THE BIG INTERVIEW: Jonathan Bruce, MD, Prestige Nursing + Care

Jonathan Bruce

Twelve years ago, Prestige Nursing + Care, one of the oldest care businesses in the country, transformed its business model from supplying nursing staff to NHS hospitals to delivering home care in the community across 34 UK branches. Leading the operation, managing director Jonathan Bruce, who this year celebrates his 25th year in the business, tells Home Care Insight how the family business found its calling, the challenges it has faced over the last decade and its hopes for a clear direction in social care

Take me back to the beginning. When was Prestige Nursing + Care established?

Prestige is probably the oldest care business out there. It was formed in Carshalton, Surrey in 1945, just before the NHS was formed. It was called Carshalton Nurses Cooporative back then. My mum was a midwife and her and my dad bought that business in 1971, so my family have owned it since then. I joined in 1994, so this is my 25th year in the business. We’ve gone from being a pure-play nursing agency, supplying staff into hospitals to switching to working in social care in the community, so we’ve seen it all. In March 2017 we sold out to Sodexo, so we’re part of that company now, which is great, and I do mean that honestly. It’s an even bigger family business – a £20 billion business – and their raison d’etre is quality of life services.

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What made you decide to hone in on home care?

Well, when we did it, which was in 2006, we had quite a few NHS contracts to supply staff and the problem was, the NHS see agencies as an issue. Any health secretary over the years has always said “we’ve got to get the agency bill down and we’ll save billions of pounds of year”. I accept where they are coming from, but the point is that agency staff are doing the job of a full-time person they can’t recruit. So agencies do well and exist because of the need to even out the peaks and troughs of demand. But it got to the point where we would be working very hard on a contract and they’d suddenly say, “sorry, we don’t need you anymore”. So you’d be investing all this time and money in making a contract work for them, recruiting their nurses, and they would just dump you without warning, and that’s no way to run a business. So we said, this isn’t working for us, let’s do something else. So we decided to look at home care, which has worked much better for us. I’d much rather go where we are appreciated and in social care 98% of the work is outsourced, so I think this where we have found our calling.

What are the biggest changes you’ve seen in the home care sector since you ventured into this area?

I think the biggest difference would be the availability of care workers. We are finding that people are leaving the social care sector because they’ll get paid more elsewhere. We have a US-based business called Comfort Keepers and one of their biggest competitors is Amazon, which has put up their pay rate to a minimum of $15 an hour, and they can’t afford to match that in their sector. Over here, Sainsbury’s is paying around £10 an hour, so a lot of these guys are upping the minimum wage. In our sector, you’ve got one or two key buyers and a multitude of suppliers, so the buyers do tend to lower the natural average pay that it should be. So the pay rate is artificially low and held down by the local authorities who can’t afford to spend more. The problem with that is you can’t get people to work for the minimum wage when they could go and stack shelves in Sainsbury’s. Home care is not the most glamorous of jobs, so you have to pay a good wage, but we’re not allowed to or if we do it’s very hard to make ends meet. Allied Healthcare went out of business last year because of that very reason. So what I have seen more than anything else is people leaving the industry and it’s getting harder and harder to recruit people for the wages we are allowed to pay.

Demand for home care isn’t the issue – demand is through the roof, but we’ve got to pay people more. Home care is not the most glamorous of jobs, so you have to pay a good wage.

What is your pay rate?

We’re trying to become a real living wage employer, which will put us at £9 an hour as opposed to the minimum wage in April of £8.21, but even then, trying to make a good margin to reinvest is going to be difficult. I do sympathise massively with local authorities, but something has got to give. Around 70% of our outgoings are made up of pay, and everything else is meant to be reinvested. Mitie sold its business, MiHomecare, two years ago and there will be more failures in this marketplace as it goes forward because of the way its set up. Demand isn’t the issue – demand is through the roof, but we’ve got to pay people more.

How have are you able to pay your workers above the National Minimum Wage when so many providers don’t, or struggle to do so?

If I’m honest, it’s the cost for the travel in between visits that’s the killer, so it’s about making sure that you don’t have people travelling all over the place for short visits. Also, if carers are travelling all the time, their affective working time is minimal. If you are doing 10 to 15 minute visits, you can’t build a relationship with people. That’s not care, it’s just checking to see if people are still alive. So it’s about good logistical management and even looking at using technology to improve services. We’re looking at trialling virtual calls so we can connect with clients using an iPad, but we don’t want to replace the human aspect – we’d like to do wellbeing checks via virtual calls, backed up with carer visits.

