Forgive me for making a less than bold prediction for what’s to come in local Edinburgh politics in the year ahead: the public provision of long-term care will come under assault, with attempts to remove NHS and council beds, on the flawed assumption that the private sector will pick up the slack.
New Year predictions of this kind could have been made and proved correct in every year since 1979, so I’m not exactly going out on a limb here, but Edinburgh in 2024 promises to be an extreme case in the continuing creep of health and social care privatisation.
In September 2021, the Edinburgh Integration Joint Board (The EIJB, which governs the Health and Social Care Partnership) agreed a ‘Bed Based Care – Phase 1 Strategy’ (aka ‘Bed Based Review’), claiming that it would better meet the care needs of the population in response to changing demographics and delayed discharges from acute hospital beds.
The strategy started falling apart before it had even been agreed when proposals to close four council-run care homes (Ferrylee, Ford’s Road, Clovenstone and Jewel House) were stopped at the last minute following a trade union-led campaign to save the homes.
That September 2021 agreement did close one care home though – Drumbrae Care Home, a modern 60-bed facility that was to be reprovisioned as Hospital Based Complex Clinical Care (HBCCC). The conversion was botched, and the care home now sits empty, decaying over two years now while the Council picks up the tab for Non-Domestic Rates. It is a scandalous waste of public resources for which nobody has been held to account.
The reprovisioning of Drumbrae was the cornerstone of the Bed Based Review, which involved a convoluted shifting around of resources that appeared to be designed to meet the need to vacate Liberton Hospital (which the NHS has sold to the Council and is earmarked for housing) rather than to meet the changing care needs of Edinburgh’s population, as its authors claimed.
The failure to convert Drumbrae left the whole strategy in tatters, and senior clinicians began publicly questioning its underlying logic. Last February, Dr Emma Reynish, a Consultant in Geriatric Medicine who sits as a non-voting member of the EIJB, said at a meeting:
“I’m concerned about our Bed Based Review – it was based on population data from 2019, pre-pandemic, and the needs of our population have changed quite a lot since then. We need to know the numbers that sit behind the Bed Based Review are fit for purpose for the current population and the population predictions going forward. I think we might find that it’s changed since 2019.”
The Chief Officer of the EIJB, Judith Proctor, resigned in May, following the publication of a Care Inspectorate Report on Edinburgh’s adult social work and social care services that found “significant weaknesses in the design, structure, implementation and oversight of key processes, including the assessment of people’s needs and in their case management”.
The following month, the EIJB announced a review of the Bed Based Review, saying then: “a commissioning exercise would cover validation of the work completed to date, expanding the bed modelling to all older people’s bed-based services in both hospital and community settings and incorporate the assumptions based on emerging trends. Senior clinical teams have requested that this exercise is completed before any reconfiguration of existing beds is undertaken.”
The ‘commissioning exercise’ is due to report back in February, but I understand that preparations are already underway for a so-called ‘reconfiguration of existing beds’ based on the flawed logic of the discredited 2021 Bed Based Review.
Hospital Based Complex Clinical Care (HBCCC)
The beds that are under the most immediate threat from ‘reconfiguration’ (let’s just call them cuts from here on because that’s what they are) are HBCCC beds. The slogan used by campaigners in 2021 was ‘Save Our Care Homes’, but ‘Save Our HBCCC’ doesn’t quite have the same ring to it because most people, understandably, don’t have a clue what HBCCC means.
HBCCC was previously known as ‘NHS Continuing Healthcare’ and eligibility is determined by clinicians tasked with answering a single question: “Can this individual’s care needs be properly met in any setting other than a hospital?”. The term ‘hospital’ is a bit of a misnomer here, as the facilities in which HBCCC is delivered are much more like care homes than hospitals and residents/patients often stay in them for months and years.
There are many reasons why clinicians may answer ‘no’ to the eligibility question and recommend admission to HBCCC. Chief among them, is the lack specialist dementia provision in the city. In my experience of working in these units as a Bank Nurse, many of the residents suffer from advanced dementia and require a level of care of that Edinburgh’s profit-driven long-term care sector is not willing to provide.
End-of-life care is another labour-intensive area which is not well provisioned outside of the NHS. Edinburgh’s Hospice capacity reduced drastically during the pandemic, something that has not been factored into the cuts that are planned for 2024.
The table below shows HBCCC provision in Edinburgh in 2019 and is taken from the Bed Based Review.
The male dementia ward at the Royal Edinburgh Hospital has now closed ‘on a recurring basis’, and it is my understanding that piecemeal reductions in other units after the pandemic mean that there are now just 124 HBCCC beds in Edinburgh, with significant further reductions planned for 2024.
These reductions contravene this crucial line from the Bed Based Review:
“Any move to redesign our HBCCC estate needs to occur in sequence with other changes proposed, particularly in relation to intermediate care and our care home estate”.
Those who intend to implement these cuts in 2024 may point to the September 2021 agreement, but I would argue that this agreement has been completely invalidated by the failure to implement other aspects of the strategy. There is no mandate for further cuts to HBCCC beds, and answers are needed about the 20-bed reduction that has already occurred.
Intermediate Care
The Scottish Government defines bed based Intermediate Care as “a time limited episode of care…[that] can be provided as an alternative to admission to hospital (step-up) or to provide further assessment and rehabilitation, following discharge from hospital (step-down)”.
