“Loneliness is one of the biggest reasons people end up in care homes,” an investor once told me. “If you’re lonely, you don’t eat, you become frail, you fall.” This man made his fortune from care homes — but, I discovered, looked after his ageing parents himself. With up to one in five hospital beds in England now occupied by elderly patients who have nowhere else to go, his remark is a reminder that we can’t ignore the human, if we want to fix “social care”.
As the NHS collapses, hiring and training more care workers is probably the quickest and cheapest way to release hospital beds and help doctors tackle the waiting list. It could also avoid a dreadful self-fulfilling prophecy: the longer someone stays immobile on a ward, the more their muscles will deteriorate, and the less likely they are ever to be able to live independently again.
A few years ago, while writing a book about the ageing world, I visited several countries that seemed to have grasped a simple fact. The longer we can keep people independent and connected, the better their quality of life will be and the lower the burden on the health service. In the Netherlands, nurses who treat frail people at home also have a remit to build networks of friends and neighbours. In Australia, older people coming out of hospital receive up to 12 weeks of support to get back on their feet, including physiotherapy, counselling and social activities. These services share a far more ambitious vision than simply managing decline — which our cash-strapped system slides into.
In England, any attempt to improve social care usually begins with funding — and ends there, because we can’t agree who should pay. As a result, we rarely discuss how we might help people live their best lives. For 11 years, British governments have nervously toyed with a proposal from the Dilnot commission to provide a “lifetime cap” on care costs. But the Treasury has never let them do it — because while the commission represented a huge intellectual leap forward, putting a cap on a system that is broken will not mend it.
In Germany and Japan, I found bigger answers. Both started thinking 25 years ago about their ageing populations, and what one Japanese professor called “the shadow of dementia”. Both created long-term care funds into which citizens must pay, and from which they will get help when they are assessed as physically needing it. In Germany, the retired, workers and employers all contribute; in Japan, all adults over 40. In Germany, the government got cross-party agreement by abolishing means testing. the deal with voters was clear: you pay more in, but you get more out.
Both systems are transparent; they provide predictable and sustainable long-term funding; and they build a sense of social solidarity. In Tokyo, young people told me they didn’t trust the state ever to pay them a pension, but they did have faith in Long-Term Care Insurance.
In Britain, there is little sense of solidarity. The debate goes only as far as “don’t ask me to sell my home to pay for care” — partly because the system is so unfair. Almost half of care home residents pay their own fees and subsidise those with fewer resources, because local authorities have been starved of cash. We need a big conversation of the kind Japan and Germany engineered, with a similarly big offer to the public: everyone contributes and can get help if they physically qualify — not only if they encounter catastrophic care costs of the kind envisaged by the lifetime cap.
Perhaps because their criteria are national and transparent, Germany and Japan seem to have little friction between commissioners and providers. In the UK, the public sector is weirdly blinkered, trusting only the fraction of the system it directly controls. Central and local government do little to support hospices and charities which do brilliant work. And they are so suspicious of the family-run and private agencies that mostly provide home care that negotiating even one extra regular visit can cost a fortune in bureaucracy (as I discovered when I wrote a review for the Department of Health and Social Care in 2020).
The Treasury sees social care as a cost: one it assumes will rise inexorably as the population ages. It could, in fact, be an investment. In England, the best care workers often quit because they are not given the time to care for the whole person. The NHS treats social care as an afterthought. But if we saw care as a continuum, leading from public health through rehabilitation to supported housing and end-of-life, the job could be more rewarding, vocationally and financially.
When home-care agencies dread a new supermarket opening on the high street because they know they will lose staff, pay must rise. Labour shortages are a huge challenge in many countries. The Japanese are turning to robots, and have issued foreign visas for care work. In the US, the White House has announced funding for more community health workers. The UK has some 160,000 social care vacancies. But there are also roughly 10mn unpaid carers, many themselves at breaking point. Germany lets people use their cash benefits however they like — including to pay relatives — with none of the bureaucracy involved in carers’ allowance. That’s something to think about.
“The most pressing priority we have”, Rishi Sunak said this week, “is to move people into social care in the communities to get ambulances flowing.” The government has pledged £500mn to speed up hospital discharges. The short-term fix will need to be much bigger — and a long-term solution is urgent. But the answers are there, if politicians dare look for them.
The writer is the author of ‘Extra Time: Ten Lessons for Living Longer Better’ and ‘Social Care Reform’, an independent review for the Department of Health and Social Care.