Alan Sinclair: Trying to fix the age-old problem of elderly care

Growing old is part of everyday life, but how we personally and politically go about it is set to be the most critical issue in Scotland for the next four decades

GETTING old is not a clinical condition. But it would be easy to be fooled into thinking that it is. Clinicians are trained to keep people alive. Pharmaceutical companies are pushing life-lengthening drugs on to the market. Health and social service policymakers are grappling with how to look after increasing numbers of elderly people.

For the past decade, health headlines have been about three issues: waiting lists, threatened closure of accident and emergency services, and MRSA. Odds on that the three issues for the coming decades are older people, older people and older people.

Hide Ad
Hide Ad

Before redesigning health and care to deal with “baby boomers” (those born between 1946 and 1964) retiring and getting older, we need to stop and ask: “What do people want as they get older?”

If a joiner only has a hammer, then every problem will be solved with a nail. If only clinicians and care workers sit round the table, then the likely answer to this question will be better clinical procedures and care.

But, even if we had lots of public money, which we don’t, there is no point in spending it in the same way. Current levels of expenditure per older person are not sustainable across a significantly larger older population (between 1990 and 2035 the number of people living beyond 85 will increase six-fold). Also, the current system does not meet our needs for a more personal and sensitive system of care.

To solve this challenge, we need to knit several elements together.

First, older people need to be at the table to say what they want as they get older. Research indicates that they see ageing is a natural part of life, not a clinical condition, and that they want to get on with life, be independent, connected, respected and live in their own homes. They value quality of life as much as, or more than, quantity. At some point it will happen, and when it does, they want a pain-free and dignified death.

Older people want to stay in their own homes and away from hospitals and care homes forever, or as long as they possibly can. Commissioners of care are more concerned about what and when specific services are provided. Older people are more concerned about the nature and quality of services. For example, do staff have the time, inclination or permission to offer companionship, human warmth or do something that is not on the checklist?

Bodies wear out and die. A large slice – around 25 per cent – of health spend goes on the last few months of life. But, when we no longer enjoy spring, smile at our children or have quality of life should we, as gracefully as possible, bow to nature and move on? Can we confront death and talk more about a life worth living and a dignified end? Our public policy and health approach has the wrong mindset; it is death denying and does not give old people what they want.

Second, money. Baby boomers have had fewer children, and, thanks to medical science, more will live into old age and very old age, many with multiple, long-term conditions. Today, three people in work support one retired person. By 2035, two people in work will support one retired person. It is a bad prognosis: extra costs and fewer hands.

Hide Ad
Hide Ad

A recent IMF report into the global economy estimates that the net present value of the costs of ageing, up to 2050, are eight times greater than the financial crisis. And in the UK, an Office of Budget Responsibility (OBR) examination into spending and revenues concluded that the projected spend on health care, state pension and long-term care would raise public spending by 5.3 per cent of national income, described by Robert Chote, chair of the OBR, as “unsustainable” (5.3 per cent of public spend is the equivalent to what we spend today on all pre-school and primary school education or on our army, air force and navy).

Across most of northern Europe, people are obliged to contribute to a health and care insurance scheme.

That was also the recommendation of the Dilnot Commission’s report Fair Care Funding. It proposed that a cap on personal expenditure on care should be set at £35,000; once an individual has spent this amount, the state would meet the remaining costs (for example on long-term stay in a nursing home). Those with assets of £100,000 or more would be expected to meet their care costs up to the cap. People who do not have this level of savings or assets would have their insurance contribution met by the state.

A great benefit of this proposal is that it deals with economic reality and provides clarity and certainty for older people. However, the Chancellor does not want to tackle an issue that will peak in 20 years time when so many people are being squeezed now. If Westminster does not implement this proposal, there would be scope for Holyrood to use its tax varying powers to prevent the problem getting out of hand.

Third, the state has to intervene and reorganise its affairs, encouraging collaboration between health and care to meet the needs, in their own communities, of older people with multiple conditions. And we all need to do more to look after ourselves and others as we age.

Here are some examples of what’s already working:

• In Quebec, first-line health services and home care – not hospitals – became the crux of the system, with a focus on patient autonomy as opposed to the need for nursing services. An overall assessment into how people can live independently in their own surroundings is conducted, only one part of which is a clinical evaluation.

• In Nairn, the GP practices, elderly social services and the third sector work together under the one roof of a community hospital. Their aim is to keep people local and out of the big hospital in Inverness. In consultation with older people, a risk register is compiled. Every older person has an anticipatory care plan setting out, ahead of time, what to do in circumstances when decision making is impaired or impossible.

• The model used by Breakthrough Breast Cancer is an example of how to give older people a voice. Volunteers are trained to interview patients about their experience of breast cancer treatment with the results measured against a national standard and a “service pledge” and tactfully fed back to the hospital. Such “quality circles” could also be used with relatives to see if their loved one has died in a dignified way.

Hide Ad
Hide Ad

• In North Lanarkshire, the council and NHS collaborate to provide “re-ablement” for people who might otherwise have lost their independence. Personalised care has been introduced: following a successful assessment, the client is made a financial allocation and it is over to them to buy what best fits. For example, daily help from a family member or a short break for an exhausted carer.

• In Holland, community nursing has been reinvented through “the Buurtzorg”. Instead of following a checklist, the Buurtzorg nurse goes back to fundamentals: gets to know each person’s history, understands how they cope, meets the family, talks to the doctor, and works out the best way to provide hours of contact. In the past six years, from a standing start, 3,200 community nurses – more than half of the community nurses in Holland – have moved to the Buurtzorg.

• Across Scotland, third sector organisations are at work: the WRVS alone deploys around 5,000 volunteers every day to help people; advocacy and other services are supporting people with dementia and their families; Citizen Advice Bureaux are giving benefits advice and community transport helps people get out and back home safely. These are the services which can make all the difference between existing and living.

Getting old is part of life. But how we personally and politically go about it is likely the most critical issue in Scotland for the next four decades.

Alan Sinclair is an associate of the Centre for Confidence and has been a fellow at the Work Foundation.

Related topics: