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Care home closures, underfunded local authority provision and growing concerns over private pensions are making old age a time of hardship and worry. Ruth Winchester examines the potential for improving this state of affairs.

Who would want to be old? Your body lets you down, your memory is unreliable, your eyesight is failing. And, to cap it all, the control and choice you have exercised for the whole of your adult life can no longer be taken for granted.

A recent Help the Aged report¹ found that age discrimination was alive and well in the UK - discrimination that would be unthinkable if it were directed at any other group. From "Do Not Resuscitate" notices in hospitals to the compulsory retirement age, it seems older people get a raw deal. And in social care, where a more enlightened attitude might be expected to prevail, the discrimination continues.

Figures from the Department of Health² suggest that the average gross weekly expenditure by social services on older people in residential or nursing care is £342. For a younger adult using the same type of service, it is £669. Rigidly enforced cost ceilings for community-based support packages exist in many authorities - the upshot being that older people who would prefer to remain at home are given no option but to go into residential care. And even in this most momentous of decisions, older people are being routinely denied choices that most of us would take for granted.

Guidance from the DoH in 1992³ gave older people the right to a choice of residential accommodation - tempered by a long list of conditions. They could have their choice - as long as it met their needs as assessed by the local authority, was not more expensive than the home proposed by the authority, was available, and was provided subject to the usual terms and conditions of the authority.

Unfortunately, the collapse of the care home sector has seen the number of nursing and residential care home bed spaces fall catastrophically in some areas, at the same time as local authorities reduce their own provision. These shortages mean that most people who are dependent on local authority funding for care home places are now likely to get a very stark choice. On one hand, they can accept whatever the local authority can find and afford, whether or not they like it, whether or not it is close to friends and family, and regardless of whether they feel it meets their needs. On the other, they are free to choose any home they like and feel comfortable with, but it will almost invariably involve relatives paying potentially crippling "top up" fees.

Age Concern and Help the Aged both run helplines that provide information to older people and their families about their rights and local authorities' responsibilities. Many clued-up older people and their families will use this information to challenge authorities to reconsider "fixed" fee levels and home care cost ceilings - figures that are supposed to be guidelines only and which should be flexibly applied on a case-by-case basis. But helpline staff argue that, while those armed with information can often persuade councils to reconsider their decisions, less articulate, less assertive older people lose out.

Elderly care is severely underfunded. And the situation is being made more complex by the looming threat of financial penalties for councils that allow older people to remain in hospital when they are medically fit for discharge. Estimates suggest that about one in 10 "bed-blockers" are people who actively choose to stay in hospital until a bed becomes available in their preferred accommodation. So what will happen to the right to choose when the local authority is paying the hospital £200 per day while an older person makes up their mind?

The shortage of beds in care homes is also driving more and more authorities to use electronic systems and web sites that keep up to date lists of vacancies to find spaces for older people. At present these systems are generally limited to one area. But as pressure intensifies, the number of older people needing care increases and the number of bed decreases, sooner or later the only appropriate bed may be found 200 miles away. Where does choice come into that scenario?

But even where a choice does exist, deciding what you want to happen can be a difficult process, says Jenny Stiles, deputy head of policy for Help the Aged. Choosing a care home often happens at the worst possible time, when someone has suddenly become ill or recently been admitted to hospital. And because very few people have to make such a choice more than once or twice in their lifetime, nobody is an expert. Stiles argues that older people often have too little information from their local authority about what is available and what their choices might be, and suggests that an easily accessible neighbourhood one-stop shop might be a more direct solution - handing out advice about pensions, grants, benefits, home care, social services and residential and nursing homes. Care Direct - a national pilot scheme that offers advice and assistance to older people, usually over the phone - may be a productive development in this direction.

At Age Concern, policy officer Stephen Lowe argues that a better system of assessment for older people would help solve the problem. He says: "When an assessment is done, assessors need to be looking at the whole picture - so they look at someone's social and psychological needs. They might feel they want to be near their family, for instance. That should be treated as a need - not just a want."

