British Parliament Takes a Look at The Green House Project

Evidence to the Health Committee: Social Care

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Valerie Vaz: Which brings me on to the future. You have seen the past, the present and the future: could you describe this new model that you have seen?

Dr Mumford: As part of our review, we conducted an international visit to the United States to see a model of nursing care—this is an important point—that is residential, like a nursing home. The model was invented by Dr Bill Thomas. It is not just a brainchild; it actually exists. There are 127 Green Houses in the US with 250 in development. Based on the assumption that, even if we get much better at providing care in the community, which I know Mr Orr has been speaking about for 20 years—that has to happen and our report gives a lot of attention to that—the prognosis for dementia and clinical dependency, and the consensus that at some point it becomes difficult to look after a clinically dependent older person in their own home, means that the need for intense-care settings is not going to go away. The need for care homes is not going to go away, so for all the policy attention to be focused on keeping people in their own home for longer misses possibilities for reform of the long-term care setting. Thus it becomes absolutely vital that we dream a different future for residential care, particularly nursing care. The Green House model presents a new way of doing that, and the innovation lies in two things.

First, the reform of design. These Green Houses are self-contained buildings for nine to 12 people with about two staff members looking after each home. Their kitchen is not downstairs or siphoned off but is actually at the heart of the home. There are no clinical corridors and the rooms are off the central area. The design is half of it. The second half of the innovation is around the staffing ethos. Basically, by cutting out middle management, the key thought is this: the staff in the care home context are bigger than the roles that they have.

By empowering the staff to actually take responsibility for the way that that particular Green House is run, and by also allowing them to take charge of cooking the meals and doing the laundry, you make huge staffing efficiencies, so that there is not actually any more hour per resident in terms of the staff labour cost, but it is for the same cost. They have seen extraordinary results from what they have achieved because of these two dramatic innovations at the heart of this new form of care. As I said, this is not just a bright idea. It is being backed and rolled out across the US.

Q516 Barbara Keeley: You said “nursing care”. Where is the medical element of that?

Dr Mumford: The medical element is the two care staff—for reasons that I will not go into they are called “shahbaz”. They basically want to create a new word, because they think it is demeaning as a job role in western societies. You have two of those for the eight to 12 people. Because you have a number of those different homes in the same place, even though each is run differently, for each of the two homes you also have one nurse attached who would be going from those two homes, and so the nursing element is there and is crucial. For us, the recommendation that goes along with new models and allowing for new models to take place and reform of long-term care, and dreaming a different future for it, is around the regulation.

At the moment, nurses have to be on site in nursing homes. We already made a recommendation in “Age of Opportunity” around a consensus forming that the distinction between residential and nursing is becoming spurious, because the clinical profile of people in residential is coming to resemble that of the people in nursing homes. Therefore we think that the nursing money that the NHS allocates to people in nursing homes should be allowed to follow the patient or resident into residential homes. That means you have to decouple it from a requirement that there be nurses on site in nursing homes, because you would not expect all residential homes to have nurses, which means we need a new role of nursing from that which, obviously, is current. Basically, that would mean changing the law—a regulatory change to allow there to be new models of doing this.

Q517 Barbara Keeley: I wouldn’t disagree with the vision that you have described for care homes, but it seems to me about a million miles away from the reality of where we are in terms of funding. Some £1 billion has gone out of adult social care funding over the last year, and more cuts are expected this year and next year. Care homes are struggling to even survive, and self-funders are carrying the burden. Although it is optimistic and a good idea to have such visions, where on earth will the funding come from to make this sort of thing happen? As I understand it, care home owners are struggling now. We have had the Southern Cross business of 750 care homes changing hands. We have a crisis going on. Although it is praiseworthy to have these sorts of visions, surely, in the current funding environment, you cannot imagine that there will be the funding to do this. Who on earth will embark on something as optimistic as this, with very small numbers, when they are struggling to maintain care homes at larger units?

Dr Mumford: The key point about this is revenue, not capital. In terms of revenue, you would be right to raise a concern if on a revenue basis Green Houses were shown to be more expensive to run.

Q518 Barbara Keeley: You can’t even design something as different as this on the current resources. What I am saying is that it is such a struggle to keep current care homes going, I cannot see a new model evolving unless some funding were found for it. Are you suggesting that the Government should fund the development of the new small homes?

Dr Mumford: Okay.  I will answer the question about the capital cost.  Yes, it would require redesigning.  We think that there are possibilities through the Homes and Communities Agency and through the way that central Government work to incentivise local provision.  We think that that could be a possibility.  I have seen cases across the country where sheltered homes have been retrofitted into extra-care housing, for example.  That would be something where that as well as retrofitting to extra-care housing, retrofitting to Green Houses could be a possibility.

