The word ‘seminal’ is bandied around a little too often these days but if there is one piece of gerontological research to which it might be appropriately applied it is Peter Townsend's ground-breaking study of residential care in the late 1950s. Townsend set out to answer the fundamental question of whether ‘long-stay institutions’ for older people are necessary in our society, and if so what form they should take. His study was immense in scale and novel in methodological approach and his conclusions kick-started the critique of residential care for older people that still rages today.
In this fascinating book Julia Johnson and colleagues set out not to repeat Townsend's study, but to revisit both Townsend's data and, insofar as they can, a number of the original homes in order to see ‘what has happened’ in the intervening 50 years. Just as Townsend did, they ‘push the methodological envelope’ and they use nearly 100 volunteer older people as ‘researchers’ in seeking out and exploring life in many of the homes that were part of Townsend's study. The resulting book is organised into three sections comprising ten chapters. The first four chapters ‘set the scene’ and include an extensive analysis of the evolution of residential care and public policy for older people more generally, that is in itself an invaluable resource for students of gerontology and a very interesting re-read for those of us who think we might already ‘know’ all this. The middle section contains the results of the study and in the final two chapters the authors reflect on methodological issues and explore the degree of continuity and change in residential life for older people between the 1950s and now.
There is much to enjoy, with many sections giving pause for serious thought about the so-called ‘progress’ that has been made. Reading about Townsend's original study provides an object lesson in dedication and innovation as well as saying a great deal about how the culturally acceptable face of research has changed, with Townsend's field note descriptions of some of his subjects being considered too frank, critical and judgemental by current mores. However, it is the description of life in the homes themselves that provides the most telling insights. Some findings will be no surprise, such as the changes in the nature of older people in UK care homes, who are now far older, frailer, both physically and cognitively, and far more ethnically diverse than in the 1950s. Care homes themselves are also now less remote, generally smaller, and with better and more diverse staffing levels. But these are largely structural and demographic changes, and it is when attention is turned to life in care homes that the text is at its best.
It is here the book has its most important contribution to make as it challenges our belief that things have significantly improved in the last 50 years. Whilst in many ways they have, this is by no means universal. For example, although older people now enjoy far greater privacy and more therapeutic approaches, routines still tend to dominate daily life, albeit being far more flexible now. Moreover, despite the significant increase in the numbers of single rooms, the authors conclude that the personal space of older people is more ‘clinical’ and less ‘homely’ than it used to be. Furthermore, although there is now much more organised and group activity, the quality and quantity is very varied and older people still have access to too little meaningful activity and, paradoxically, far fewer opportunities to engage in resident-initiated activity. This is due, the authors conclude, to the over-regulated nature of current care homes with the emphasis on ‘risk and its consequences’. What is perhaps most fascinating is the conclusion that the culture of many homes seems relatively little changed over a period of more than 50 years, with the dominant way of ‘doing things around here’ having been ‘passed from one generation (of staff) to the next’. This tellingly captures the complexity of culture change and gives a lie to the present preoccupation with ‘quick fix’ solutions.
There are also areas of continuity, one of the most important messages being that work in care homes and related environments is still perceived of as low status, remaining undervalued and under paid. Despite the ongoing efforts of recent initiatives such as ‘My Home Life’ (www.myhomelife.org.uk) to raise the status and profile of living, dying, working in and visiting care homes, wide-ranging change seems unlikely until these fundamental issues are addressed. For me, however, the most telling quote in the book reinforces the need for a move away from policies that focus on the individual to those that recognise the interdependence that underpins quality of life for all of us:
As in the 1950s it is really the personal relationships, with each other, with staff and with family and friends outside the home, rather than activities per se that sustain residents. (p. 163)
A case for relationship-centred care if ever there was one. Overall this excellent book has much to commend it, and if I have a criticism it is that it tends to shy away from the really difficult question, originally posed by Townsend, about the future role of longer-term care environments for older people. However, as successive generations of academics and policy makers have failed to adequately address this issue perhaps this is a bit too much to expect. Whilst the hardback version may be prohibitively expensive for personal purchase, this book deserves a place on all library shelves and should be required reading for anyone interested in the welfare of some of the most vulnerable members of society.
