With Respect to Old Age - Elderly Client Adviser

Feature

posted 1 May 1999 in Volume 4 Issue 4

"With Respect to Old Age" an Appreciation

The main recommendation of the Royal Commission, that the cost of long term health and personal care for older people ought to be met by the taxpayer, could not have taken the Government by surprise. The research evidence was well known before the Royal Commission started work. It concludes that the great majority of the public, irrespective of age, wealth or political preference, feel that the provision of a basic level of long term care should be a public responsibility1.

Immediately after the Report was published, Swiss Re undertook further market research2 to test public reaction. Once again, a substantial majority of those sampled thought that the state should pay all, or a substantial proportion of care costs.
The Government is backtracking, however, and has announced a further debate on the Commission's findings, which will, at best, delay any public expenditure commitment. In fact this debate has already been carried on by policy makers and service providers since at least 1948, and there has also been a chronic inability to move it forward. In their recently updated work on the development of welfare services for older people3, Means and Smith highlight a number of recurring themes, in particular:

The periodic anxiety of central government about the public expenditure implications of an ageing population;

How best to fund long term care;

How governments redefine the boundaries between health and welfare, and so between 'free' and means tested services;

The failure to give priority to the health and welfare needs of older people4.

One thing is overwhelmingly clear. Older people have consistently been "a low priority for resources, the services offered have been of a low standard, they have been patronised by policy makers and sometimes abused by practitioners"5. To a large extent overhyped "community care policies" have been prompted by a desire to reduce the costs of residential and hospital care6 and to throw the burden of caring on to families or voluntary agencies. In short, negative and ageist attitudes to older people have dominated social policy for the last fifty years.

The whole thrust of the Royal Commission's Report is to expose this perspective as both unethical and hopelessly pessimistic.

"People see it [old age] as a problem that society is somehow managing to contain at the moment"7

"Society should recognise the value inherent in older people"8

"We wholly repudiate any remaining negative images and urge society as it approaches the new millennium to take a different and more positive view of ageing"9

The Report is explicitly based on a set of core values: that older people are a valuable part of society and should be valued as such; that old age should be seen as a natural part of life, not as a burden; that it is morally and practically intolerable to describe old people as a "problem"; and that old age represents an opportunity, not a threat, for individuals, and for society as a whole.

Space does not permit a full analysis of the Commission's recommendations. As might be inferred from what has already been said, they challenge government and society to re-examine many of the unspoken assumptions about old age which permeate "cool" Britannia. Two themes only will be explored.

(i) The Demographic Time Bomb

The Commission concludes, quite rightly, that there is no 'demographic time bomb' as far as long term care is concerned. It points out that the number of people aged 65 and over has already increased by 400% since the turn of the century, and has doubled since 1931. There is still an upward trend which is projected to continue until about 2030, when the population of under 84 year olds will stabilise, or even decline10. The "oldest old", over the age of 85 will continue to increase in numbers, although they will only ever comprise a small percentage of the population as a whole.

Furthermore, given the overall improvements in public health and material surroundings, life expectancy may continue to increase, and even the oldest old people may remain healthier for longer. To a large extent, therefore, the UK has already survived its demographic time bomb, and certainly we are not facing unprecedented demands on public resources.

Looking back for a moment, there is abundant evident of periodic concerns about demographics. In 1942 Beveridge himself, the proponent of contributory retirement pensions and a free national health service suggested that11 "it is dangerous to be in any way lavish to old age until adequate provision has been assured for all other vital needs". During the 1950s and 1960s there was widespread concern about the "flood tide of dependency" and this was reiterated during the 1980s12. The demographic trend throughout this century is undeniable, but it has consistently served to justify affording lower priority to the needs of older people than to the needs of other groups. The real problem is that older people are bound to struggle for resources in a society where institutions are "geared primarily around issues of production and reproduction"13.

(ii) The Boundary between Health and Welfare

The Royal Commission emphasises that older people need long term care not simply because they are old, but because their health has been undermined - by Alzheimer's Disease, stroke or some other disabling and incurable condition. It points out that the only difference between cancer and Alzheimer's Disease is the limitation of medical science14.

This is a powerful argument, which goes to the inequity of the present system. Since 1983 the number of NHS long stay beds has reduced by 38%, and the number of private nursing home places has increased by 900%. Only 8% of the additional nursing home places are paid for by the NHS. The rest are paid for by individuals or by local authorities. The Commission suggests that, "in order to concentrate its resources on acute care, the NHS has been increasingly reluctant to provide long term care for older people", and recommends that the Government should conduct a scrutiny of the shift in resources supporting long term care since the early 1980s15.

The Commission's own enquiries have revealed pronounced feelings that "the Government was meant to underwrite the system in some universal sense through taxation, and it has not done so..... there is a linked feeling that the Health Service is abnegating its responsibility for care and making people rely on their own resources16". Respondents felt "defrauded" because they thought that they had paid NI contributions to cover all necessary care from cradle to grave17.

It is certainly true that the National Health Service Act 1948 set up a comprehensive service which was free of charge at the point of delivery. However, the NHS institutions were grafted on to an existing infrastructure. Before 1948 most chronically sick older people were cared for in "public assistance institutions" - formerly workhouses - which lumped together older people who needed medical and nursing care with those who were simply frail and needed to be looked after. After 1948 it was accepted that the NHS was to concern itself with the sick, whilst the National Assistance Act 1948 was to establish a system of local authority residential care for those in need of care and attention. Such provision was always means tested. At that time both government and the medical profession assumed that it was possible to draw a distinction between people who are sick and people who are merely frail.

Since then policy makers have struggled with this distinction. Guidance was issued in 1957 and again in 1995 but was always full of grey areas. Each "redefinition" has tended, however, to include increasing numbers of sick older people within the 'care and attention' provisions of the National Assistance Act and so to require them to fund their own care within the limits of their resources18.

The effect of the Royal Commission's main recommendation is to shift this crucial boundary to where many people clearly think that it should have been, but where in fact it has never been. Personal care has never previously been exempt from means testing. Of course definitions are everything, and that offered in the Report is not without its own grey areas19. Nevertheless it is important to emphasise just how radical the proposal is. Chapter 3 of the Report contains a clear and eloquent justification:

"Paying for long term care.... Involves making provision in one way or another against catastrophic and, in principle, unforeseeable costs.... Universal risk pooling represents the most effective way of providing the coverage required. This views the risk of needing long term care as, in practical, moral and social terms the same kind of exceptional risk as of having a heart attack or contracting cancer. It requires provision that pools the risks in a similar way"20.

Margaret Richards

1 With Respect to Old Age, Research Vol. 1, p.237.

2 Swiss Re: Stopwatch, No.6, April 1999.

3 From Poor Law to Community Care, Robin Means and Randall Smith, Policy Press 1998.

4 Ibid, p.3

5 Ibid, p.331

6 Ibid, p.8

7 With Respect to Old Age, para 1.11

8 Ibid, para 1.14

9 Ibid para 1.10

10 Ibid, para 2.17

11 Beveridge Report, 1942, Social Insurance and Allied Services, Cmd 6404, para 15.

12 A Happier Old Age, DHSS 1978; Growing Older, DHSS 1981.

13 Means and Smith, op cit, p.2

14 With Respect to Old Age, para 3.7

15 Ibid paras 4.7 to 4.8

16 Ibid, para 4.34

17 Ibid, page 37

18 Circular 14/57; HSG(95)8; and see the amendments to section 21(1) NAA

19 Op cit, para 6.44

20 Op cit, paras 3.2 and 3.16