This blog has been written by one of our commissioners, Professor Ruth Pearson of the University of Leeds and Women’s Budget Group. The blog is based on comments that Ruth made at the University of Warwick launch of the Care Commission Report on 12th January 2017.
Under the hullabaloo of Brexit and the talk of Trump and the noise about the NHS one can – just – discern a continuous murmuring about the ‘crisis in social care’.
It is quite clear that there is one – funding decimated; hundreds of thousands of older people not entitled to funded care; care homes going bankrupt or no longer able to provide local authority care because of the growing gap between costs and available fees; zero-hour care workers squeezed into 15 minute visits which are inadequate, frustrating and often leave people with mobility and other issues trapped in their beds or unable to move to other rooms.
And as we are all aware the contraction of real spending in the NHS has led to ridiculous pressures on A & E departments, insane queuing of ambulances outside hospitals, outrageous warehousing of seriously ill people on trolleys and corridors – we are all too familiar with the scenario we and our families and friends are facing this winter.
As we hear daily – it is us – the public who are blamed for this. We use the hospital services for trivial complaints; or some other part of the system is at fault – the GPs don’t have evening and weekend appointments, though GP funding has been squeezed and workloads intensified, community mental health services have been cut so much they are barely a skeleton of their former selves. AND we have the temerity to be growing older. So – yes a lot of the pressure on hospitals is laid at the door of us older people – who either should not be old, not be sick, and certainly not ‘blocking beds’ in hospitals which should be used for the deserving sick and injured. And to add insult to injury Tory Care Minister David Mowat has recently told us that it is the responsibility of families (read women) to take care of elderly parents just like we take care of young children.
So who can we blame for the crisis? Let’s blame the social care system for inefficiencies in organising post-hospital care, (in spite of the extensive slashing of budgets and entitlements); and most of all let’s blame the older population – not just the frail elderly who need constant care – for being old.
Everyone here is aware of the some of the underlying causes of the current crisis cycle of blame shifting – it’s austerity, its unlimited demands on health care resources, – or even it’s the profligate baby boomers who have put pleasure before self preservation in their over indulgent lives, who have spent their ill gotten pensions and savings rather than squirreled them away against future care needs. There is talk about conflicts between the old (read rich) and young (read poor, struggling) groups and indignation about the ways in which current generations of workers and family might be expected to support the wrinklies.
These debates – and this ongoing blame culture – give some indication as to why successive governments have allowed this gathering storm to continue unabated over recent decades. Various attempts to devise a more equitable and realistic system of funding – such as the Dilnot report which recommended capping life time charges for care – have come to nothing.
We presented our report on the need for a New Deal for Care and Carers in the House of Lords on November 1st 2016. Well attended, good discussion, evidence of some cross party consensus that ‘Something Needs to Be Done’ – and the report cited in parliament. A couple of weeks ago, a cross party group of MPs representing three House of Commons Select Committees have called for an urgent review to cover both the health and social care systems, warning that separation of the two is ‘creating difficulties for individuals and avoidable barriers and inefficiencies in our society’.
So why has political consensus about the urgency of the issue of finding and organising appropriate social care for older people not galvanised this, and previous governments, into action? Interestingly the recent initiative from the chairs of the three key select committees – Health, Communities and Local Government and Public Accounts indicates that a consensus is both desirable and possibly achievable:
‘In short, the problem is widely recognised – we now need political agreement so that a solution for the long term can be found. For our part we shall do what we can to contribute to a consensus.’
On the other hand Chris Ham, chief executive of the influential health thinktank The King’s Fund stated that ‘[f]or too long there has been a lack of political leadership on these issues’. He added ‘[w]e agree with the committee chairs that a political consensus that puts health and social care funding on a sustainable footing is sorely needed. Without a consensus, patients and people in need will suffer.’
The lack of attention to this issue in the November Autumn Financial Statement (Spending Review) is an indication of this lack of leadership, a point underscored by the head of the Local Government Association:
‘Following last month’s local government finance settlement, we said there needed to be an urgent and fundamental review of social care before the spring budget, and we are pleased the select committees back this.”
Personally I don’t think there really is the political will to change. The King’s Fund responded to the letter from the Select Committee chairs:
‘Securing sustainable funding for social care is a challenge that successive governments have failed to meet. The result is that the social care system has become a threadbare safety net that is being stretched ever more thinly, with the sector facing a £2.4 billion funding gap. The impact of this is felt by the most vulnerable in society… For too long there has been a lack of political leadership on these issues. We agree that a political consensus that puts health and social care funding on a sustainable footing is sorely needed. Without a consensus, patients and people in need will suffer.’
The government has already ignored the recommendations of the Barker Commission which reported in 2014, calling for a New Settlement for Health and Social care. This report received very little public discussion in spite of its very clear and sensible proposals. It called for a ring-fenced budget for health and social care with a single local commissioner. It proposed working towards much more social care being delivered free at the point of use, and other changes which would avoid a stand off between health and social care budget holders. But the findings of this Commission were rarely dusted down after 2014.