Unfortunately, people conducting assessments and putting their findings into practice can already be in a difficult position. Glenys Jones is director of social services for Middlesbrough Council and chairperson of the Association of Directors of Social Services older people's committee. She says: "It's simply not a case of free and open choice. It's really important that there is honest discussion about the difference between need and want. For instance, someone might want to go into a particular nursing home, when they haven't been assessed as needing nursing care. Of course, if you have wealth you do have more choice. The class system is alive and well in old age."

So what about alternatives to residential care? While there is a well documented - and welcome - trend for older people to be given packages of care that enable them to stay in their own homes, there are issues around choice here too.

According to Anchor Trust chief executive, John Belcher, there is still a culture of older people "fitting in" with services rather than being able to control them to meet their needs. "One of the constraints is the nature of contracts with local authorities - so you operate under a contract that says you will provide 15 minutes of home care at 9.30 in the morning, when what someone really wants and needs is half an hour at 8 o'clock. Or they want to talk about something important that happened yesterday, but the care worker has a number of contracted tasks to perform in those 15 minutes. It's very difficult, and I think all providers struggle with it."

One possible solution to the rigidities of conventional home care is direct payments - something that has started to gather momentum among disabled people. But while local authorities have the discretion to provide direct payments, they are not under any duty to do so. Councils that actively promote direct payments for older people are very few and far between - a missed opportunity, according to Liberal Democrat MP and spokesperson on older people Paul Burstow.

"I'd want to look at the whole issue of direct payments - they're very underused, undervalued, poorly advertised," he says. "Some of the research I've seen suggests it's a very cost effective way of providing services. I think the reason it hasn't taken off in older people's services is because social services have difficulties with the idea of giving someone the control over their own pot of money. There are some professional and employment reasons within local authorities, some staff are not very enthusiastic about it or feel a bit threatened by it. And there are still some places with a very paternalistic attitude to services."

But while direct payments offer older people far greater control than mainstream services, there are problems. In Middlesbrough, Jones says: "I don't think they are popular - we are clearly offering them and trying to get people to think about it, but they can be hard work and seem too complicated to people. And to be honest, people who are elderly and frail don't want to be given money to employ people, they just want the services to be there when they need them."

Burstow acknowledges that direct payments are not for everyone but feels that active promotion would increase their use. "Take-up has been pathetic," he adds, "and it's not that people don't want them. If you went to the people who were at the early stages of needing help and asked them, I think many of them would be completely unaware of it."

But there is, perhaps, a bigger issue looming on the horizon for all those involved in care of older people - that of demographic change. As well as the burgeoning elderly population, there are fundamental changes happening in the way people view statutory services. Whereas the majority of those using care services now are used to accepting what life throws at them, that will most definitely not be the case with subsequent generations.

According to Burstow: "At the moment the older generation tend to accept very unquestioningly what they are being given. Subsequent generations won't accept things the way they are now - they will kick up much more of a fuss. On one level its welcome, it has to be good news. On the other, it's going to be a big challenge for social services."

At Anchor, Belcher agrees: "That's very true, and it's already started happening. If you look at the older people who are moving into sheltered housing, eight years ago about 90 per cent of them were on full or partial housing benefit. Now a lot of them are owner occupiers who are selling up, and they are a quite different set of individuals, with a very different approach."

Hopefully, when people who are now in their thirties and forties get to the stage of needing help with daily living, they will be offered a menu of flexible, responsive, person-centred services that fold seamlessly around them, whether they want to sit in an armchair at home or go surfing in Hawaii. But if the state is struggling to pay for the care of the elderly now, it seems extremely unlikely to be in a position to pick up the tab in 30 years. Better start saving.  

¹Help the Aged, Age Equality Campaign, www.helptheaged.org.uk/campaigns  

²Department of Health, Personal Social Services Performance Assessment Framework, DoH, 2001.

³Department of Health, The National Assistance Act 1948 (Choice of Accommodation) Directions 1992, LAC (92) 27, DoH, 1992. Document can be found at www.doh.gov.uk/pub/docs/lacs/90_92/27lac.pdf