Thursday, 21 May 2009

Different depressing chat for a change

As a committed smoker I can comment on care for the elderly with a high degree of objectivity; it’s not as if I’ll be around long enough to need it. Otherwise I’d be cacking myself.

I normally see this bit of the healthcare market as the outcome of three factors

2) Government policy
1) Demographics
3) Supply-side conditions

Over the longer term I guess you can swap the supply-side for broader trends in personal wealth. Anyhoo, starting with demographics – the usual cliché here is we’re all getting older, which is a fair point, but its the growth in the old-old population i.e. 80+ that’s the issue because they’re the ones that usually need care.

Unfortunately, while more people are living longer, practically this means living longer in poor health e.g. the likelihood of dementia increases exponentially beyond the age of something like 70, so by the time you reach say 85 the odds of being senile are horrendous.

Besides age household composition is a big factor. In particular people are having less children. People are also more likely to be single. These trends are pains because children and partners are the main source of voluntary i.e. free care. More divorcees + less children = progressively less voluntary care resources for an aging population. Yet despite this the number of care home places has fallen in recent years along with the number of people receiving state funded care. How that then?

That’ll be government policy that will. The nice explanation is there’s a greater emphasis on providing care in the recipient’s home rather than in a home. This is true, but alongside this conditions that in the past would have received some sort of assistance now don’t because state funded care is being more tightly rationed. This is also why government focuses on the number of care hours provided rather than the number of state funded care recipients, an awfy good means of avoiding the reality which is a smaller number of people are receiving more intensive care.

But, what about all those who would have got state funded care in the past but don’t now? Good question, I’m not sure anyone has a particularly good answer other than they’ve been left to their own devices. With few signs of a significant increase in private intermediate care e.g. private home help arrangements,you could already argue that the elderly quality of life is getting worse.

What the governments we elect are willing to spend on care is also key, because it accounts for around two-thirds of the market. Here government has been pretty stingy on the one hand while pushing up the care home cost base with the other.

To give a quick and dirty example care homes are way labour intensive and reliant on cheap labour. So say labour costs = 50% of a care home’s cost base, which isn’t that far off if I can vaguely remember, then any increase in the minimum wage tends to feed straight through and if the increase in what government is willing to pay is less than half the national minimum wage increase, the care home is worse off (and that’s ignoring the accompanying push to raise standards and associated costs even if this is applied pragmatically e.g. the targets aren't too stretching because government doesn't want too many homes going bust/exiting). This is why businesses simply leaving the market because it doesn't pay is a key explanation of why the number of beds has fallen.

Nor is there much chance of a return to state provision. Because state employment conditions are normally more generous what with things like being able to claim expenses and what not, punting out auld yins to the private sector is a way of doing things on the cheap even allowing for care home profits.

Except, so many care homes went out of business some survivors started turning round to local authorities and saying no, we’re no taking in any more wholly government funded residents. This is why top-ups are increasingly important - these see families “top-up” the local authority contribution with more cash to ensure their elderly relatives actually get into a home.

So the rather shitty arrangement we now have is actual fees can increase faster than government conributions leaving relatives to make-up the difference. This is a largely unreported step away from the free at the point of use principle that underpinned the creation of the welfare state and NHS. As such it differs from the ongoing debate about the NHS and whether say people can get a free NHS bed but pay extra to get drugs the NHS is unwilling to pay for. Practically, top-ups also see relatives subsidising wholly state funded care recipients. Even better the use of means testing already means anyone who hasn’t passed on their house to their children before they end up in a home, loses the bulk of the equity before getting any state support anyway.

Then the demographics sneak back in – we’re all having progressively less children and becoming increasingly likely to end up single in later life remember! Then there’s personal wealth – the death of the final salary pension in the private sector and its replacement with the defined contribution pension means more and more people are increasingly likely to have lower pensions.

My guess is this combination of progressively more old people in need of care, poorer pensions and fewer voluntary carers, will produce an increasingly 3 tier system made up of the existing wholly private sector that only a teeny minority can afford, a mixed part top-up part state funded sector and a bottom rung of homes affecting a substantial minority you’d have second thoughts keeping a dog in.

Alongside this we'll see a growing army of "under-cared"; elderly people who can just about get by themselves, but not quite who are increasingly left to fend for themselves. To be fair this is already prompting something of a debate, but its a ghastly one - by leaving these people to their own devices until they really, really need help do they eventually end up needing more expensive care than they otherwise would of e.g. would a home help visit today have stopped them needing two nurses tomorrow.

In response the average age at which people stop working will creep ever upwards regardless of the official government retirement age. Working till you pop yer clogs will become increasingly common and with ever tighter rationing by the state there will be more and more focus on getting every penny an auld yin has before they get any state assistance whatsoever.

If only old people weren’t so embarrassing and (politically) set in their ways all this might prompt a more meaningful debate, its not as if this particular part of our future is difficult to work-out. Instead, all we have is a cringing sense of guilt everytime some headline grabbing care home scandal prompts clichéd comparisons with Italian families .

So save for old age? Sod that I’ll keep on smoking.

Then theres parliamentary expenses – my suggestion here would be
1) No more second home allowances. Instead, politicians do their bit for the credit crunch via parliament buying up 650 or so unsold new build flats across London. These are then provided free of charge to MPs. Those that don’t want them can rent them out via an agency with the proceeds of this the sole contribution to their alternative choice of home. If you need someone to pay for your constituency house then feck you, you're not of that area.

2) Alongside this a jury is borrowed from a court and used to assess the changes in expenses policy during and at the end of the revision process. The jury is given access to the press to express their views – and ideally get their puppies out if their half decent looking in a lad’s mag - and then post implementation a new jury is called in every 18 months to audit a sample of claims.

Michael Martin though, what a guy. He's made a good living off the Labour party for decades, so much so his son is now a professional politician. So having presumably been forced to resign from the gravy train he’s chosen to throw his toys out the pram and resign from his parliamentary seat as well, forcing what’s likely to be an embarrassing by-election defeat i.e. bite the hand that’s kept him and his family in chaueffers(1). Aye well, rather than honour,decency and loyalty, the words vanity, arrogance and ego spring to mind, that and slimey wee prickish fucker.

(1) a June 19th PS - mind reading about another Scottish Labour bod trying to persuade Martin to not stand down. Then read today he's obliged to. Still a grotty, vain wee prick right enough judging by his leaving speech

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