So why would anyone have any optimism that the current initiatives by select committees and MPs is going to make any headway? This is not a rhetorical question. What faith can we have in progress towards the urgent changes needed in the social care system – regarding resources, finance, training, employment, and all the other things which we detail in our report which are needed to provide appropriate, dignified and hassle free care to those who require it?
I am pessimistic about this. One of the reasons – and here I speak in my personal capacity – is because the call for integrated health and social care service, finance and provision is, in my view, reactive, reflecting the high political priority of sorting out the NHS – and at the same time the low priority for funding social care properly. It has now become impossible for even the current Conservative government to ignore the crisis in the NHS – and it may well give some attention to the bits of the care system which impacts on this – i.e. ‘bed blocking’ by older patients unable to return home because of lack of care provision (whatever happened to Convalescent Homes?).
But this is just the tip of the iceberg regarding social care. This is ‘crisis care’. It is not everyday care. It is not the daily support required by the well elderly- who just need a bit of help with household chores and cooking – what we used to call Home Helps. It is not the kind of care older people on their own need with regard to sorting out their medical appointments, dealing with bills and finance – every more difficult in this on-line age. It is not the kind of care that offers company, activities, entertainment, and joining in with others. Recent research findings suggest that over half of the over 75s live alone and nearly one fifth of them have contact with friends and families once a week and one tenth have contact less than once a month.
This aspect of aging in addition to the deterioration of care for older people, has not been prominent in political debate. Partly this is because there is an assumption – now made explicit by Minister Mowat, that older people will be cared for by their families – despite clear evidence that demographic change has meant that the majority of the population now live very far away from their older relatives. This has been exacerbated by the rapid and sustained increase in women in the labour market which means they are less available for informal care for older people. And unlike childcare – which governments have recognised is a barrier to women working, eldercare is not such a political priority – no doubt partly because women are generally in their 50s plus when they are required to deal with the care needs of their parents and other older relatives – at the end of their working life rather than at the beginning like parents of young children. Indeed there has been far more public discussion of the fact that large numbers of grandparents are leaving employment to care for their children’s children (because of high cost and inadequate child care provision) than the fact that many of that same cohort face ongoing care responsibilities for older people. These are the kinds of long–term care issues that the current focus on what I call ‘crisis care’ will fail to address. They do not begin to take in the need – and I would argue the desirability – for appropriate everyday care for all people in the country as they get older and less mobile and capable.
So, what is to be done? Firstly I think we have to re- think the way we conceptualize care for older people. We tend to think of it as services – which need to be funded – which compensate for incapacities of older people. For this reason the emphasis is on personal care, which should be provided in people’s homes until their need is such they have to be catered for in particular residential facilities – sheltered accommodation, care homes, nursing homes etc. I think that is important. But also we need to see social care for people as they get older as normal, natural, desirable and deliverable – not as reflecting imminent decline, disability or even dementia.
In the Women’s Budget Group we have long argued for a re-prioritization of economic planning and priorities – one that puts wellbeing or all generations in the foreground. Most people accept that if we invest now in infrastructure that will serve us over time into the future – then the economy will benefit, employment and tax revenues will increase and we will all be better off. But such infrastructure projects need not just be ‘shovel–ready’ engineering or construction projects; the economy will also benefit from investment in the social infrastructure – not just hospitals, but health care staff and services; not just schools and nurseries, but teachers and childcare workers; and not just nursing or care homes but in the recruitment, training, and employment of care workers. In the PSA Commission on Care Report, we have suggested a National Care Service, and initiatives such as Care First – parallel to Teach First – which will give a professional basis and promotion structure for care workers.
But we should go beyond this. We should think about all the other services and opportunities that enable people to live fulfilling lives as they get older, not just when they are sick, or have a fall, or need personal care and attention. We need accessible public transport – so people can get to their doctors, or sort out their glasses or hearing aids themselves. So they can get to the cinema or participate in a neighbourhood choir or go to their chosen place of worship. For how can older people enjoy organised walks in the countryside if there is no public transport to get there. Lots of other countries prioritise exercise programmes for older people (for instance in Cuba and Japan) but to do this properly the complementary services need to be in place.
How are we going to achieve this? Of course funding is a key issue and we have talked a lot about these options in the Care Commission report. But we also need a structural rethink – we need to discuss all policy – the built environment, the transport network, housing options, public spaces, libraries and community centres – through the lens of care. The needs of people as they age needs to be normalised rather than treated as an unfortunate exception to the norm. We need, in effect, to mainstream care in all public policy – so that we can all enjoy the last decades of our life as healthy, independent, social and dignified human beings. It’s obvious really. Now we just need to persuade the rest of the world.