The age old story

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