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Why small is beautiful

Why small is beautiful

By: Nick Bruce

The challenge of funding elderly care is very much in the headlines and has led to ever ‐ larger omnicare facilities catering for clients with often radically different needs as a way to minimise costs. Whilst omnicare facilities are often lauded as a ‘home for life’, what receives rather less attention is the considerable research that reinforces that, when it comes to both quality and quantity of life, smaller homes who specialise win hands down.

The twin ‐ track approach

The State’s preferred solution for the elderly is a twin ‐ track policy of encouraging the elderly to stay at home for as long as possible, and then to move to residential facilities that cater for all needs (omnicare facilities). For some, these solutions are a good fit, but for others they often feel loneliness rather than independence when their home becomes a ‘prison’, and a poorly ‐ matched omnicare facility can actually increase and accelerate their needs.

The State’s influence

For the care home market, the State effectively controls 75% of expenditure either directly (48%), or through family fee top ‐ ups (17%) (Hancock & Hviid, 2010:23). The State’s influence on the care sector is therefore so large that, where it leads, the care industry is drawn to follow. Unfortunately, so do the consequences. Because the State consistently underfunds care, by £500 million according to Age UK (2012), care facilities must attract sufficient private clients to balance the books (Hancock & Hviid, 2010). This means that restricted and often less than ideal service choices for State ‐ funded clients often become a fait accompli for private clients too.

The omnicare solution

To encourage you to choose them, omnicare facilities often cite that they are able to offer a home for life in case the client’s needs change. Unfortunately, in order to be able to provide care at a cost the State is prepared to pay, these facilities tend to provide care on a scale that is far from homely, and where the reality of the lived experience is often far from the picture painted by marketing hype. If the consequence is Relocation Stress Effect, the mitigation of being able to cope with increased care needs can become a self ‐ fulfilling prophecy. Simply put, moving is a stressful experience, whatever age we are, but particularly for the elderly. The impact tends to be moderated by how different the new environment is. The smaller the change in environment the less the consequences are likely to be.

Avoiding the self‐fulfilling prophecy

Omnicare, by its nature, caters for clients with widely differing needs which these facilities typically manage by either mixing everyone together, or separating them in different parts of the facility. However, being with someone with radically different care needs is often traumatising, and being in proximity to them is a potential source of stress as it reminds more able clients of what their future might be. Both can lead to a self ‐ fulfilling prophecy of premature demise (Keller et al., 2012), pathological illnesses (Brame & Singer, 2010), depression (Bartolomucci & Leopardi, 2009), and more ‐ serious cardiovascular disease (Esler, Schwarz & Alvarenga, 2008). When we stop to think about it, this shouldn’t surprise us. Most people feel more comfortable being with a few people they know rather than many people they don’t know, and we all feel stressed when being around others who are very different to us. So whilst omnicare can be a solution to unavoidable increasing care needs, when poorly chosen, it can be a cause.

Why small is beautiful

By choosing a small home that specialises in clients with similar needs three areas of potential stress are minimised: the stress of being with strangers; stress caused by the behaviour of others, and; stress caused by a fear of moving to a higher ‐ needs unit. The consequence is often a significantly better quality of life when compared to larger, omnicare facilities (Kane, Lum, Cutler, Degenholtz, et al., 2007). The sad irony is that, whilst omnicare facilities claim to offer a home for life, specialist smaller homes normally actually achieve the same, but with one key difference; they offer an environment that many clients are happy to call home.

Further information

If you are considering care for yourself or a loved one, you may be interested to read Choosing the right care, A home for life, The transition to residential care and Funding care.

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About the author
Nick Bruce holds a doctorate from the University of Liverpool and has specialised in care for the elderly for more than thirty-five years.

Age UK (2012) ‘£500m funding gap for older people’s social care  ‐  and widening’, Age UK Website , [online] Available from: ‐ press/500m ‐ funding ‐ gap ‐ for ‐ older ‐ peoples ‐ social ‐ care/ (Accessed 7 December 2012).

Bartolomucci, Alessandro and Leopardi, Rosario (2009) ‘Stress and depression: preclinical research and clinical implications.’, PloS one , 4(1), p. e4265, [online] Available from: gi?artid=2629543&tool=pmcentr ez&rendertype=abstract (Accessed 28 November 2012)

Brame, Aimee L. and Singer, Mervyn (2010) ‘Stressing the obvious? An allostatic look at critical illness.’, Critical care medicine , 38(10 Suppl), pp. S600–7, [online] Available from: (Accessed 28 November 2012).

Esler, Murray, Schwarz, Rosemary and Alvarenga, Marlies (2008) ‘Mental stress is a cause of cardiovascular diseases : from scepticism to certainty’, 180(July), pp. 175–180.

Hancock, Ruth and Hviid, Morten (2010) ‘Buyer Power and Price Discrimination : The Case of the UK Care Homes Market’.

Kane, Rosalie a, Lum, Terry Y, Cutler, Lois J, Degenholtz, Howard B and Yu, Tzy ‐ Chyi (2007) ‘Resident outcomes in small ‐ house nursing homes: a longitudinal evaluation of the initial green house program.’, Journal of the American Geriatrics Society , [online] Available from:

Keller, Abiola, Litzelman, Kristin, Wisk, Lauren E., Maddox, Torsheika, et al. (2012) ‘Does the perception that stress affects health matter? The association with health and mortality.’, Health Psychology , 31(5), pp. 677–84, [online] Available from: (Accessed 28 November 2012).

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