With respect to old age

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7185.681 (Published 13 March 1999) Cite this as: BMJ 1999;318:681

At last, the 1948 show

  1. Elaine Murphy, Chair
  1. City and Hackney Community Services NHS Trust, St Leonard's Primary Care Centre, London N1 5LZ

    The last royal commission to deliberate on the problems of funding long term care for elderly people, which reported in 1895,1 was a disaster from start to finish. Despite growing national prosperity and a falling bill for poor relief, workhouses and poor law infirmaries were rapidly filling up with destitute sick old folk. Thousands more were reliant on their children for the basics of life. Old people's dependence on the unforgiving poor law system was becoming a deeply unpopular and unacceptable indignity. The Prince of Wales, a member of the commission, withdrew his support because of the endless political squabbling in committee. Joseph Chamberlain and his “pro-universal old age pension group” submitted an angry minority report, and five other members inserted disaffected addenda of dissent. To cap it all the commission's unfortunate chairman, Lord Aberdare, died the day before the report was published.

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    Most members of that early commission were steeped in the culture of the poor law of 1834. They could not make the visionary leap into a world of planned personal pensions and therapeutically comfortable institutions, even when the mood of the public should have told then that some revolutionary thinking was required. With Respect to Old Age, the report of the recent Royal Commission on the Funding of Long Term Care,2 also fails to make a visionary leap. It harks back to a welfare philosophy of 50 years ago, rendering the recommendations alarmingly expensive and missing an opportunity for creative thinking about what elderly people in the future will really want. The report takes little account of expected increases in the personal financial resources of many older people in the next 30 years and sidesteps current public and political rejection of indiscriminate universal welfare benefits.

    The task of the commission was to address the current inequities in the cost to elderly people of long term care in institutions and to suggest a fair and affordable system of funding. Inequities were introduced in 1948, when the free NHS funding system diverged from the means tested National Assistance Act, under which local authorities could charge for care. While causing some resentment in wealthier neighbourhoods, the inequities were nationally unimportant as long as the NHS provided for those with the most disabling long term disabilities and very few elderly people owned their own homes. The policy of transferring the care and funding of increasingly property owning frail elderly people from the NHS into the means tested, welfare benefit funded, independent sector in the 1980s and 1990s exposed the discrepancies in a funding policy now 50 years old. This led to considerable resentment in a cohort of elderly people expecting free state care “from cradle to grave.”

    There are many laudable suggestions in the report—not all of them new. Legislation is already in train to facilitate pooling of relevant NHS, social services, and housing budgets; the pooling of budgets for aids and adaptations should follow naturally. The possibility of providing loans for the purchase or hire of aids for living is constructive. Increased help for carers, especially respite care, is a popular recommendation that has been largely ignored in the past. Wider use of direct cash grants to enable elderly people living at home to make their own decisions on care is welcome; improved access to advocacy is uncontentious.

    A key recommendation is the creation of a National Care Commission to monitor demographic and spending trends, keep under review the market for care, and represent consumers‘ interests. There are already numerous local and national bodies inspecting and auditing the institutional empire and plans to introduce a single regulatory framework.3 Standards are raised through consumer pressure, good management, adequate resources, and tight monitoring by local statutory purchasers. Whether we need yet another central agency in this area is doubtful.

    The commission's primary recommendation, however, is the most controversial. It is to make personal “hands on” care free for those who qualify for it. Providing public funds, irrespective of income, for all elderly people living at home or in residential care would transfer wealth to better off members of society and their heirs at the expense of those most in need. Such a proposal is extraordinary when the government is groping towards a welfare system that promotes social equity but is neither wholly state funded nor wholly dependent on private personal investment but rather is based on a partnership between public and private sectors.

    Elderly people increasingly want the dignity of choosing for themselves the type of care they receive by buying it rather than having “assessed care packages” doled out by social services. Already, a third of elderly people pay for their own care, and this is estimated to rise to 50–60% over the next 20 years. 4 5 Although there are some abnormalities and undoubtedly some hardship in the way the current means test operates that need remedying, the commission's proposal smacks of outdated paternalism that tomorrow's elderly people will not need, expect, or want.

    Not a single penny of this extra state money would go to improving standards of care for elderly people. Universal state funding would tend to depress standards to the lowest the state could get away with and impede the improvement of wages for poorly paid care staff. It would transfer vast sums of money out of the public purse to those who are currently deemed to be able to afford their own care. Since very little of the preserved capital would be spent by disabled elderly people themselves, the state would secure for elderly people's heirs an inheritance for the future.

    The commission's minority report, from dissenters Joel Joffe and David Lipsey, is more practical in examining a range of insurance and loan schemes that could defer the disposal of assets until after an elderly person's death. To provide some equity between people in residential and nursing homes and free NHS hospital care, it suggests an increase in the capital sum that those in care could retain before being eligible for full fees and proposes a far more restricted increase in state funding to cover qualified nursing care only. Joffe's and Lipsey's proposals are more affordable, in tune with our changing welfare scene, and should be scrutinised closely.


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