What’s wrong with money?

Caring and carers - Flickr user: Kai Hendry
Photo: Kai Hendry via Flickr

Care Services  Minister Paul Burstow’s latest idea for alleviating the deepening social care crisis is Hureai Kippu , or ‘caring relationship tickets’. This is a scheme which originated in Japan, whereby people volunteer to help older people who require care and support . In return they receive a credit which they can bank in anticipation of the day that they need care themselves, or they can transfer their credit to a relative so that they can obtain care.  In the UK we have for many years had a not dissimilar system of exchange called ‘money’. People make a contribution to society and in return receive ‘money’ which they can then put aside to buy care.

So what’s wrong with money? Well for a start local authorities don’t have much of it. The monetarisation of relationships can also be criticised for de-humanising relationships, and it can be seen as a sad condemnation of society that many people who need care never see anyone who is not paid to be there. On the other hand, cash payments that are supposed to turn people into empowered consumers of care services, are seen by many disabled people as the key to independence and choice.

In fact evidence from Japan indicates that Hureai Kippu works. Older people prefer to receive care from someone who is being paid with ‘care relationship tickets’ rather than someone who is being paid cash. And there is a growing body of literature on the benefits of alternative systems of exchange, such as time banking and Local Exchange Trading Systems. These alternative currencies can foster local relationships and, since everyone’s contribution is valued equally, promote equality.

The problem with the latter argument is that not everyone will be able to accumulate credits, or has children to do it for them. The success of such local schemes is likely to be based on the characteristics of the community – for example whether people have free time, whether they have strong roots in the area or are transient.

Hureai Kippu seems distinctive in that, in order to work, it has to be rolled out on a large scale, and people have to trust that their credits will still be valued by future generations. In a climate where people don’t trust the state to care for them in their old age, don’t trust insurance companies and don’t trust banks why should they trust in the value of ‘caring relationship tickets?’. It might also be the case that the success of timebanking schemes and LETS derives from the fact that they are usually small and that their character would change if they were developed on a much larger scale.

So Hureai Kippu might be worth trying out, but  as with the ‘Big Society’ the trouble is not so much the idea itself but the ambitious  claims being made for what it can achieve.

‘Caring Relationship tickets’ along with other big society ideas for encouraging small scale, neighbourhood and mutual support can make a significant contribution to changing people’s lives. But replacing social care services, or even mitigating the impact of cuts to services is another matter altogether. Social care services for older people are now concentrated on those with the greatest need. Family carers often have to develop skills comparable to those of specialised nurses in order to provide such care – it’s not a role for untrained volunteers.

Invisible but Invaluable

Christine and her mother Margaret. Photo: Sam MellishThis is Christine and her mother Margaret. Christine has been her mother’s carer for the past 14 years. She is one of nearly a million people in England over the age of 65 who provide unpaid care to a husband, wife or partner, an adult child with disabilities or even a parent.

Christine and Margaret’s story is a powerful one. It’s a story about huge responsibilities, emotions and life-changes. Margaret moved in with Christine when her husband died. Christine continued to work, but after Margaret contracted an infection and needed a leg amputation, life changed ‘dramatically’. Christine was ‘forced’ into early retirement and full-time caring. Ending work meant that the family’s finances ‘nosedived’ and Christine’s pride was dented when they had to claim benefits. Christine said she then ‘understood what a carer is’ and recognised that carers ‘are entitled to a life of their own’. She now gets 4 hours a week support. It took Christine hitting crisis point to get that support.

Age UK has listened to the experiences of hundreds of older carers like Christine, and despite the fact that many of them find caring rewarding, and an expression of their relationship with the cared-for person, they also talk about how they feel invisible and undervalued. Many are stressed and exhausted.

This week a new exhibition opens at St Martin-in-the-Fields church on Trafalgar Square. It’s called Invisible but Invaluable.  Working with photographer Sam Mellish the exhibition aims to make the invaluable work of older carers visible.

The stories illustrated in the exhibition are personal and deeply moving. Every situation is different. But there are common threads. Many people become carers in later life almost without realising it. At a time when their own health may be deteriorating, they find they are having to prioritise the needs of someone else. Then they must navigate their way around the ‘system’ to get the support and help that they need.

Age UK’s call to policy makers is to prioritise the needs of older carers, and to ensure that they receive the financial, practical and emotional help they need. In the current financial environment, the Government needs to be thankful for the unpaid care which older carers contribute – a whopping £15billion in care each year.

A new report by Age UK, Invisible but Invaluable, tells the experiences of hundreds of older carers. It outlines measures which the Government, local authorities and health providers could take to improve the lives of older carers. Simplifying the application for Carer’s Allowance and other benefits, for example, could have a massive impact. As would a drive targeting carers to register as carers with their GPs and receive regular health checks.

If you are in London, go and have a look at the exhibition – it’s open daily from 10am to 5pm, until Saturday 20 November. If you can’t make it, you can view the photographs on the Age UK website

Real terms growth in older people’s needs

Following the intense interest in the Comprehensive Spending Review, we can be forgiven for thinking that the only figures that matter are the ones with pound signs in front of them. However, the Hospital Episode Statistics (HES) released last week come as a timely reminder of how important the NHS is for many older people.

