Making the UK a great place to grow old: Issues for the incoming Government
Simon Bottery sets out Independent Age's key manifesto asks ahead of the June General Election.
The challenges of an ageing population need joined-up thinking
There is an opportunity for the next government to tackle one of the biggest issues of our generation. It has been repeated to the point of cliché but the UK population is ageing. By 2030, 20million of us are expected to be over the age of 60. This is partly because we are living longer and partly because there was a rise in births after the Second World War – the ‘baby boomers’ – who are now reaching retirement age. While this is a cause for celebration, it creates challenges across a range of government departments from housing to benefits but, in particular, health and social care. The main one is that while some of our extra years are lived in good health, some of them are lived in poorer health so there is an increased demand on health and – particularly – social care services. No government has seriously attempted to tackle these issues. We are – as the House of Lords Committee on Demographic Change said – ‘woefully underprepared’ for the coming change. And our health, housing, social care and benefits systems remain – to a greater or lesser extent – in not-so-splendid isolation from each other.
The Triple Lock has to stay until Pension Credit uptake is significantly increased
The coalition government rightly recognised that pensioner poverty was a shame on the nation and its approach was to implement a triple lock whereby the basic state pension rises each year by the greater of wage inflation, price inflation or 2.5%. Seven years on, with pensioner household income having risen faster than any other age group, there are now repeated calls for the triple lock to be abandoned, most recently by the Cridland review into the state pension age. These claims tend to overlook a fundamental issue: until the government rolled out its new flat-level state pension in 2014, the basic state pension was not in itself intended to be enough for an individual to live on. Poorer pensioners were expected to claim a means-tested benefit, Pension Credit, to raise their incomes above the poverty threshold. Sadly a third of them (1.4 million people) do not, and for these people the triple lock – which guarantees an increase in their basic state pension - is the only income boost they ever see. If the triple lock is lost, they will suffer enormously – which is why it cannot be abandoned without far more serious attempts to boost Pension Credit take-up.
Social care funding needs radical reform
Nearly twenty years ago the Sutherland Commission said that ‘doing nothing’ about a social care funding was ‘not an option’. Successive governments have however chosen precisely that option, except that the austerity measures targeted at local government since 2010 have now turned a problem into a crisis. Local authorities now need – by their estimate - £2.6bn of funding to fill the gap between demand and supply. Yet simply piling more money into a byzantine system with ‘the worst means test in the whole of the welfare state’, as described by Andrew Dilnot, is not the answer. The current government, if re-elected has promised a green paper on social care funding by the end of 2017. Whoever is in government, there is an urgent need for a long-term, comprehensive and sustainable approach to social care funding. It will need to pull off the difficult trick of being radical enough to tackle a serious and intractable problem yet have enough cross-party support to be a solution that future governments can live with.
NHS funding needs to increase and the shift in service patterns must continue
The NHS is attempting a remarkable transformation: a radical shift in service delivery that involves, among many other things, less treatment in hospitals and more in the community while at the same time spending less money per person, even though the typical person is now older and more likely to have multiple, complex conditions. There is little confidence with health professionals that this can be achieved.
It is likely that the NHS will need more money more quickly than the current government is prepared to admit. This is likely to emerge as an election issue not just in England as a whole but in individual constituencies where local NHS/council partnerships have developed (but poorly communicated) Sustainability and Transformation Plans (STPs) that attempt to juggle that shift in service delivery with the required reduction in per head spending. There is widespread political and professional support for integration of (physical and mental) health and social care as the way to achieve improved outcomes, increased user experience and reduced costs (although not much evidence on the last) and a huge array of initiatives to achieve bits of this – the Better Care Fund, New Care Models, STPs, devolution, Integration Pioneers, there is a lack of clarity on what the vision is for integrated care, what “good” looks like and what patients and service users should be able to expect from their service. However, the impact on services of funding reductions, and in particular the potential closure of hospitals to which the public has an understandable loyalty as symbols of those services, will spill over into potentially bitter local political arguments. Will we see balanced, rational debate about new models of care and the potential benefits of multi-speciality community providers to populations? No, we are likely to witness vicious infighting with (largely irrelevant) claims of American-style privatisation raising public fears and demands to ‘save our hospital’. It will take a brave prospective MP to be on the side of reason.
