July 1926: ‘No adequate protection is taken to prevent dissemination of contagious or infectious diseases, and frequently patients are unable to obtain any assistance when they require It….’

[Report of the Select Committee on Nursing Homes]

One of the many tragic consequences of the coronavirus within the UK has been the effect on care and nursing home residents and staff. At the height of the pandemic, the Office of National Statistics (ONS) stated that from 2 March – 12th June 2020 around 30% of the 66,000 deaths in English care homes  could be attributed to the coronavirus, that the death rate was significantly higher than usual across the country and care home residents over-represented . Public health policy, whereby care home residents were excluded from hospital admission, discharged to release hospital beds and denied testing may be a factor, as may the lack of adequate Personal Protective Equipment (PPE). Further, early findings from the Vivaldi study, undertaken by the ONS to try to understand this disproportionate death rate, identify a cluster of factors: high rates of staff infection, the use of agency or casual staff, and lack of sick pay. Collectively these increased the residents’ infection risk in and between homes. This ‘perfect storm’ is one of the abiding narratives of the pandemic in the UK – particularly in England. One hundred years ago, the same sector was in the news for the first time.  

In the late 19th and early 20th centuries institutional care for the sick grew exponentially, in the form of teaching, municipal and cottage hospitals, plus asylums for the mentally ill. Generally funded and regulated through voluntary contributions or government sources, they were not-for-profit institutions that, by the end of World War One, were increasingly the expected location of care for working class patients. In parallel there existed an unquantified, unregulated sector loosely defined as ‘nursing homes’. These ranged from prestigious establishments serving a much wider section of society, such as the patients of top Harley Street Doctors in London, through to cheap rooms in private dwellings where a poor, desperate or unscrupulous relative might leave the frail and elderly to their fate.

Criticism and scrutiny, in part due to reports of neglect, but also, following the Nurse Registration Act of 1919, of unsuitable people claiming to be ‘nurses’ when they had no registered qualification, led on 2 March 1926 to the formation of a Select Committee on Nursing Homes [Registration]. It was formed to: ‘consider and inquire into the question of the inspection and supervision of nursing homes’. Its report to parliament on any legislation that might be ‘necessary or desirable’, led to the Nursing Homes [Registration] Act in 1927 – the first such attempt to investigate and understand this sector and the grandparent of our current legislation.

The 282-page report makes fascinating reading.

The first task faced by the Committee was to define ‘nursing home’. This alone demonstrated the complexity of the sector and they found that the single uniting feature was that they were, almost always, run for profit. In conclusion they stated that some regulation of this ‘legitimate industry’ was necessary.

The Committee was faced with many competing interests and challenges: The medical profession, strongly represented by the British Medical Association, argued that as long as a qualified doctor was involved no further legislation was necessary; they were, by their registration already accountable. The newly formed General Nursing Council insisted that only a registered nurse should be entrusted with running a nursing home; she alone would have the skills to manage the total experience, including housing, hygiene, nutrition and care. Those running homes wanted flexibility; many respected Matrons were of a generation that pre-dated nurse registration, the less respected feared scrutiny. Lay visitors reported harrowing stories of neglect, in particular of the senile and elderly; poor food, insanitary rooms, cross infection and no means of complaint or escape, also figured highly in the list of criticisms. This neglect extended to nursing staff who often lacked adequate accommodation, food and personal protection from injury or disease.

Money and its relationship to quality was also a thorny issue: The committee managed to establish £5 per week as the minimum fee necessary to offer the most basic, adequate care for a patient in a single private room. This was well beyond the means of many needy people so the cheapest rooms were exploitative and wholly inadequate. At the top end of the scale upwards of 20 guineas could be charged, but with no more guarantee that the person giving bedside care was qualified to do so than in the seediest of establishments. Amongst shining examples of loving and expert care, fraud, malpractice, exploitation and greed were rife.

The recommendation to legislate was inevitable, but how, and by whom, was hotly contested. Too local and inspector and proprietor were likely to be one and the same. Too centralised and bureaucratic red tape would bring the system to a standstill. A fully representative inspection team raised fears of extortionate fees for registration.  Too small and each vested interest argued hotly for their own expertise being essential. The subsequent Act of 1927 did its best to resolve the dilemmas and bring some order to the chaos.

Nearly a century later, shadows cast by the report’s findings can still be seen in our current challenged times.  Written three years before Covid 19, the 2017 report by the Competitions and Markets Authority shows the sector to be deeply problematic and at its worst failing those in its care. Calculated to be worth £15.9 billion in 2017, for-profit and market demands ensure that funding continues to undermine care standards and regulation seems inadequate to the task. Little wonder then that this sector, above all, has suffered so acutely of late.