The difference between Good and Outstanding tends to centre round community engagement and how well we work in the community.

The government wants to ease the pressures on the NHS by enabling people to live at home for longer, but the social care sector still needs appropriate funding. Is this creating a vicious circle?

Yes. A lot of it’s about enablement, preventing readmissions and there’s a lot of things that you can do in the community now that are much better, and preferable. But what goes on in the community is less visible – it’s not your PFI funded gleaming new hospital, it’s stuff that goes on every day and it’s not eye catching, so you don’t get much political capital from that because it’s below the radar. It’s not exciting. I think it is, but politicians don’t, and I’m not holding my breath on the release of the Social Care Green Paper.

How do you manage the quality of care across your 34 branches?

We manage the quality of care across 34 branches by first of all ensuring that the recruitment and training of our care workers are as thorough and stringent as possible to ensure we attract and retain the right candidates. The assessment of a client’s needs is equally comprehensive to ensure we subsequently place the right member with the client. Ongoing supervisions of our care packages, combined with frequent internal audits ensure we can identify and resolve the usual small issues that arise with care quickly and effectively. 

People want to live in their own homes, but there is a cost to that and no one is actually telling people how much is going to cost.

Prestige was rated as ‘Good’ by the CQC during your last inspection. What plans do you have in place to be rated ‘Outstanding’?

The difference between Good and Outstanding tends to centre round community engagement and how well we work in the community. So we have a specialist dementia nurse and we are going to use her more and more to offer free surgery sessions to people. Even if people don’t use our services, we want to make sure that people know where to go. The biggest part of our job is education. People don’t know where to go – they think ‘my mum’s not well, what should I do? How do I get her assessed? Is she eligible for home care? What are my options?’ The government needs to set out clear guidelines on this. It shouldn’t be left to charities like Age UK to educate people. The government should take the lead.

*Note: Prestige’s Plymouth branch was rated ‘Outstanding’ by the CQC following this interview.

A lot of people think that they don’t have to pay for social care…

Well that’s the shadow of the NHS. People think that because the NHS is free, so is social care. We did some research a few years ago and one of the questions was ‘what would you be prepared to pay for?’ At the top of the list was gardening, taxis and hairdressers, and care was ranked ninth on the list. People don’t think you should pay for care and they aren’t saving for it because there are very few schemes that will help them save for care. We’re all going to need someone to look after us in our old age.

A voucher scheme to help people save for care has been proposed. What do you make of this?

I haven’t really looked into that, so I can’t really comment, but anything that stirs up the debate about how we fund care, and educates people that care needs to be saved for, has to be a good thing. People want to live in their own homes, but there is a cost to that and no one is actually telling people how much is going to cost. And it comes back to the question, how do we fund it? And how do we find a quarter of a million care workers to meet demand?

What do you hope to see from the Social Care Green Paper?

A clear direction. A clear funding settlement, saying it’s going to cost X amount. Let’s say it’s going to be percentage on national insurance or a penny on the pound, but whatever it is, let’s have a clear direction. So more than anything else, it comes down to how social care is going to be funded. Once that box is ticked, we can work on other things like training and retention. Unless the funded is right, how do you make a difference?

What can we expect to happen after the paper is published?

It depends on the landscape. If there is another election then it might get looked at again and I’m not sure what Labour’s position is on social care just yet. Their instinct is probably to get rid of private sector involvement, but it shouldn’t be about public versus private, it should be about ‘what does good care look like and who is going to deliver it?’ Let’s have some vision. So, hopefully the green paper will say what care will look like and what will happen if your mum breaks her hip, so it’s signposted for people and it’s clear for everybody.

How does Prestige expect the home care sector to be affected by Brexit?

I think the key issue will be the effects on the long-term recruitment of care workers from the EU. Although the government has transition arrangements for EU workers as part of its proposed Brexit deal, and a temporary residency arrangement for EU workers in the event of no deal, the uncertainty surrounding the whole exit means that inevitably there will be fewer people coming to work in the UK’s care sector, just at the time when there are significant and ongoing capacity issues.

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