The headline figures showed that average hospital stays for people over 75 years have grown by 66% since 1999. For people between 60 and 74 years, this number has grown by 48%. By comparison, people between 15 and 59 years saw growth in hospital says of 28% in the same period.

Further detail reveals how much longer older people need to stay in hospital compared with other groups. Observing average length of stay, we can see that people over 75 years are in hospital for almost three times as long as people between 15 and 59. However, people over 75 years have also seen the biggest drop in average length of stay since 1999, a decrease of almost four and a half days.

So apart from reflecting the growing numbers of our older population, what do these figures tell us? The growth in NHS funding since 1999 could explain the extra numbers of people being treated – we are spending around three times as much today then we were in 1999. People are also living longer and therefore could return to hospital on more occasions later on in their lives.

What of the decrease in the days spent in hospital? Reducing bed days has been a significant focus of the NHS for the past ten years and this clearly shows it has paid off. Certainly, getting people home, in appropriate circumstances and with the right level of support, should always be a priority. Advances in medical practice and the opportunity to treat more people as day cases have also paid dividends.

However, the numbers presented in the statistics relate to episodes of care, not individuals. We also know that emergency readmissions have gone up significantly since 1999. It could be that as the number of bed days go down, people have become more likely to return to hospital, thus generating a new episode of care. The Nuffield Trust recently made an assessment of rises in emergency admissions and highlighted the need for better care outside of hospital and prevention services. Whatever the figures show, it is important to remember that achieving more episodes of care is only one part of the picture.

The figures need further analysis to draw any firm conclusions, though it is immediately welcome that more older people are receiving care (though obviously less welcome that they need it in the first place). As we concentrate on the figures in the CSR going down, we must not forget those critical figures that continue to go up.

Progress on personalisation?

Last week’s Audit Commission publication of Financial management of personal budgets: challenges and opportunities for councils shows that there is still progress to be made in rolling out personal budgets across the board, and especially amongst older people. Only six councils have met the target of 30% of those eligible for social care to receive a personal budget (and a smaller proportion still receive this money as a cash payment). There is huge progress to be made before April 2011.

The report makes the valid point that personal budgets are not cost-saving in comparison to traditional services, and luckily councils involved in the research seem to have taken on the message.

There are some challenges for councils, not least to ensure their internal procedures and processes are capable of dealing with the requirements of a person-centred approach to care. The report also highlights that councils should be prepared to be flexible in the use of their Resource Allocation Systems which work out how much money can be used to meet someone’s needs. Councils should be prepared to increase the budget, using the Resource Allocation System suggested figure as a good initial ball-park. Coventry’s outcomes-based model of assessing what support someone needs is the way forward, but I wonder whether many other councils will take this on? It involves a reversal of the traditional ways of assessing someone.

However, what the report doesn’t mention is what councils have been doing to persuade those who need care and support that these budgets are a good idea. Mention is made of the attitude of staff being paramount, but this idea is not explored to see whether this might be the root of the lack of take up.

There is also very little mention of people’s rights and entitlements in social care. Unfashionable in today’s choice-and-DIY-social-care landscape, but nonetheless, a statutory responsibility that can’t be wriggled out of if councils provide services. The report talks about brokerage and care management as though the two are the same. This is a fundamental distinction, as care management is part of the statutory duty of the council, brokerage could be a charged-for service. It makes you wonder whether people are being charged incorrectly for care management?

Back to the 30% target. A bit of me can’t help wonder if personal budgets are not the rip-roaring success for older people that they were branded to be simply because for many people they do not work? There’s a world of difference between a younger physically disabled person using a personal budget for their stable and predictable needs and an older person learning to cope with a new disability which they’re not used to. It’s not impossible for this to be achieved by older people, but it needs careful thought and a great deal of support from the council providing the budget or the care and support to the budget holder.

We expect the coalition government will push personal budgets even harder. Some councils are clearly well on the way to broad provision of care in this way but they are few and far between, the majority need to up their game.

Introducing ELSA for the 4th time

As the dust was settling from the Spending Review, the world of UK ageing research gathered at the Royal Society last Thursday for the launch of the fourth wave of the English Longitudinal Study of Ageing. ELSA, as it ubiquitously known, is the single best source of data on experiences of later life in England. It tracks a group of people aged over 50 every two years, returning each time with detailed questionnaires and medical tests. After a day of presentations from researchers, focusing on everything from energy prices to sleep patterns, I joined a panel, chaired by Sir Michael Marmot, tasked with summing-up and reacting to the findings. So what were my first impressions?

Royal Society, London
Royal Society: Flickr user SBishop

Drawing some of the bits of the jigsaw together, first of all, the report shatters a few myths about getting older: people have better experiences of sleep as they get older; the number of people in later life who are underweight is very low; withdrawal from organised social activity in late old age is far less common than you might think; and caring for your partner is a greater burden than caring for your parents.

