for people with dementia. Typically referred to as ‘person-centred care’, it emphasises the importance of care and caring, and the role of the professional carer in promoting the wellbeing of the person receiving care. This concept gives the carer and the care home the responsibility of ensuring that people with dementia are supported in maintaining their identity and to articulate their wishes and preferences. A central aim is here to help people with dementia to maintain a sense of continuity between their lives before and after the onset of dementia, and their experience before and after moving into a care home.
Clearly, these two sets of ideas are not mutually exclusive. Proponents of person-centred care would always emphasise the importance of giving residents choices and control over their daily activities and to support them to lead as fulfilled lives as possible. Likewise, the idea of choice and control does not preclude people from enjoying caring relationships: indeed, most direct payments in domiciliary care are used by service users to select and employ their own carers.
However, these two sets of ideas differ in how they conceptualise the approach to personalisation and make different assumptions about the person receiving care. While person-centred care is rooted in a philosophy that accepts that the need for care and support is part of the human condition and a universal experience, choice and control casts the individual as a consumer in a market for care. They therefore differ in their assumptions about the relationship between the individual and the provider of care, the ability of the person to exercise choice and make their own decisions, and by extension, the person’s cognitive capacity. They also make assumptions about the level of support required for individuals to derive benefit from such choices and decisions and how this support is organised and funded. Both versions of personalisation have cost implications. Both necessitate adequate levels of staffing and training. Yet while the investment in staff is associated with the provision of customer care in one model, the other model requires an adequate number of skilled care staff to be able to build the relationships that underpin the provision of person-centred care.
In our study, we found both sets of ideas reflected in the care homes. When interviewing managers in care homes, almost all recognised the concept of person-centred care, noting the importance of trust between staff, residents and their family members; a cornerstone of personalised care. Some evoked images of the ‘family’ of care home residents and staff to describe these close, trusting relationships. In contrast, others used the image of the care home as a ‘hotel’ to express their aspiration to provide comfort and convenience to their customers, as if they were ‘on an expensive holiday’. Such customer care was reflected in practices such as providing menus on the tables of their ‘restaurant’ (rather than dining rooms); and it resonates with practices in certain types of more upmarket homes.
What are the implications of different concepts of personalisation in care homes? In principle, the availability of different models of personalised care enhances choice. If someone wishes to live in a ‘hotel-style’ care home they should be able to do so, even if the type of care such homes provide may be less focused on personal relationships. In practice, however, people with fewer resources have considerably less choice of care home than those with greater resources. People with low incomes, few savings and no relatives able to contribute to the costs of their care face a choice limited to those care homes which accept residents at local authority rates. Those with relatives able to top up local authority rates have more choice of care home. People with high incomes or substantial savings, while not eligible for local authority support, have the widest choice of care homes. This means that there is socioeconomic inequality in choice of care home. In addition, there is also the question as to whether the model of personalisation they offer, perhaps especially for ‘hotel-style’ homes, will be suitable for people whose care needs are substantial and who may be better served by a different care model such as one modelled on small ‘family’ units.
To date, the diversity of approaches to personalisation in the care home market and their implications for service users are not well understood.When the care home sector emerges from the pandemic, time should be taken to reflect on the funding and policy support needed to develop a sector that is not only more resilient to emergencies, but is also more equitable. It is time to reimagine the future of residential care to create homes that people would like to live in as a form of supported, communal living, rather than a place of ‘last resort’.
Ettelt S, Damant J, Perkins M, Williams L, Wittenberg R (2020): Personalisation in care homes for older people. London, Policy Innovation and Evaluation Research Unit.