The First Care home – 936 AD
The history of care homes in Britain begins in 936, when the first-known almshouse was built in York.
The story goes that King Aethelstan, at that time King of the English, provided funding for it after seeing clergymen of an older incarnation of York Minster using their own money to care for the elderly. ‘Alms’ means to give to others, through virtue or compassion. Also known as bedehouses, from the Anglo-Saxon word for prayer, these houses were funded by wealthy people hoping that their funding would increase their chances of being accepted into Heaven.
Almshouses were religious places, and their aim was to nurture the soul as well as the body. Residents, known as Bedesmen and Bedeswomen, would have to live under a strict regime of prayer and worship as part of their care.
Ill, disabled, or elderly people could also be given residence in monasteries and later the first hospitals. The first hospital known to care for people long-term was St. John’s Hospital in Canterbury, founded around 1087. In these hospitals, long-term residents were cared for alongside short-term patients, with leprosy being a common reason for temporary admission. As leprosy rates waned, many smaller hospitals were converted into almshouses while large hospitals were established to care for temporarily ill people and wounded soldiers.
In Elizabethan times, the 1601 Act of Relief for the Poor, now known as the Old Poor Law, made it every parish in England and Wales’s responsibility to house people who could not work. The ‘impotent poor’ included people who were too ill, disabled, or old to maintain employment. Some were sent to almshouses and some to early workhouses.
By Victorian times, care for the elderly still fell under the same category as care for the sick and for the poor.
The 1834 Poor Law Amendment Act, also known as the New Poor Law, put stricter methods in place for helping the poor. It got rid of ‘outdoor relief’, i.e., providing food and clothing to poor people, and made the workhouse the main source of aid for anyone unable to work.
Workhouses were grim and designed as a deterrent, making conditions so bad people would do anything to avoid them. Older people would be made to work for 11 hours a day to earn their keep, with elderly women often working as nurses to other inmates, despite having no medical training whatsoever.
The first state pension
The twentieth century saw significant reforms in care for older people. The 1908 Old Age Pensions Act brought in the first pension for anyone over 70 years old. It was means-tested and deliberately low to encourage people to save privately towards their retirement and included a behavioural test in order to redeem it. The 1925 Widows, Orphans and Old Age Contributory Pensions Act introduced the first contributory-pension, where some of the person’s wages went into their pension pot, as opposed to solely the employer contributing.
In 1927, parliament passed the Nursing Homes Registration Act, with Scotland following suit in 1938. At this time, as defined by the latter, a ‘nursing home’ meant a home “providing of nursing for persons suffering from any sickness, injury, or infirmity, and includes a maternity home”. These laws made it compulsory to register nursing homes so they could be inspected and introduced penalties for those who failed to do so. Homes also now had to keep proper records of every patient.
Labour’s post-war reforms
The Second World War brought a need for a new solution for housing for the elderly. Many were still confined to hospitals, but the huge number of casualties, both of soldiers and citizens during air raids, meant that hospitals were crowded. At this time, medical care was still privatised and with men away fighting, affording it was extremely difficult.
Shortly after the war, the Labour Party came into power and started to lay foundations for the Welfare State. Prime Minister Clement Atlee created National Insurance, and his Minister for Health, Aneurin ‘Nye’ Bevan, formed the NHS in 1948. This was followed by the 1948 National Assistance Act that abolished the Old Poor Law. This legislation made local authorities responsible for assisting ill, disabled, and older people with care.
Professor Peter Townsend
A twentieth-century hero of social care named Peter Townsend (not to be confused with Group Captain Peter Townsend, one-time love interest of Princess Margaret). This Townsend was a sociologist who visited 174 care homes in England and Wales in the late 1950s.
The resulting book that described his findings, The Last Refuge, showed the inequality of standards of care between those in private homes and those receiving support. He was alarmed by the treatment of those whose care homes were former workhouses, finding that the old workhouse ways still haunted the homes, such as deaths being kept secret from other residents. His findings led to widespread reform in improving the standard of care for older people who were unable to pay for care privately, including central heating and single-occupancy rooms becoming standard.
Business in the 1980s
In the 1980s under the new Conservative Government, residential care homes became big business. Prior to this, local authority homes had been the majority, but self-funded care homes increased and the number of places in them tripled over the course of the decade. While some were against privatisation, this did free up more places in local-authority funded homes for those that really needed them. The Registered Homes Act 1984 ensured that all private homes were still regulated.
The 1990 NHS and Community Care Act Reform, implemented in 1993, brought in the idea of care centering on individual needs and the care needs assessment was introduced.
New standards for the new millennium
In 2000, the Care Standards Act, though not enforced until 2002, replaced the Registered Homes Act and for the first time considered nursing homes to be a form of care homes for the elderly. The legislation also established care councils in England and Wales, regulated the training of care workers and introduced a new set of minimum standards that all forms of care home were legally obliged to comply with.
The Health and Social Care Act of 2008 aimed to combine the three existing regulatory bodies into one all-powerful inspectorate. This resulted in the Care Quality Commission (CQC), that inspects medical practices and care homes in England, beginning in 2009. In 2011, Scotland introduced the Care Inspectorate, but both lagged behind Wales, who had had the Care and Social Services Inspectorate Wales (CSSIW) in place since 2002. In 2018, the CCSIW changed its name to Care Inspectorate Wales.
The landscape for care homes is still changing. According to an IPPR thinktank report, 84% of care home beds occupied by older residents are in for-profit homes, while 13% provided by the voluntary sector with just 3% offered by local councils.
In recent years there has been a push from developers for more luxury care homes, with the number of small care homes falling. These large builds offer luxury living with fine dining at every meal, facilities like salons, spas and cinemas and services like chauffeur-driven cars. Some even have built-in high streets to provide a safe community for their residents. There has also been an increase in demand for retirement villages, as people look to find a balance between independence and support.