These snapshot findings are startling enough, but the real strength of ELSA is the portrait it can paint of change over time. With data now available from 2002 to 2008 a picture of the last decade is starting to emerge.  We know that on average older people now have higher incomes, driven by wealthier groups reaching old age with a higher share of non-state income than previous generations; spending on energy has risen significantly, as had spending on essentials overall, for poorer households; the credit crunch led to a noticeable decline in average personal wealth between 2006/07 and 2008/09; and over a longer period there was also a concerning decline in satisfaction with life and an increase in loneliness.

The single most positive change over the decade I picked up was the population-wide decline in cholesterol levels, evidence of the impact statin prescriptions have been having.  But the news on health in general is far more concerning: within each age group there is no clear evidence that health has been improving over the course of the last decade. Given that life expectancy has been rising fast, this implies people are living for more years with ill-health and disability – so called, extension of morbidity. The researchers were careful to say these were early findings; but if they’re backed up by other sources, this is a very serious trend, both for personal wellbeing and the national finances.

Finally, ELSA wave 4 paints a new portrait of inequality in later life. In some areas the evidence suggests that inequality is entrenched, but not growing worse – examples include quality of life, loneliness and many measures of health. But on other measures inequality in later life increased. Income inequalities widened over the period, and there is also evidence that opportunities for older workers are becoming polarised, with poorly educated people being much less likely to benefit for the general rise in 50+ employment.

These are just a few minutes’ reflection on a few hours of presentation; they merely scratch the surface. The latest ELSA report, like its predecessors, will be worth returning to for years to come.

Cuts to Local Authority funding – opportunity for a fresh approach?

The 26% cuts over 4 years to the grants from central to local government announced in last week’s CSR will burn a significant hole in the local public purse, and challenge even the most innovative and well-prepared local authorities to look again at how they can provide consistently ‘more for less’ between now and 2015.

The removal of ringfencing, the development of community budgets and the reduction of targets will be welcomed by many councils, as this will offer the freedom and flexibility they need to bring agendas together internally and externally to produce improved outcomes while reducing spend.

But will they take advantage of these new opportunities?

Age UK has recently been calling for a new cross-council approach to ageing, building the needs of older people into all departmental plans and factoring demographic change into all council budgets.

Too often ageing as an issue gets passed to the adult social care department. However, an Audit Commission report revealed that 85% of people over 65 don’t use council care services, but they do use – and often rely on – the majority of general council services and many use other services such as transport, leisure, and housing.

With growing numbers of older people in all but four of the local authorities in England, surely now is the right time to take a fresh look at ageing as a cross-cutting priority and bring together strategic thinking and budgetary planning at the highest levels to ensure reform of any or all public services has our ageing population in mind.

The fiscal clouds and the long-term vision

Pound coins - Photo: Flickr user hitthatswitchOver the last few days and weeks economists and analysts have speculated about the comprehensive spending review. In the build-up, endless rumours and ‘leaks’ and even snapshots of confidential papers inundated the media and kept almost everyone busy – and worried.

After the announcements, some breathed a deep sigh of relief, many felt disappointed while others felt outraged. However important it may be, the CSR only presents a set of fiscal measures to tackle the short term – until 2014 at the most – or, as the Chancellor put it in his speech, measures that ensure “that what we buy, we can afford; that the bills we incur, we have the income to meet; and that we do not saddle our children with the interest on the interest on the interest of the debts we were not ourselves prepared to pay.”

The Chancellor also announced that “a stronger Britain starts here”. Perhaps, but it will take a lot more than fiscal restraint for this attempt not to become a false start.

Fortunately, economics has developed the life-cycle approach, but unfortunately it is taught solely as a way to study consumption and saving decisions. There’s more to it than this.

Let’s consider the Marmot Review on health inequalities, for example. It lists a number of key policies over the life course. When it comes to ‘adults of retirement age’, one of the policy objectives was to increase access to apprenticeships. Certainly most apprentices are young adults – so, how come this is an appropriate objective for people past state pension age? It is, if we look far at the horizon where these young people get to retirement age.

Around 21 per cent of all economically active adults in England have qualifications below Level 2. Students who leave our schools with no or very low qualifications are twice as likely to claim job-related benefits before they are 25 as those with better qualifications. And it is also much more likely that it will be them who may have to struggle most to keep warm in winter and who may have to get by on very low incomes when they get to retirement age, and it is them who are more likely to endure worse health earlier in life and even more likely not to make it to retirement age.

A life-cycle or life-course approach helps dispel the short-term fiscal clouds and focus our effort on the long term vision more clearly. In our submission to the Comprehensive Spending Review, we highlighted 12 key long-term challenges we face as an ageing society. That is, even though we discussed and proposed measures related to public spending over the next four years, we refused to be locked in the short-term fog and never lost our vision.

The best thing about the CSR announcements – if there is such a thing as a ‘best thing’ about it – is that now the focus of the economic discourse may concentrate on the bigger, more meaningful and crucial picture, that of raising productivity and employability, and reducing inequalities, on behalf of everyone – including the people currently in older age and the future older people. This is the real challenge facing us in the longer term and Age UK will be seeking to ensure that it is not forgotten.