Let's face the future

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The day after we publish the final report of our review of social care for older people, led by Sir Derek Wanless, chief executive Niall Dickson argues that there is now a glimmer of hope that care really can be transformed. But the details of the Wanless report and other recent studies show just how big and deep-rooted the current problems are.

This week on Channel 4 (The Trouble with Old People), Tony Robinson – aka Baldrick in Blackadder – asked 'how will future generations look back on how we care for older people today?' It's a timely question, and the answer may say more about us as a society than we think. If recent evidence is anything to go by, our children and grandchildren will not look favourably on our efforts.

As well as the disturbing series on Channel 4, we have just had a depressing report from the Audit and Healthcare Commissions and the Commission for Social Care Inspection, which found that there was a lack of respect and dignity in the way older patients were treated in hospital. They had their meals removed before they had time to eat them, and many were discharged with insufficient planning, having been 'rushed through the system'. In both health and social care, few older people are asked their views and mental health services were described as 'particularly poor'. Those with dementia suffered long waits for specialist care.

Very few older people are now eligible for NHS continuing care. The shift from 'free' NHS care to means-tested social care, which began more than 20 years ago, has been shameful. Not because the policy was necessarily wrong but because it has been conducted by stealth and denial.

Thousands with dementia are already excluded from NHS care but in future, as government seeks to tighten NHS eligibility rules still further as reported recently, free continuing care may well become unavailable to people with other long-term conditions. The notion of a cradle-to-grave NHS has always been a bit of a myth but we do seem to be heading towards an NHS with a completely different attitude towards older people than to other groups.

Into this depressing picture we have just launched our review of social care funding for older people, led by Sir Derek Wanless.

Its description of the present state of social care will be familiar to many but is worth restating. Today, up and down the country, care packages are provided only for those with the most severe needs, leaving thousands with little or no support and a reduced chance of staying healthier for longer. At the same time, the funding system penalises those who have even moderate savings and discourages hundreds of thousands from receiving the support that they need and that might well help them stay in their own homes. In social care, the postcode lottery is alive and well – the variations in charges and care packages are simply not acceptable.

And yet the immediate reaction the review has provoked must be a cause for real optimism – one or two days’ headlines do not mean transformation, far from it. But there are signs that we may have reached a tipping point where government and opposition will acknowledge what the report makes all too clear – that there are major shortcomings in both what is provided now and how it is paid for. And, more to the point, it is clear that changes in the population over the next 20 years demand a significant increase in spending even if the present, highly unsatisfactory, system were to be retained. As the review points out, not only will the very old population increase by two thirds, levels of disability and need will rise at an even faster rate.

Sir Derek also advocates scrapping the current means-tested funding system and introducing a new so-called 'partnership' model. Everyone in need would be entitled to an agreed level of free care, after which an individual could take up more care with the state paying £1 for every £1 he or she contributed, up to a defined limit. Those on low incomes would be eligible for benefits that they could use to fund their contributions.

The government has welcomed the review and has invited Sir Derek to advise on its own examination of social care needs for the comprehensive spending review. This is a great advance on the position just over a year ago when the message was unequivocal – there would be no more resources.

So, we have a profoundly unsatisfactory present but a glimmer of hope on the horizon. I believe the Wanless review is a thorough and highly significant piece of work that has the potential to change the debate around social care and give it the attention and the funding it has lacked for so long.

It's time we all faced the future.

This article was originally published in Insight, The King's Fund bi-monthly update, March 2006