Ageing costs

Providing and paying for long term care for Britain’s ageing population is an urgent issue. The fastest growing sector of the population is the over 80 year olds. By 2030 a third of the population will be of pensionable age.¹ Last December the government set up a royal commission to produce costed options for the next 50 years and report back. The commission has accumulated a mountain of opinion and evidence from some 2000 individuals and special interest groups concerned with care of the elderly. Last week it held its final public hearing to give them the opportunity to hammer home their messages.

Much consensus was evident. Radical organisational change and new methods of financing are needed to reverse the effects of policies which have left old and vulnerable people hostage to confusing, inadequate, inequitable, and poorly coordinated services. The onus on elderly people to demonstrate what they can’t do rather than what they can in order to get help is one of many perverse incentives that need to be removed. Independence should be seen as the goal and more resources directed towards prevention and early intervention to help keep people in their own homes. The current approach of plunging in late with a battery of expensive services before arranging (cheaper) institutional care should be a last resort, not the preferred option. Elderly people and their carers should have better information and more choice about what services are provided, when, and by whom.

Much current dissatisfaction is to due the divide between health services (which are free) and social services (which are not).² Cost shunting between agencies has resulted in many people having to pay for what by any reasonable definition is really nursing (and hence health) care.

The argument for structural change to achieve an integrated and coordinated service is widely accepted. The government’s recent discussion document Partnership in Action, which advocates joint working, pooled budgets, and a lead authority has been welcomed.³ Most organisations representing elderly people also share the view that housing should be an integral part of community care. Whether the various agencies should be controlled by a new overarching community care agency, as advocated by the charity Age Concern, is debatable, but all agree that a single point of access and delivery is essential. Information and advice needs to be available, free of charge, from the same body that is responsible, and accountable, for assessment and delivery of multidisciplinary services. At present assessment of “need” and the response to it is arbitrarily determined by individual local authorities—hence the wide geographical variations. The case for setting nationally agreed methods of assessment and criteria for eligibility for services is strong.

Most dissension arises over money. All agree that more funds are needed, and the estimates are daunting. Two years ago the Rountree Foundation emphasised that totally new methods of funding long term care for elderly people had to be introduced and that, until they kicked in, the cost to the taxpayer for continuing care would be around £540m a year.⁴ “The trouble is, the figures are largely speculative,”said Sir Stewart Sutherland, chairman of the commission. “We don’t know what current costs are, nor which models of care provide best value for money.” There needs to be a consensus, it was suggested, on what constitutes good quality long term care for elderly and disabled people. Ideally, national standards for care in all the different settings in which it is provided should be defined, costed, and made explicit.

Broad agreement seems to exist that, subject to means testing, individuals should bear the costs of accommodation, food, and certain domestic services while the state should pay for health, personal, and social care. What then are the main options for raising revenue to fund the state’s services? Few favour increasing taxes. Many see a long term care insurance scheme as the answer. A common view is that people should pay weighted premiums into a compulsory scheme throughout their lives. In return their long term care would be secured and they would know exactly what they were entitled to. Means testing seems inevitable but remains controversial.

Another thorny issue for the commission is what to do to safeguard the vast army of unpaid, largely female carers. Their contribution is acknowledged to be crucial and will remain so. If they were paid for what they do it would cost the exchequer an estimated £8bn a year.⁵ They will not easily be replaced by new recruits, for the working patterns and expectations of young women have changed. The commission is not short of advice, and it has only eight weeks left to marshall its thoughts if it is to meet its target publication date of early January 1999. Few reports will have been so eagerly awaited.