of a life can be measured by its length. But if we assert the unique individuality of the person, then the only person who can put a value on a life is the person living it. Grimley Evans’ conclusion is that lives of people are not formally comparable; it is ‘mathematically as well as ethically improper to pile weighted valuations of them together as an aggregable commodity like tonnes of coal’. He continues by taking a swipe at nations who value their citizens only for their use to the state. Yet the NHS was at least in part set up to create that healthy workforce for the state, and people were not expected to live on into frail old age and lengthy retirement. He also suggests that the UK has a different set of values about individual human life from the economists’ outlook. He may be right, but it is as yet untested. He argues that we should not create, on the basis of age or any other characteristic over which the individual has no control, classes of untermenschen whose lives and well-being are deemed not worth spending money on.
But however the argument is played out, it has influenced older people. My father, who had his first heart attack at the age of 51 in 1965, survived to be 82. He was plagued with coronary heart disease for the rest of his life, but managed, despite a second coronary, to continue working until he was seventy years of age and to survive, with considerable determination, two coronary heart bypasses, one endarterectomy to prevent him having a stroke when the carotid artery became narrowed, and several other minor bits of surgery. Towards the end of his life, when he was over eighty, he would often say to me, as some other intervention or new drug was proposed, that perhaps he should not be having all this attention lavished on him. Yet he had a considerable quality of life. He carried on writing and thinking until just before he died. Determination made life, for him, very much worth living. And it did so for us, who did not want to lose him.
It is against that background that I think every day about the question of rationing on the basis of age. Can it be right? Is age the only determinant? Is it, indeed, a determinant of the kind of care one should receive? Pensioners make up a quarter of the bottom fifth of the income distribution. Householders aged 75+ are more likely to have housing that is unfit or substandard. Over 250,000 are on council waiting lists for sheltered accommodation. Isn’t the test of a civilized society not only how it treats minorities, but also how it cares for its older people who are dependent on it? Do we send them to the knackers’ yard, drown them in the well, cook them up for a stew like the cock? At least we’d get some last bit of use out of them. Or do we value them for who they are? Is there an inter-generational obligation?
Can we calculate what people should be entitled to? Should families have to look after their older relatives? What does that mean as families change? Should an ex-daughter-in-law look after her ex-parents-in-law? If so, this tells us a lot about older people and families generally. Can we judge other people’s families and what they do? Or is it a state duty to provide? Our four animals ended up living happily ever after in a house that had been taken by robbers, which they then took by force from them. We have no equivalent, unless we argue that being denied care when the NHS promised to look after them ‘from cradle to grave’ is a kind of robbery. But, whatever we feel about that analogy, the point has to be made that caring for older people properly is expensive. Someone has to pay, and it may be older people themselves. Even so, is it acceptable to treat them so poorly? Or is there truly a lesson to be learned from the Bremen town musicians: that older people will only succeed in getting decent care if they extract it by force? And what would that suggest then for the nature of our society, if groups had to become violent to get noticed?
Nursing Homes and Care Provision
The nearest we have seen to this kind of public anger was over the Royal Commission on Long-term Care, chaired by Sir Stuart (now Lord) Sutherland, which was set up when the Labour government came to office in 1997. Its members were chosen from a variety of areas, with a heavy weighting given to nurses. Its conclusions were, essentially, that the government, with restrictions according to nursing assessments, would have to pick up the cost of the long-term care of older people.
The Commission’s basic argument was that, in an NHS that was free at the point of use, there was no distinction to be drawn between the kind of long-term care a person needed when very old and frail and the kind of help and care they needed when acutely ill in hospital. This was the majority view, though the debate over the distinction between nursing care and social care demonstrated the impossibility of the position we had got ourselves into, historically speaking. There were two dissenters, the aforementioned Joel Joffe, now Lord Joffe, who was worried by the rising and unsustainable costs of long-term care for the elderly, and David (now Lord) Lipsey, who realized that the Commission was moving towards a conclusion that would be entirely untenable as far as the government was concerned. He did everything in his power to make the other members change their view. His final minority report made it clear that he believed that older people themselves would have to pay the costs of long-term care.*
Both the government and the Royal Commission missed a trick here and caused deep resentment amongst older people and their families that has not gone away, at least in part because people feel a grave injustice has been done. Indeed, it is in this area that real political action by older people might still become a reality, in a society where grey power has been a long time in coming. The curious thing is that this was, and is, an entirely unnecessary outcome. The Royal Commission ended with a recommendation, essentially, that long-term care should be paid for by the statutory sector. The implication was that the tax rates would have to rise to pay for this. They never quite got to the bottom of what was nursing care and what was social care, a problem that has bedevilled the care of older people for all my working life and which has caused much unfairness.
The classic question is that of the bath. Is giving someone a bath because they smell a nursing or a social task? If they smell, it is argued, it is a social bath. If they have sores or the possibility of them, then it is a nursing bath. On those grounds, the same bath, given to the same person, could either be given for free, for medical reasons, or be paid for, for social reasons.
After the government decided to reject the Royal Commission’s recommendation of requiring statutory payment, it came up with the worst of all settlements. According to assessments made by nurses, older people would get a weekly payment according to need, but this was not enough to pay the cost of a care or nursing home.
This has led to some bizarre results and is a good example of the politics of unintended consequences. Relatively wealthy older people, already in nursing homes and deeply dependent on nursing and social care, are getting help with the fees for their homes, usually allowing the nursing homes to raise their fees. Poorly off older people, not quite so dependent but without the children and relatives who might provide a some care, do not get enough help to allow them to be in a nursing home or care home, unless their dependency becomes so severe that the reluctant local authority decides to pay. Meanwhile, for many nursing home owners the fees provided by local authorities are so low that they have decided the whole area is uneconomic. They can make more money by selling the properties, especially in the booming southeast, and pocketing the profits. Staff costs have been rising and the availability of staff generally declining. The government settlement of help with nursing care has done nothing except raise costs and give a bit of help, often to the better off who are already paying their way in nursing homes.
In Scotland, where the decision was made to go the other way and to pay the full cost of care, the nursing homes are now deluged with older people and the system is cracking under the strain. Despite the strong feeling within the Scottish Parliament that this was the right direction, the total subsidy of nursing home care makes it virtually impossible to choke off demand. And in parts of Scotland where there is low employment or where property prices have not risen very rapidly, there has been an epidemic of nursing and care homes opening, simply because the income–though not huge–is assured.
All of this has been horribly unfair and has disappointed older people, who greatly fear the need for nursing home care and the giving up of independence. And it was unnecessary. Few older people and their families feel that it is essential that the whole cost of long-term care should be borne by the state. Approximately one in four older people will need long-term care