The Bed Based Review highlights the increased demand for Intermediate Care and consequent need for a larger proportion of Intermediate Care beds than Edinburgh currently has. Part of the justification for the reduction in HBCCC beds was that some of these would be reprovisioned as Intermediate Care beds, however, between the failure to convert Drumbrae and the rush to vacate Liberton Hospital (where most of the city’s Intermediate Care currently sits) it is unclear how this can be achieved.
Facilities that previously delivered the types of care that are now defined as HBCCC and Intermediate Care have been decimated over the past 25 years or so.
When I first started working for the NHS in 2005, Liberton Hospital, the Royal Victoria Hospital, Corstorphine Hospital, Astley Ainslie Hospital and the Eastern General Hospital provided hundreds of beds that would now fall into these categories. Those with slightly longer memories will recall the Northern General Hospital, the Princess Margaret Rose Hospital and the City Hospital. While many of the services that were provided from these hospitals have been reprovisioned in more modern facilities and are better for it, much of the rehabilitation, end-of-life care and long-term care capacity that they provided was never replaced.
In East Lothian and Midlothian, new community hospitals have been built during this period. This hasn’t happened in Edinburgh, and now we are being told that further reductions in long-term care beds are required to make up for what has been lost.
Care Homes
When the original proposal to close five council-run care homes (Drumbrae, Ferrylee, Ford’s Road, Clovenstone and Jewel House) came forward in June 2019, councillors from across the political spectrum were keen to validate the assumptions that supposedly underpinned the strategy. Their argument was that older people didn’t want to live in care homes anymore, and that technology was allowing people to stay in their homes where they would previously have been admitted to long-term care. Statistics were presented that showed a decline in the number of care home places, and it was presumed that was the result of a reduction in demand.
Indeed, the annual Scottish Care Home Census shows an overall 4% reduction in care home beds over the past decade, decreasing from 32,888 to 31,459. However, this reduction has taken place exclusively in the public and third sectors, with private, profit-making care home beds increasing by 2%, while third sector beds reduced by 33% and Council/NHS beds by 20%.
That leaves the 2023 breakdown of Scottish care homes beds for older people as follows: 83% private, 10% Council/NHS and 7% third sector.
Even if you don’t agree with me that the pursuit of profit is generally incompatible with the delivery of decent care, there are obvious and immediate practical concerns about long-term care being so dominated by private interests. It’s simply far more difficult to generate profit from people who require high levels of care, such as those with advanced dementia. While demand for care home places may have reduced slightly, the demand for specialist dementia care is definitely increasing, and demographic changes mean that it will continue to do so.
To a limited extent, the Bed Based Review recognises this fact.
Proposals to employ registered nurses in three council-run homes (Royston Court, Marionville Court and Inch View) thus allowing them to provide more specialist dementia care, were welcome. However, there has been no feedback on the effectiveness of this move, and no confirmation that it has even taken place.
Meanwhile, the four homes that were saved from closure in 2021 continue to operate with low occupancy at great cost to the EIJB. When the closures were stopped, it was agreed that the issue would be revisited in the form of a ‘public consultation on the future provision of older people’s care’ and it was hoped that this would allow for a conversation about how they could be adapted or replaced so that the EIJB could better meet the growing demand for specialist dementia care.
But just six months after the remit of the consultation was published, it was revealed that a secret decision had been made to narrow its scope to focus only on when and how the four homes would close, with any discussion about replacement and adaption of services removed.
UNISON official David Harrold said the consultation had been reduced to a “sham to justify the outcome certain individuals wish for” and described the alleged move to change its scope as “not only undemocratic but sly and underhand”. A subsequent investigation by Council Chief Executive Andrew Kerr found that “a breakdown in communications…..occurred through a combination of officer error and a lack of communication”.
All of the evidence suggests that there will be a fresh attempt to close the homes this year. The point has been made repeatedly by those campaigning against the closures that we are not attached to the bricks and mortar of existing homes. But we will not countenance the closure of these homes while there is no plan or commitment to invest in adaptions or replacements. We will not consent to any further withdrawal from public provision of long-term care.
Enough is Enough
Taken on the whole, the episode around the Bed Based Review must be seen in the context of the 45-year period during which responsibility for long-term care has been almost entirely removed from the public sector and handed over to multinational corporations.
I expect any proposals coming forward in 2024 will follow the same trajectory, and the privatisation playbook will be utilised to full effect. Those making proposals to cut long-term care beds will first attempt to argue that the changes will improve the service. When that argument fails, they will point to an urgent need to make ‘savings’ and present alternative social care cuts that would have to be made if the cuts to long-term care aren’t implemented.
Nobody ever suggests closing an acute hospital or a school without detailing how it will be replaced. The money is always found.
Yet, for some reason, caring for people at the end of their lives is considered something that can be cast off to the private, profit-making sector. The little public provision of long-term care that remains in Edinburgh supports many people who require a level of care that the private sector is just not willing to provide.
We can’t let them down.
Cllr Ross McKenzie is the Independent councillor for Ward 7, Sighthill/Gorgie. He is a Specialist Community Public Health Nurse, has worked in care since 2001, and for NHS Lothian since 2005. Most of his career has been spent in care settings for older people, and his dissertation was titled ‘Assessing the quality of care in non-profit and for-profit care homes for older people’.
