The writer, a former head of the Downing Street policy unit, is a Harvard senior fellow
The shape of the post-Covid Johnson government will emerge on Tuesday, with a Queen’s Speech containing bills on everything from planning to state aid. Missing will be social care, which the prime minister has promised to “fix”. As usual, funding is the stumbling block: the chancellor is reluctant to throw £7bn-£10bn into what looks like a black hole. It’s time to change the conversation, from a narrow one about managing decline, to a big one about how we can all age better.
Social-care reform has eluded successive governments because the debate always starts with money and gets stuck there. A creaking system held together by families and underpaid carers, with the unlucky paying monstrous sums in care-home fees, looks terrifyingly expensive to fix. It is also politically thankless. No one wants to pay more for something that affects only a small proportion of the public at any one time. Britain has the additional problem that most voters assume the NHS will pay if they become frail or develop dementia, and understandably are angry when it doesn’t.
It’s not surprising the Treasury is scared off: the subject is shrouded in gloom. For years I’ve sat in rooms where scary graphs are presented, showing inexorably rising costs from an ageing society. But it doesn’t have to be that way. In the 21st century, some people are healthier, and working longer, than ever before. The UK’s oldest Ironman athlete is a 76-year-old who did no exercise until she was 50. We need to be much more ambitious about preventing chronic disease, rehabilitating people properly after hospital operations, and investing in at-home and care-home care that keeps people independent and connected to their communities for as long as possible.
Looking around the world, there are signs that services that focus on how to keep people independent and connected for longer can reduce demand for social care. Dementia is a scourge, for which there is as yet no cure. But some conditions that become crippling are preventable.
According to the Academy of Medical Royal Colleges, over 40 per cent of UK adults fail to do even 30 minutes of moderately intense exercise five times a week. If they managed that relatively small amount, their risk of developing heart disease, stroke, dementia, diabetes and some cancers could fall by at least 30 per cent. The UK National Institute for Health and Care Excellence agrees, saying that “disability, dementia and frailty can be prevented or delayed” if people lose weight, drink less alcohol and become more active. Even modest improvements in fitness, according to one study, could save social care between £1.5 and £3bn a year.
The world’s oldest society, Japan, already knows that better healthcare can stave off the need for social care. The Japanese Orthopaedic Association recommends that older people do 10-minute bursts of brisk walking and squats to prevent a “heightened risk of care dependency”. We know that even 90-year-olds can improve their strength and balance through simple exercises, reducing their risk of falls. Yet most care packages just focus, depressingly, on washing and dressing.
Part of the problem is the idea that care is about passive recipients being “done to”. When my own aunt started to ail, I was desperate to maintain her weekly lunch with her best friend, which she had enjoyed for 40 years. Both women had carers, whose agencies put endless obstacles in the way. The travel time was a problem, it didn’t fit the rota, health and safety required there must be one member of staff for each woman and so on. I won the argument in the end, but the lunches were still often cancelled at the last minute. Bureaucracy trumped humanity, despite the big fees we paid, and both friends went into rapid decline.
Treating people as barely human is a false economy. In the Netherlands, an organisation run by nurses lets staff decide what patients need, and builds partnerships with friends, neighbours and family to maintain independence. It has high levels of customer satisfaction and actually saves money. Yet this is antithetical to our way of thinking. There is an assumption that if you ask people what they want, they will ask for expensive equipment or more nursing care. In fact, what they often want is friendship and hope.
None of this obviates the need to spend more money. There are detailed discussions going on in Downing Street about how to cap costs and pool risks without unduly penalising those who have worked hard and saved all their lives. We may see national insurance rise for the over-40s or on working pensioners, a version of what happens in Japan and Germany. We might see a lump sum raised from the retired, to be recouped after death. Years of wrangling have made me agnostic about which funding model is used, as long as it gives people a life, not just a “package”, within a joined-up health and care system that does everything possible to keep us all independent for longer.
Some years ago I visited a care home in the Netherlands where university students live with the elderly, and where the on-site gym has 19-year-olds cycling alongside 80-somethings. The home, in an ugly concrete block in a rundown suburb, is oversubscribed. In the old days, they told me, would-be residents had to fill out a complex financial and medical questionnaire. Now, the management asks only three questions: “Who are you? Who were you? and Who are you going to be?” If we were as ambitious as that, we could not just ‘fix’ social care but make it magnificent.