Mary Dejevsky: Tomorrow's aged will demand better

Neither the NHS nor local councils want to pay for elderly care if they can avoid it
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The Independent Online

When the three major political parties go into a huddle to reach a consensus on anything, you should smell a rat. In the case of what is optimistically called "social care", you should small a very big rat indeed. Separately and together, the parties seem to have judged that this one issue risks being a deal-breaker with the voters. Far safer to take it off the electoral agenda by dint of agreeing to agree. Whoever is elected can then set about the unpopular job of actually doing it.

Well, we should not let them get away with it. Social care – or, more accurately, what the State should do about the needs of elderly people – is exactly the sort of issue that the election campaign should be about. Because older people need it and today's working population will have to meet the cost, caring for the elderly is an issue for everyone.

Unfortunately, in so far as any serious discussion has yet taken place, it has centred on who will pay for what is projected to be a stratospheric bill as the elderly population increases, and with it the number who will need care. The Conservatives made hay with reports that Labour was considering a £20,000 "death tax", or a percentage levy, to be taken from an individual's estate. The Tories themselves have floated a one-off insurance premium to cover the cost of "free" social care, though it has been argued that this is nothing like enough. The Liberal Democrats have mooted publicly funded personal accounts, based on need.

The whole focus has been on cost. And cost, of course, is a serious consideration, especially when public spending looks bound to be squeezed. But a more productive approach would be to look at the social care issue the other way round: what are people likely to need, and how, in an ideal world, would they want those needs met? With answers to those questions, we could then talk about how, as a country and as individuals, we might fund it.

Here, let me hazard a guess: there will be very few people, of any age, who do not view arrangements as they are as disgraceful, indeed unworthy of an advanced country. Scots, who are currently guaranteed free "social care", might be a little happier, but their exchequer, too, is coming under strain. Both there and in the rest of the UK, a huge amount of money – public and private – is already spent on care; how well it is spent is another matter.

Of the most obvious defects, the first is the sharp division made between "health" and "social" care. If you suffer from a disease, you are supposed to be the responsibility of the NHS and your care is free. If your only ailment is old age, your care is provided by the local authority and rigorously means-tested. Dementia is not the only condition to fall awkwardly between the two, precipitating arguments about what you need and who should pay.

Which only highlights the underlying problem. Neither the NHS nor the local council wants to pay for elderly care if it can avoid it. As for working together, you can forget it. They have different geographical boundaries, different work cultures, different structures and separate hierarchies. With care for the elderly, this makes for expensive contradictions and duplication, not to speak of empires that are easier to build than dismantle.

The second defect is the actual care provided. Local authorities offer some services in the home, which vary from one council to another and are being stripped as money grows short. Some councils run their own care homes; others pay for private places, but the main choice – which for many people is no real choice – is between help at home, which can be haphazard and of a variable to poor quality, and residential care, which seems extortionate, given how badly most care workers are paid.

In between, there ought to be decent sheltered housing, with self-contained units for singles and couples and a full-time warden. It should be near shops and community facilities and available for rent on a means-tested scale. Not only is this cheaper than full residential care, but many people, given the choice, would prefer it.

The difficulty is that in many parts of the country such provision remains a dream. Where it does exist, local authorities guard it jealously for "locals", so preventing many elderly parents from moving near their children – unless they can afford to buy into a (pricey) private scheme, or are so poor that they qualify for charitable housing.

And payment is the third big defect of the present arrangements. As things stand, people on middle-incomes are left high and dry. The rich can opt out, buying into a luxury retirement complex and paying private carers. At the bottom, those with assets of less than £23,000 receive free "social care", in their own, or a residential, home. But everyone in the middle has not just to contribute to their care, but to pay a supposed market cost. What is more, as "self-funders", they often fall outside the council's remit even for advice.

Now I don't find it unreasonable to expect those with assets of this order to contribute to their care. But whether or not you think your home should fund your care at the expense of your children's inheritance, this all-or-nothing threshold will increasingly act as a perverse incentive. It will encourage people not to save or, if they do, to reduce their assets by living the good life while they can. The decline in private pension yields reinforces that instinct: why pay into a pension if its value will bear no relation either to what was promised or to what was paid in?

It is a sad comment on public confidence that so many people now regard buy-to-let investments as more reliable than a private pension. But why is there no incentive for people to put that same money into private-public partnerships for decent retirement homes? The next generation of pensioners – my own – would, I do not doubt, contribute more willingly to their care, if the means-testing was not all-or-nothing and they received a decent standard of living for their money.

The NHS survives to this day because the service was good enough – though it could be better – for middle- earners not to begrudge their National Insurance. Something similar will have to apply to care for the elderly, or the slightly better-off will withdraw from the social compact altogether and the public bill will end up even higher.