People with complex mental health care needs require robust staffing and regulatory practices from domiciliary care providers. The UK is falling painfully short of such standards, with the BBC reporting an increase in serious injuries of 300% in the last eight years for residents with complex needs being cared for in the community. Such a rise is shocking and begs the question: If the UK can’t manage it, can domiciliary care anywhere really meet the needs of such residents, and at what point do we decide when a patient should move to community care?

In the UK, the “Transforming Care” policy is moving care for adults with learning disabilities into the community. Such a move is being encouraged across the spectrum of mental disability and ill health, but alarming incidents of extremely poor care and inadequately trained stuff are arising. Worrying trends have also begun to emerge. Residents in community care facilities have in effect become tenants who can apply for housing benefit. For local authorities, this is an immensely attractive option as the cost of rent then comes from the government’s funding pot instead of from local government budgets. But this also means the landlord can cut deals with domiciliary care agencies to service the entire facility in exchange for nomination rights over tenancies – essentially choosing who can be a resident. This defeats the entire purpose of community care, which is meant to increase patient choice and give residents the ability to decide on a care provider. This is especially worrying when all care is not created equal.

Only about 20-30% of community facilities, termed ‘supported living’ facilities, can be termed excellent – the vast majority would apparently go nowhere near the standards required to care for residents with complex needs. Families of residents are left wondering whether their loved ones wouldn’t be better cared for in an institution, though local authorities often don’t give them that choice. Instead, they present supported living as the only option, which is ironically sold to families as an improvement in patient choice. It would instead seem that local authorities are desperately trying to find ways to minimise spending while juggling economic pressures that make delivering adequate care impossible.

Critics are going as far as saying care for the most vulnerable is coming full circle – at worst, resembling old school institutions where bad care and little choice over that care become commonplace. This is maybe going a little too far – but such concerns are valid. The BBC’s report describes autistic residents being cared for by over 20 different carers a week, a shocking amount for a person who needs consistency of care.

This is not just a UK problem, of course. Elsewhere in Europe staffing issues also abound – the people needed to be recruited and trained to deliver good standards of care are not always available, and rising demand and competition for the best staff means retention is difficult. Increasingly, European providers are putting an onus on training carers. One group, Dutch provider Buurtzorg, does this and is exporting this model into Asia by entering into joint ventures with nurse and careworker skilling companies. They call it a ‘resource-led’ model, seeing staff as the bedrock of any domiciliary care organisation – which they should do.

But this is just putting a plaster over a wound. Unless and until more money is made available – and possibly even thereafter – staffing will remain a huge problem.