Only a new funding regime can address the uneven provision of care in different parts of the UK, writes Donald Hirsch
Who will care for me if I cannot look after myself when I grow old? This fundamental question is faced by individuals, as well as by society as a whole. Last year a report from the Joseph Rowntree Foundation showed that collectively we are not addressing this challenge:
our present system for paying for long-term care for older people is “incoherent, unfair and unsustainable”.(1) Now, new research from the JRF shows people are finding different ways of meeting their care needs.(2)
Two studies drawing on census data give detailed information on how the provision of care varies across the country, and some insights about how it is changing. The findings suggest that family-based, unpaid care is more important in some parts of the country than others, while the availability of care homes, which has been declining overall, is also uneven geographically.
The most striking finding from this research is illustrated on the map. It shows that in parts of Wales, Merseyside and north east England, 5-8 per cent of the adult population devotes at least 20 hours a week to caring. In much of south east England, on the other hand, it is only 2-3 per cent. So the army of unpaid carers who provide an estimated 70 per cent of social care in this country is three to four times more plentiful in some local authorities than in others.
There are many reasons for this disparity.
People who do not work, who are older, who are less well off and who are themselves in less good health are more likely to be carers. Economically depressed areas have more people available to look after others. But the correlation between deprivation nd caring is far from exact; some highly deprived inner London boroughs have relatively low proportions of carers, for example.
Another crucial factor is the settled nature of communities. Much informal care is provided by extended family, so in areas with more mobile populations, where people are less likely to live close to their parents, there may be less informal care. In contrast, some parts of north Wales have among the highest proportion of carers in the population. Ethnicity also plays a part, with more than 8 per cent of Bangladeshi and Pakistani women spending at least 20 hours a week caring.
This may help explain why inner east London bucks the trend elsewhere in the capital. The availability of care homes is also uneven, following different patterns. This is the focus of the other recent JRF study by researchers from the University of righton.(3) Across Britain the number of care homes fell by 11 per cent between 1991 and 2001 and the number of local authority homes by more than half. Only in Scotland was there an overall rise, by 11 per cent.
This decline has been driven by the desire for more people to be cared for in the community, but the geographical pattern has raised worrying issues. The reduction in care homes has tended to be greater in more deprived areas with poorer health. This raises concerns that care homes may not be located where there is most need. Indeed, many inner London boroughs are now moving more care home residents outside their boundaries than they accommodate within them. This creates particular difficulties in deprived and some ethnic minority communities, where older people may be reluctant to move away and relatives find it difficult to travel to visit them.
At first glance, this evidence seems to indicate that people on lower incomes tend to enjoy more support from family members, whereas those who are better off have more access to care homes. But this is a simplification. In fact, among a group of people tracked between the 1991 and 2001 censuses, it was the more deprived groups, such as people who rented their homes, who were more likely to move into institutional care.
The research does not tell us whether owneroccupiers are less likely to move into residential care because they must pay for it privately with the proceeds of their home. The situation of individuals and the decisions they take (or have forced on them) may also interact with the quality and accessibility of home-based care services in their area. Worryingly, the Brighton research found that those areas where residential provision had declined most did not tend to be those where home care services had grown the most.
Rather, local authorities supporting high levels of residential care tend to support relatively high levels of home care services too.
This suggests that substitution of residential care with home care has not been carried out systematically. It also underlines the arbitrary nature of the availability of care. Much has been discussed about the postcode lottery of local authority domiciliary services. Yet for an individual, the lottery depends on a complex set of factors, including whether members of their family live close by and have free time, and whether their local authority can offer a satisfactory residential solution locally. Not to mention whether they live in Scotland and are exempt from home care charges and also receive a subsidy intended to cover the personal care element of care home fees.
It would be unrealistic to imagine that all elements of good or bad fortune could be taken out of the care equation. Yet other countries have reduced the stakes in this lottery. Germany has a care insurance system delivering consistent benefits for people with a given condition, not just within but across sectors. Graduated payments are available to support (at the lowest level) families providing informal care, those buying home care and (at the highest level of payment) those needing residential care. In the UK, only 10 per cent of family carers receive direct state help.
Can Britain move towards greater coherence in supporting care provision? As part of the comprehensive spending review next year, the Department of Health is carrying out a fresh review of care funding. It looks unlikely that there will be a thorough overhaul. But ministers will do well to note that the patchwork of care now available leaves many older people with huge uncertainties about how they will cope if they become unable to look after themselves.
DONALD HIRSCH is a special adviser to the Joseph Rowntree Foundation and an independent consultant on social policy. He has recently helped the JRF bring together evidence and arguments about the need for a better way of funding long-term care in the UK.
TRAINING AND LEARNING
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.
This article considers two studies published this year by the Joseph Rowntree Foundation mapping the availability of informal care and of residential care homes in the UK. The studies identify an uneven supply of care, with deprived groups often better able to provide informal care but with inferior access to care homes. The article argues that a new funding regime should aim to provide greater consistency.
(1) D Hirsch, Facing the Cost of Longterm Care – Towards a Sustainable Funding System, JRF, 2005
(2) H Young, E Grundy, M Jitlal, Care Providers, Care Receivers: A Longitudinal Perspective, JRF, 2006
(3) L Banks, P Haynes, S Balloch, M Hill, Changes in Communal Provision for Adult Social Care 1991-2001, JRF, 2006
● JRF, Paying for Long-term Care – Moving Forward, 2006
● Wanless Review, Securing Good Care for Older People, King’s Fund, 2006
● C Glendinning, B Davies, L Pickard, A Comas-Herrera, Funding Long-term Care for Older People: Lessons from Other Countries, JRF, 2004
● D Hirsch, Five Costed Reforms to Long-term Care Funding, 2006
This article appeared in the 7 December issue, under the headline “The great care divide”