Читать книгу The Moral State We’re In - Julia Neuberger - Страница 11

The nearest we have seen to this kind of public anger was over the Royal Commission on Long-term Care, chaired by Sir Stuart (now Lord) Sutherland, which was set up when the Labour government came to office in 1997. Its members were chosen from a variety of areas, with a heavy weighting given to nurses. Its conclusions were, essentially, that the government, with restrictions according to nursing assessments, would have to pick up the cost of the long-term care of older people.

The Commission’s basic argument was that, in an NHS that was free at the point of use, there was no distinction to be drawn between the kind of long-term care a person needed when very old and frail and the kind of help and care they needed when acutely ill in hospital. This was the majority view, though the debate over the distinction between nursing care and social care demonstrated the impossibility of the position we had got ourselves into, historically speaking. There were two dissenters, the aforementioned Joel Joffe, now Lord Joffe, who was worried by the rising and unsustainable costs of long-term care for the elderly, and David (now Lord) Lipsey, who realized that the Commission was moving towards a conclusion that would be entirely untenable as far as the government was concerned. He did everything in his power to make the other members change their view. His final minority report made it clear that he believed that older people themselves would have to pay the costs of long-term care.*

Both the government and the Royal Commission missed a trick here and caused deep resentment amongst older people and their families that has not gone away, at least in part because people feel a grave injustice has been done. Indeed, it is in this area that real political action by older people might still become a reality, in a society where grey power has been a long time in coming. The curious thing is that this was, and is, an entirely unnecessary outcome. The Royal Commission ended with a recommendation, essentially, that long-term care should be paid for by the statutory sector. The implication was that the tax rates would have to rise to pay for this. They never quite got to the bottom of what was nursing care and what was social care, a problem that has bedevilled the care of older people for all my working life and which has caused much unfairness.

The classic question is that of the bath. Is giving someone a bath because they smell a nursing or a social task? If they smell, it is argued, it is a social bath. If they have sores or the possibility of them, then it is a nursing bath. On those grounds, the same bath, given to the same person, could either be given for free, for medical reasons, or be paid for, for social reasons.

After the government decided to reject the Royal Commission’s recommendation of requiring statutory payment, it came up with the worst of all settlements. According to assessments made by nurses, older people would get a weekly payment according to need, but this was not enough to pay the cost of a care or nursing home.

This has led to some bizarre results and is a good example of the politics of unintended consequences. Relatively wealthy older people, already in nursing homes and deeply dependent on nursing and social care, are getting help with the fees for their homes, usually allowing the nursing homes to raise their fees. Poorly off older people, not quite so dependent but without the children and relatives who might provide a some care, do not get enough help to allow them to be in a nursing home or care home, unless their dependency becomes so severe that the reluctant local authority decides to pay. Meanwhile, for many nursing home owners the fees provided by local authorities are so low that they have decided the whole area is uneconomic. They can make more money by selling the properties, especially in the booming southeast, and pocketing the profits. Staff costs have been rising and the availability of staff generally declining. The government settlement of help with nursing care has done nothing except raise costs and give a bit of help, often to the better off who are already paying their way in nursing homes.

In Scotland, where the decision was made to go the other way and to pay the full cost of care, the nursing homes are now deluged with older people and the system is cracking under the strain. Despite the strong feeling within the Scottish Parliament that this was the right direction, the total subsidy of nursing home care makes it virtually impossible to choke off demand. And in parts of Scotland where there is low employment or where property prices have not risen very rapidly, there has been an epidemic of nursing and care homes opening, simply because the income–though not huge–is assured.

All of this has been horribly unfair and has disappointed older people, who greatly fear the need for nursing home care and the giving up of independence. And it was unnecessary. Few older people and their families feel that it is essential that the whole cost of long-term care should be borne by the state. Approximately one in four older people will need long-term care of some kind–a proportion so high that it might seem like the kind of risk we should expect people to take on for themselves. Supposing the settlement went rather differently. Supposing older people themselves were required to take on part of the risk–perhaps paying for up to two years of care, which is the average time older people spend in long-term care. Beyond that period the costs would be fully covered by the state. One major advantage of such a scheme is that it would deal with the issue of unfairness. Though there is still a one in four chance that long-term care will be needed, it is reasonable to ask people to plan ahead for such an eventuality. But the cost would not be open-ended and, if prepared for by saving or by taking out an insurance policy, would not require people to realize major assets, such as selling their house, which is currently a cause of huge resentment. Though many people might not like such a system, they could not say it was unfair. Nursing contributions could then be restricted to those who elect to stay in their own homes-a further discouragement, if one were needed, to going into a nursing home.

The reason for the anger on the part of older people was so predictable and so unnecessary. The government was trying to choke off the cost of long-term care to the statutory sector, which is what governments do. But to older people, as well as their carers and children, it seemed as if the government thought people were going into nursing homes for fun, as if it was some kind of luxury item, like going on exotic foreign holidays. But for most older people, going into a nursing home is the last stage on a journey to death, much resented, much feared, the last thing most of them want to do. It was completely unnecessary for older people to become distrustful of a new government that had come in promising to do something about a situation that was generally agreed to be appallingly unfair. All the accusations were thrown into the ring: older people had paid their taxes, older people had given service to King and country during the war, older people were being abandoned, older people were being neglected, older people were being badly treated by the NHS and were now not even being helped when they needed long-term care. But underneath all this there was genuine resentment. Older people had paid their taxes on the basis of care ‘from cradle to grave’ and this undertaking had been broken without any debate, without consent from those for whom it had, apparently, been made. Older people had trusted the new promises of the welfare state from 1948. And that trust was being betrayed.

People do not choose to go into long-term care, even though their relatives sometimes think it is the best option. People want to stay in their own homes and remain independent for as long as possible. Sometimes this is not possible. Did the government not understand what an awful decision it is to have to give up one’s home, to embark on a one-way journey into a care home, to surrender one’s privacy, to have no control over one’s own life? Did they not understand that care homes and nursing homes are a necessity, not a luxury? Could there not have been some sympathy, some generosity, here? Instead, there are cases, time after time, of the Ombudsman finding that guidance on NHS funded care has been misinterpreted to save the NHS money, with a particularly heavy judgment in April 2000 that lead to considerable payouts by the NHS. The scandals about payment are legion, with an excellent campaign being run sporadically by the Daily Mail, ‘Dignity for the Elderly’, about the perversity and unfairness of the system. Since the government has paid out over £180 million in compensation to people who should never have had to pay their fees at all, it has been argued that ‘this is just the tip of the iceberg…The system is failing the most vulnerable members of our society, many of whom fought for our freedom and paid taxes throughout a long and productive life…More than 70,000 are selling their homes every year to pay nursing home fees often amounting to hundreds of thousands of pounds.’* The Daily Mail has not been alone in taking up the cudgels on behalf of older people. No one wants to be in a care home, and this is where government has made such a huge mistake.