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SKIDMORE CHRISChris Skidmore is the Member of Parliament for Kingswood, a Member of the Health Select Committee and recently authored 'The Social Care Market' for the Free Enterprise Group.  Follow Chris on Twitter.

Much of the debate over the Care and Support White Paper has, to date, focussed on the big question of how we pay for long-term care for the elderly. This is fair enough – funding will always be a prerequisite for any policy. However, it is also as important to look at how we care for older people, not just how it is paid for. And this is an area where we can learn from innovation and excellence abroad.

The next generation of older people will be culturally very different to their parents. For we are now approaching the time when the baby-boomer generation are retiring – not only are they the most affluent generation in history, but they are also steeped in the principles of consumer choice and the expectations of high quality services. Unlike their parents, who lived through the war years and unprecedented austerity, this is a cohort which is not content to settle for adequacy. One suspects that this will be equally true when it comes to long-term care- and with the advent of greater personalisation we can expect them to exercise this choice.

One of the most exciting examples of innovative care for the elderly comes from Dr William Thomas, an American who specialises in elderly care, and in particular its deinstitutionalisation. Dr Thomas pioneered the ‘Green House’ model of care, and there are now projects based on this principle in each of the 50 states.


In terms of design, Green Houses appear more similar to a large family home, rather than a care home or medical facility. They are small and self-contained – each housing no more than a dozen residents – whose private rooms are situated off a bright central lounge and kitchen area. This layout avoids long, impersonal corridors, which would isolate frailer residents. Each room has its own attached bathroom and a medicine cabinet- again avoiding the appearance of an institution.

Part of the blueprint mandates that the kitchen and dining area contains a table that is large enough for everyone to eat at communally. This is important, rather than being a functional place for food preparation, the kitchen becomes the heart of the home. Residents can eat when they choose, and indeed seem much more like partners in their care, rather than simply people receiving a service.

The staffing ethos is the key – as Dr Thomas explains. Believing that terms like ‘carer’ or ‘care-assistant’ tend to have a low status stigma attached to them; Thomas instead calls his multi-tasking staff members ‘Shahbazim’ – Persian for falcon. These Shahbazim cook, clean, do laundry and provide day-to-day care – a drastic departure from the traditional model that is de rigeur in most care homes. They even eat with the residents, as part of the familial nature of these homes, and wear their own clothes rather than uniforms. They are also responsible for communicating with family members, and assist the external Clinical Team with preparing individual care plans. Effectively, they do everything but sleep there. Residents are more content, and so too, importantly are the staff.

There are usually two members of staff for each Green House, as well as a ‘Guide’, who is responsible for the overall operation of the home, usually overseeing more than one home. The staff are organised in teams so that they can provide 24 hour care.

The instinctive reaction is that this sounds expensive. And elements of it are – for example, the staff are paid around 10% more than their equivalents elsewhere, reflecting the additional training that they receive. At the same time, though, the multi-tasking nature of their role means actual hours of labour remain the same- rather than employing several different people to do different elements of the work. Crucially, Green Houses are specifically designed to be affordable for those people who are on Medicare- the poorest, state-supported residents. Dr James Mumford of the Centre for Social Justice demonstrates that the costs are realistic ones in a British context- in front of the Health Select Committee he said:-

"If you calculate that an average nursing home bed in the UK costs £650 a week, and therefore, £2,800 a month, which is to say $4,000, that sits right in the ballpark of where the reimbursement for the Green Houses comes from".

This is just one example of where innovation and experimentation can have remarkable results. Clearly replicating this model in the UK is not something that can be done overnight- there a number of complex issues of regulation and law that would need to be carefully examined. But person-centred care is the wave of the future, and it is Green Houses that are showing the way.

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