Care is best at home

The benefits that would accrue if we had a
well-funded system of domiciliary care would far outweigh the
costs. So why do we keep older people in hospital and not at home,
asks Conrad Russell.

One of the places where the link between body
and mind is strongest is the desire of most old people to remain in
their own homes. The sense of safety of being on one’s territory is
a psychological factor that seems to be common to almost all in the
animal kingdom.

Yet there is a practical dimension to this
feeling too. Being in one’s own home is being able to find the
light switch in the dark. It is knowing how long a stride must be
to put the foot securely on the next step, and where the rough
patch in the kitchen linoleum is. These are physical safety

Yet, because of increasing longevity, more and
more old people are finding there are some chores involved in
keeping their homes going that they cannot do. Those with
osteoporosis may be no longer able to reach to change the ceiling
light bulb. Those with heart trouble may be no longer able to carry
home the shopping. Meeting these needs may be small, it may be
undramatic, and it may even be cheap. Yet it is none the less

Yet with this growing need comes a smaller
supply of money to meet it. Local authority social services budgets
have long been perceived as the Cinderella of public spending. It
is a useful place for Whitehall to let cuts fall, since they can
always use the debate about local autonomy to pass the buck of
blame. The rationing system in home care outlined by the report by
the Social Policy Ageing and Information Network
(Spain)1 involves denying any help at all to those with
moderate care needs, queuing for those with high care needs, a cash
limit for each person, and strict limits in quality.

It is typical of the contradictory policies of
Whitehall that the proposals outlined in the reports by Spain, and
Laing and Buisson2 of a regulatory regime and training
requirements, with all the attendant increases in costs, coincide
with the threats to basic services from funding shortages. It is
somehow typical of Whitehall that it should react to trouble caused
by its own underfunding by a drive on quality, which is designed to
divert the blame onto everyone else. One thinks of this
government’s restriction of childminding to only those who are
registered, whose employment is beyond the means of many of those
who need the service.

Of course we all understand the need of
Whitehall to save money. Yet the need to save money is an excuse
for wasting it. People who can no longer live at home have to be
taken into residential care. People in hospital who could have gone
home to accommodation where someone would come in to do the heavy
cleaning have to stay longer in hospital if no such help is
available. The Spain report estimates that 700,000 older patients
have experienced problems in leaving hospital in the past year,
leading one speaker in the House of Lords recently to refer to the
waiting list for leaving hospital. In a government that has nailed
its colours to the mast of hospital waiting lists, policies that
increase them offer opportunities that opposition parties are
unlikely to resist.

Even if we leave the politics out of it,
hospital is hardly the cheapest way for accommodating people who
are capable of being at home and would like to be at home. We must
also add in the costs that result from postponing the admission of
those who would otherwise be occupying those beds. Cuts in home
help probably rank pretty high in the list of false economics.

There is an even bigger issue behind this one.
That is the constitutional one of decentralisation of power. The
day before writing this article, I was speaking to the Western
Region Conference of the Liberal Democrats and listened to many
people saying that all the areas of power between Whitehall and
citizens were being “hollowed out” by the use of quangos, targets,
cash limits and ministerial directives. The end of this is
Whitehall making all the decisions.

This means they are based not on need but on
what Whitehall thinks we ought to need. England’s medieval system
of government was once described by the historian Frederick William
Maitland as “self-government at the King’s command”. Is this an
ideal which is due for revival?

1 Social Policy Ageing and
Information Network report from

2 Laing and Buisson,
Domiciliary Care Markets 2002, from

Conrad Russell is Liberal Democrat
social security spokesperson and professor of British history,
King’s College, London.

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