Nick Kempe: The case for nationalising Scotland’s care homes

“The biggest argument for nationalising the care home industry now is what will happen if the Scottish Government doesn’t intervene and continues to waste resources on trying to make the current market system work.”

OVER the last month there had been signs that the care home industry was concerned that the Scottish Government’s Adult Care Review, which reports at the end of January, would recommend that it is brought into public ownership. 

A story in The Times published on Christmas Eve reported that earlier last year, the Care Inspectorate had obtained a “rough valuation” of the sector from Christie and Co. The £2 billion answer was provided months before the Adult Care Review was set up, but could be used either to argue that nationalisation is unaffordable or cheap at the price.

More recently, Guy Stenhouse, the Herald’s voice for city interests, argued that the SNP government shouldn’t please the crowd by including care home nationalisation in its election manifesto.  On Tuesday, the Cabinet Health Secretary put those concerns to rest when she stated “we won’t nationalise social care”.

It appears that the Scottish Government  Are about to ignore the views of the majority of the public who believe care should be about care, not money.  Meantime  evidence has continued to emerge on an almost daily basis which shows that a significant part of the sector is rotten to the core and incapable of reform.

An analysis by the Herald of inspections completed by the Care Inspectorate in the two weeks before Christmas found that no less than 10 of the 22 care homes had been graded weak on infection control.  In one, Thornlea Nursing Home in Loanhead, 15 out of 29 residents had died from Covid-19 and the rest were evacuated by Midlothian Health and Social Care Partnership. While it was good to see the Care Inspectorate at last take rapid and decisive action, the scandal is that nine months after the start of the pandemic, the owners of some care homes are still failing to implement even basic measures to protect their residents. 

The explanation for this arguably lies in how care home owners often treat their predominantly female workforce, providing little or no training and rock bottom pay and conditions. For example, a Care Inspectorate report had this to say about Hawkhill House Nursing Home, Milltimber:

“We identified serious concerns relating to the cleanliness of the environment, furnishings and shared equipment used to support people. Not all staff demonstrated an understanding or knowledge about COVID-19 and infection prevention and control in practice. Practice was unsatisfactory in relation to the use, disposal, storage and location of PPE in the home.”

Much of the private sector is incapable of providing the training that staff need and deserve. Caring Homes (TFP) Group Ltd had had months to ask public authorities for support, but appear to have failed to do so and then to have been caught out by an unannounced inspection. 

The situation on pay is no better. On New Year’s Eve, the UK Government put out a news release naming and shaming 139 companies that had failed to pay the statutory minimum wage throughout 2016-18. It included one care home from Scotland, run by Oakminster Healthcare Limited, which “failed to pay £1,292.30 to 21 workers”. Small amounts you might think, but from Autumn 2016, all care home providers were funded to pay the Scottish Living Wage – £8.40 an hour compared to £7.20 for the statutory minimum – as part of an agreement reached between Scottish Care, Local Authorities and the Scottish Government. Its not clear if that massive underpayment has ever been rectified.

That Oakminster was one of the few care homes listed tells you more about the light touch regulation of the market than how it operates or the extent of the problems. Without an organised trade union presence in every care home, it is almost impossible to monitor and control how private providers treat their workforce. Where care homes did increase hourly rates as a result of the introduction of the Scottish Living Wage, there was nothing to prevent providers who so wished from taking the money back in other ways – for example, through reducing staffing levels.

The fundamental problem is the care home market is based on exploitation, both of the workforce and those who pay for care.  Another Herald investigation revealed that care home residents face fee hikes of £240 a month, which providers are claiming are necessary to meet the costs of Covid-19. The truth is that the large, financially-driven providers have been levying similar fee increases of c5 per cent, i.e. well above inflation, year on year – Covid is just an excuse.  The attempt by the Competition and Markets Authority to protect care home residents from financial exploitation by the market using consumer law has done nothing to change this.

The levels of public disgust should not be underestimated. The Daily Mail, otherwise a bastion of free market fundamentalism, has led the campaign, knowing that many of its readers face having their life savings wiped out by care home fees. As part of its coverage of the exorbitant amounts extracted by owners and senior managers, last week it revealed that the Chief Executives of three care home providers had had themselves vaccinated before their residents. They included Dr Pete Calveley of Barchester Care, which runs 17 care homes in Scotland, who awarded himself a pay rise of c£1 million last year.  Both greed and corruption are rampant through the sector.

There are three main justifications the care home sector offers for its continued existence. The first is consumer choice, as expressed by Guy Stenhouse and reflected in the investigation by the Competition and Markets Authority. Under neoliberalism, consumer choice is often portrayed as a fundamental human right. People, so it is argued, should have the right to choose their care home, spend their money as they wish, and the market is the only way to facilitate this. 

The market reality is that for many people this choice is extremely limited, either because there is only one care home where they want to live (common in rural areas), or because they either can’t afford the fees or care about being ripped off. On top of which, the majority of older people in care homes have dementia and lack the mental capacity to make choices about where to stay.  The system may work for the few, those with full mental capacity and who can afford to pay £50-£70,000 in fees on a good quality provider, but not for the many.

