Editorials

Long term care in later life

A charity providing residential care for older people has just published the proceedings of a symposium held to celebrate its first 10 years.¹ Brendoncare espouses the unification of "residential" and "nursing home" care; making best use of professional skills; and the view, delicately put by one of its trustees, that not everyone wants to play bingo and watch EastEnders.² The title of its wide ranging symposium, The 4th age in the 3rd Millennium, smacks of a countdown--as well it might. If things go on as they are, population aging will lead to 10.8% of the gross national product being consumed by domiciliary and institutional long term care by 2030.³

Three things need to be done. Firstly, care must be as efficient as possible. We know too little about the cost effectiveness of the components of long term care, and there are intriguing variations in policy. Shreeve quotes people receiving domiciliary care costing £700 a week in an area where residential care is available at £120. Elsewhere, local authorities cap spending on domiciliary care at levels around the cost of institutional care.⁴ What are the ethical and economic implications of such contrasting policies?

Secondly, we must try to reduce the need for care by minimising disability in later life. There is hope here. The Medical Research Council has reviewed the topic⁵ and is launching a link programme on integrated approaches to healthy aging.⁶ The European Union alsoclaims an interest in the topic, albeit it has little impact on its research funding.⁷

Thirdly, we must agree on how to pay for the growth in long term care. The three options that seem most plausible are insurance, taxation, and liquidation of personal assets. Insurance would be unlikely to work except for very rich people and, at taxpayers' expense, very poor people. Germany is pleased with the hypothecated tax for long term care that it has recently introduced, but this tax replaced a liability falling on families. In Britain hard pressed working families might balk at paying taxes to protect the inheritances of better off people; a non-selective inheritance tax might seem more equitable.

Liquidate the assets?

The British government seems to have opted for liquidation of old people's assets. The recent guidance on long term care starts with a homily on the responsibility of the NHS to provide some "free" continuing institutional care but goes on to define eligibility in ways that could be interpreted to exclude virtually everyone from receiving it.⁸ The costs of most long term care will fall on the means tested social services budget. As part of a coherent, phased in national strategy providing means of spreading and underwriting costs this might be made socially acceptable.

As it stands, however, it will function as a selective inheritance tax imposing a double jeopardy. Those older people unfortunate enough to become disabled must watch whatever wealth they had hoped to pass on as a last gift to their children melt into the pockets of nursing home proprietors and shareholders.

Here is another ethical issue: the Brendoncare conference heard of a company with no previous interest in residential care buying into profit making nursing homes to "enhance earnings."⁹ In institutions in the charitable and public sectors unspent income goes not to shareholders but to improving the quality of life of residents. Should profit making nursing homes join tobacco companies and manufacturers of antipersonnel mines as industries in which decent people do not buy shares?

Charities such as Brendoncare offer inspiring visions of how good institutional care can be if it is compassionately planned and adequately funded. Sadly, the national picture is more of community care budgets becoming exhausted, hospitals silting up, and widespread anxiety about the quality of care available in an inadequately regulated private sector at prices that the statutory bodies and families can afford. Politicians and the public must face up constructively to the funding issue and must do so now. It would be in nobody's interest for a crisis manipulated by the media in the run up to a general election to precipitate some ill considered expediency.

In his summing up of Brendoncare's conference Niall Dickson made a telling point. We were expecting that we would by now be living with a generation of older people loyal to the welfare state for which they had fought and acting as a potent political force in pursuit of better care for themselves and others. This has not happened. Until older people in Britain learn to use tactical voting as the credible threat so effectively deployed by their coevals in the United States, politicians of all hues will continue to put their priorities elsewhere.

Professor Division of Clinical Geratology, University of Oxford, Radcliffe Infirmary, Oxford OX2 6HE

J Grimley Evans 

1. The 4th age in the 3rd millennium. Winchester: Brendoncare Foundation, 1995.
2. Theobalds S. An overview of provision for those in the 4th age. In: The 4th age in the 3rd millennium. Winchester: Brendoncare Foundation, 1995:5.
3. Nuttall SR, Blackwood RJL, Bussell BMH, Cliff JP, Cornall MJ, Cowley A, et al. Financing longterm care in Great Britain. Journal of the Institute of Actuaries 1994;121:1-53.
4. Shreeve M. An overview of provision for those in the 4th age. In: The 4th age in the 3rd millennium. Winchester: Brendoncare Foundation 1995: 10, 16.
5. Medical Research Council. The health of the UK's elderly people. London: MRC, 1994.
6. Medical Research Council. News. MRC News 1995 summer:7.
7. Minerva. BMJ 1995;331:462.
8. Department of Health. NHS responsibilities for meeting continuing health care needs. London: DoH, 1995.
9. Tombs D. Social services initiatives. In: The 4th age in the 3rd millennium. Winchester: Brendoncare Foundation, 1995:37.