I really think that the key point is the revenue.  If it were shown that the running of it—with the downward deflation on pricing by social services departments—was much more expensive, there would be a real force in this current environment of how we could possibly think of new models that may be better but a lot more expensive.  I draw the Committee’s attention to a peer review journal of the American Geriatric Society.  It has written up the costing implications of the Green House model.  I would be happy to supply this as a note to the Chairman.  It actually shows that it is not more expensive to run them, because you are redesigning where staff and labour cost is allocated.  You are basically getting much more face-to-face contact between the care workers in the Green Houses and the residents, because it is a smaller context.  You are taking out the middle management.

For example, if you calculate that an average nursing home bed in the UK costs £650 a week and, therefore, £2,800 a month, which is say $4,000, that sits right in the ballpark of where the reimbursement for the Green Houses comes from, because half of all people in Green Houses are on Medicaid.  It is state reimbursement money that they are looking for.  It is non-profit.  It is looking for the kind of people who would be provided by the state in a different way that the US states do it.  It is not an upper end brass and glass provision, which is really the key point for thinking about why this could be relevant to our context.

Q519 Chair: If we had a more flexible system, we could probably look at extra care housing that would be significantly less costly in terms of the public revenue that would be required.  Instead of having three or four classifications, we would have a continuum of different models of care that were more appropriate to individual sets of circumstances?

David Orr: Which is precisely what we need.  A lot of that is covered in a publication that we produced last year, called “Breaking the Mould”.  If you haven’t already seen it, please take a copy.  I can circulate others.  It covers quite a wide range of ideas.  Some of it envisages the future happening now.  We just have to be clear about the funding challenges that there are.

Like it or not, the Homes and Communities Agency’s capital funding is two thirds down on what it was in the last comprehensive review period.  It meant that the mechanisms by which housing associations produce new homes are based on revenue subsidy, higher rents and more housing benefit.  That will not work for capital investment in specialist residential accommodation.

The incidence of new specialist residential accommodation in the present framework is miniscule, partly because the capital is not there, but partly because no one is confident about the revenue funding being there to support specialist capital provision.  We have to be very thoughtful about how we make this whole system as flexible as it possibly can be.  Dr Mumford’s idea is potentially worth further exploring, but it is about having a wide range.  We call it “Breaking the Mould”, because we have to think differently about how we do it, and I hope that there are some useful examples.

Q520 Grahame M. Morris: While you are on this issue, one aspect of Dilnot is capping living costs of between £7,000 and £10,000 a year, which has revenue implications.  What is your view on the downside of that aspect of Dilnot’s findings?

David Orr: Honestly? We have to see Dilnot as the start of a negotiation.  If you accept the basic principle, you have to get drilling down into what numbers will work and what numbers will not work.  In many cases, those will be sensible. But people’s needs change, so how do you assess what constitutes a housing cost, a support cost and a care cost? That was really what the Supporting People fund tried and, in the main, successfully delivered in doing. The Government have protected that, but because of the exigencies of local government at present, the amount that has gone into local government is not coming out for the provision of new, supported housing.

Some 75% of our members who are in this business say that they expect cuts of 12% or more. Nearly half reckon more than 20%. There are some local authorities cutting by 40%. Provision is going, and the way that commissioning is working means that there is an expectation that costs will be squeezed and squeezed. That is happening to the extent that one or two housing associations, which care about the standard of living of the people whom they employ as well as about the care that they can provide, are saying, “We are not going to do this any longer, because we think it is taking us to a place where we cannot provide to the level that we want.” We have to think very carefully about the consequences of some of the squeeze that is happening at the moment and see if we can think creatively about different ways of funding it. If we are ever to get insurance in, you need to have a cap on the exposure to the insurers. That’s where Dilnot is right.

Q521 Dr Wollaston: I want to touch on a couple of things. First, to Dr Mumford, does the level of dependency in these Green Houses reflect the level of dependency that we see in nursing homes in the UK? It strikes me that the staffing model means that their staff are doing effectively what carers do in the UK—they are doing the shopping, the cooking, the cleaning and the caring. But if you’ve got only two for a ratio of up to nine residents, that is presumably not going to be effective if they have got high levels of dependency. In other words, is what you are classifying as nursing dependency equivalent to what would be nursing dependency in this country?

Dr Mumford: I would be happy to find more of the evidence base around the profile, but yes, it is the same clinical dependency profile. When I visited Albany in the state of New York, the Green House I visited there sat alongside what the American term for our residential is, which is assisted living. Those two facilities sat alongside each other, and it was very obvious that, having seen the difference between some of the self-payers, for example, in the care home that I volunteer in, in London, and nursing home patients—in this country, the difference is merging—the self-payers in that context, in a residential home, are very different from the nursing home patients in a UK context. That difference was similar to the difference between assisted living and the Green Houses. The assisted living was that there would be high rates of dementia, but in terms of other things, in other levels of clinical dependency, some of the people in the Green Houses were really dependent. Again, on the concentration of staff there, of those shahbazim, by increasing the time spent—it is a smaller context, and it is how they feel that succeed in that—they would be the first to stress that they are dealing for a typical nursing home population group.