The truth is that there is no reason why a National Care Service shouldn’t offer people the right to choose their care home – this is particularly important where older people want to move closer to their families – but for most older people and their relatives it’s having assurances about the quality of care they will receive which is far more important.

The private sector has generally ceased trying to justify itself by claiming it offers better care than the public sector; Care Inspectorate grades show otherwise. Instead, it points to the failings of the public sector while arguing that its own failings are a consequence of inadequate public funding. 

It is true that standards in some public sector care homes have been unacceptably low. The Care Inspectorate report before Christmas showed that it had taken Edinburgh Health and Care Partnership five months to raise standards of infection control in Royston Care Home to an “adequate” standard.    That is not good enough.  But we need to understand the reasons for this, the year-on-year cuts in local authority budgets which have left many public services close to collapse, and the differences to the private sector. At the end of the day the public sector is accountable to the electorate, who do care about care, whereas the private sector is controlled by shareholders, who care about money.

In the case of Barchester, whose profits rose from £10.3 million to £15.8 million in the last financial year, those shareholders are three Irish billionaires, Dermot Desmond, JP McManus and John Mangier, who own the care homes through a complex set of subsidiaries operating through a parent company in Jersey. This difference in accountability really does matter. Under a National Care Service, we could develop new mechanisms to control and hold care provision to account in a way that would be simply impossible with the private sector.

The argument that levels of public funding, including “free personal and nursing care” for self-funders, are inadequate also contains an element of truth. If staff working in the private sector were to be properly rewarded, the cost of care would increase. But this is a sector that has relentlessly eroded staff pay and conditions over the last thirty years, makes a profit out of the fee levels the public sector currently pays and would exact a very high price for investing in staff. With interest rates at record lows, there is simply no justification for the Scottish Government to attempt to fix the problems besetting the workforce by fuelling the profits of the few. Whatever fair cost of care is agreed, it would be much better value for the public (and voluntary) sector to provide that care directly itself.

None of this is to deny that there is a significant minority of private care home providers in Scotland who don’t treat care only as a commodity, who had retained sufficient skilled staff to respond to the Covid pandemic and who have shown they can put people before profit in a pandemic. The problem, however, is markets are never static and the care market has been constantly evolving since the Community Care Act in 1990.  In the case of these better care home businesses there usually comes a point – often on retirement – that the owners want to realise their capital. They sell out, almost invariably to larger businesses. The larger the business, the greater it tends to be financialised and the more the emphasis turns to profit and shareholder return and away from care.

The biggest argument for nationalising the care home industry now is what will happen if the Scottish Government doesn’t intervene and continues to waste resources on trying to make the current market system work. For that, we should look to how the care home market in the United States is developing.  Mike Davis, in his analysis of the US election results in New Left Review, has a section on the land of the lumpen billionaires:

“Forrest L. Preston, net worth $1.8 billion, who owns Life Care Centers of America, the largest nursing home chain in the county with 220 facilities in 28 states and 30,000 employees. The long-term-care industry collects most of its income from Medicaid and Medicare, and Life Care was accused by a whistle-blower of routinely filing false claims, keeping patients in facilities longer than needed and charging for unnecessary procedures. Faced with the possibility of prosecution, Preston agreed in 2017 to pay back $146 million dollars to the Justice Department.”

And so it goes on, the workforce appallingly treated, infection control laws (much tougher in the US than here) flouted, $48 million in relief handouts from Trump pocketed etc.  For another account of the scandalous state of care in the US I recommend reading this. Anyone who believes that couldn’t happen here should consider the close links between US and UK capital, for example the healthcare real investment trusts that are investing in care homes across both countries, or the role of US based private market think tanks.

Derek Feeley, who chairs the Adult Care Review, should know this more than most. As well as being a former Chief Executive of the NHS responsible for the Health and Social Care system in Scotland who played an important part in creating the current system, until last summer he headed the Institute for Healthcare Improvement based in Boston. That was set up primarily to improve, rather than abolish, private health care and has been used to drive cost cutting exercises in the NHS in Scotland. 

Feeley may have found it impossible to look beyond his experience, but he must be able to put the principles of care first and follow them to whatever conclusion about the structure of care that those goals demand, even and especially if that means – as I believe it does – the full nationalisation of social care.

Whatever Mr Feeley and the Adult Care Review recommends, the response from  politicians of all political parties to the review should be partly judged by their willingness to end the market in care (there are many other issues that also need to be addressed).

That would not mean nationalising the whole care home sector at once – public authorities currently don’t have the infrastructure to cope and there is no need to take over the better providers in the short-term – but it should mean nationalising or forcing out of the market in the near future the providers who repeatedly fail to provide good quality care, fail to invest in their staff and who extort money from residents. In a just world, those care homes would be valued as worthless.