Equal treatment for mental health must apply to older people too
Many across the political spectrum now urge ‘parity of esteem’ so mental health receives the same level of attention in NHS funding and service provision. We are likely to see significant increases in demand for mental health services for older people in years to come – we know that many older people currently have mental health needs but don’t always recognise those needs or don’t speak out. As younger generations age, for whom it is culturally more acceptable to seek help for their mental wellbeing (or who are already receiving help for an established problem), demand will increase and so must funding. There is some appreciation of increasing levels of demand for physical health problems associated with old age, as well as dementia, but less so for mental health problems. And to make a meaningful difference for older people, this needs to also translate into ambitious plans to tackle the loneliness and isolation that can all too often lead to older people experiencing depression and a drop in wellbeing.
Urgent action is needed on the quality of social care
While the quality of social care is surely related in part to its funding, money alone is unlikely to account for the huge disparities in care, between that which is genuinely outstanding and that which descends into neglect and abuse. This was shown most graphically in our report into local and regional quality of care homes, demonstrating wide gaps between neighbouring councils that no one has yet been able to explain. Though the Care Quality Commission has made welcome improvements in the last few years, in itself its activity and reporting is insufficient to give older and disabled people, families, commissioners and the wider public the information and knowledge they need. As a stark example, we simply do not know the extent of neglect and abuse that takes place in care homes and home care because we have no way of identifying it. This alarming information gap – allied to the graphic images of abuse now captured by easily-available hidden cameras - has led to the public believing that neglect and abuse is widespread, and may well account for at least part of the perception that the quality of social care is falling. It has inevitably also led to the call for cameras to be installed in all homes. We disagree with these calls (not least because many people are happy with their care and should not have to put up with the loss of privacy involved) but the longer we fail to provide far more transparent information about our care services the louder they may become. We should start by first of all commissioning an annual survey of all staff working in care homes to identify where neglect and abuse is occurring. This should be part of a wider push for more information on quality in social care helping to drive improvements in performance in the sector.
Politicians and public to avoid the ‘us and them’, ‘old versus young’ rhetoric
After the Brexit result, there was a torrent of abuse directed at older people on social media, much of it centred on the perceived differences in voting patterns between the young and the old. It stemmed in part from a wider intolerance in our society, a failure to accept that other people’s views can be held honestly and reasonably, whilst still being opposed to your own. Yet the specific ‘old versus young’ narrative was not just about Brexit but was part of a wider perception that the old have done well while the young have suffered. There have certainly been changes in average incomes that applied too crudely can lead you to that line of thought. Yet age is far too crude a way of segmenting those who are well-off and those who are not. When we speak of generational divides for example we fall to grasp that there are at least two generations of over 65s – the ‘baby boomers’ of course but also the ‘silent generation’ of over 75s who lived through the Second World War and who are, on average, poorer than working age adults. And of course there are plenty of very poor baby boomers. During the election campaign and after, politicians on all sides need to make sure that age is not used as a casual explanation for complex issues. After it, the government will need to make sure that it is not seen to be acting largely for the benefit of older people, even if – as happens typically - they vote in greater numbers than their children and grandchildren. The genuine concerns of younger people – employment, debt, and housing – have to be addressed.
The UK needs immigration and workforce policies that meets the needs of health and care
In 20 years, the UK could need up to one million additional care workers simply to meet the projected needs of an ageing population. Identifying where they will come from will be a key issue for an incoming government. To date, the health and care sector has relied in part upon migrant workers, originally from countries such as Nigeria and the Philippines but more recently from Eastern European countries like Romania, whose care workers were able to move here as part of the EU’s free movement of people. There are understandable concerns about the effects of Brexit upon a workforce that still has high levels of vacancies and struggles to recruit. Though migrant numbers are relatively small, their loss would cause significant problems in areas such as London and the South East. So it is likely that the UK will continue to rely on migrant workers in health and care, at least in the short to medium term, and an immigration policy will need to reflect this. But in the longer term, we will need to consider whether we can meet the growing demand for care services simply by recruiting more staff, wherever they might come from. We will need to change our models of care and also introduce greater work flexibility for the many family carers who want (and often need) to work while also to look after an ailing mum or dad.
We need to keep a wary eye on life expectancy to ensure that the recent fall is no more than a blip
For a number of years we’ve been able to point to increasing life expectancy as a marker of our nation’s improving health and as a symbol of improving circumstances for older people in particular. For the first time, this year saw a fall in life expectancy (or – more accurately – a reduction in our prediction of how long we expect people to live). While it is premature to ascribe this fall to issues such as the crisis in social care, not least because other countries are also experiencing life expectancy falls, we should nonetheless watch the trend with real concern. Is it merely a statistical blip? Or is it something more sinister, such as obesity and other long-term health issues finally catching up with us? And are those concerns about health and social care services genuinely a factor? If the trend persists, an incoming government will need to understand and tackle the problem urgently.
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