Care of the elderly can be shocking.

For most people their first experience of seeing Geriatric care can come as something of a shock.

I was speaking to a retired NHS manager who told me about the geriatric hospitals he saw in the 60s. Nightingale wards with 90 patients. At night there were two staff. The beds were around 2 feet apart.  It was part of the night staffs duty to get the ward up, dressed and sitting out by the time the day shift took over. In order to achieve this they began getting patients up at 4.30 in the morning.

This style of ward is perhaps ideally suited to being able to keep an eye on vulnerable and confused patients at minimum expense. The cost is that there is no peace, and no privacy.

I remember visiting geriatric wards in a converted poor house in Edinburgh in the 70s and seeing  40 or 50 elderly confused people sat round the walls of the day room. The television was on, but no one was watching. Sometimes an old lady would try to get up from her chair, and would be sat down again by an assistant, fearful of falls. This kept old people safe, but denied them their most basic freedoms.

By the time my own mother was suffering from dementia some 30 years later things had changed. The improvements to medicine and surgical care meant that people were surviving much longer, so that many of the patients were dependent in ways that were quite new.

Patients who suffered strokes, could be treated with very effective drugs to prevent a second stroke, and could survive for years in a highly impaired state. If they could no longer swallow then they could be fed through peg tubes.

Operations for Cancer and for broken hips, that would have killed patients in the 70s were routinely survived, leaving patients alive but in very poor health.

When you see care in action you see the casual indignity of the use of incontinence pads, for people who would rather be helped to a commode. You see people being dressed in clothes that are not theirs. You see all the small choices that we take for granted stripped away.

The press now has an interesting relationship with stories of care of the very old. It is something that does touch us all, because we can so easily see this could be our parents, our friends. It could be us.

The convention is that we do not see faces, because this could be exploitative, so we tend to see pictures of withered hands.  In many cases this is all we see. Our elderly are locked away in nursing homes. They are invisible. The connection is not there.

We have had, perhaps especially since the Midstaffs Healthcare commission report hit the press, something of a vogue for bad care porn, where we hear in all the shocking detail the highly uncomfortable facts about management of bodily functions.  Perhaps I am not as shocked as many are by this. After nursing my mother for many years, changed many wet pants and seeing her pretty dramatically covered in faeces on three occasions I am aware that on occasion s*** happens.    

Our willingness to accept that on many occasions these indignities are no one’s fault, is a little further eroded by every new press scandal or undercover television special that we see.

The willingness of decent caring people who are really suited to providing the compassionate care older people need to become nurses, is probably also eroded by every emotive story we hear of cruel and uncaring staff.

What has bothered me as I listen to the evidence from the #midstaffsinquiry is that we have wasted so much precious time in seeking to find out “the truth” and who is to blame.

There have been real benefits from the Stafford process.  Valuable systems to help judge the quality of care better have been created over the last four years.  The Dilnot report on Care funding which is this government’s response to the work on Care funding done by the Labour Government in its last term has now reported and may be offering us better ways to fund the quality of care that we want, in different settings. This is a separate issue, but essential to make hospital care work.  All this is good – but there is so much more to be done.

One of the distinctive features of this government is that it is decentralising and cutting, so we in our communities will now have the responsibility of specifying and taking the financial decisions on the care that we want for our older people.  For all the people who have been watching the #Midstaffsinquiry the level of responsibility that will now fall on local people without the expertise to do this job is terrifying.

Will the press who brought us the care porn, and relished the search for people to blame now turn its hand to helping communities work together, putting party barriers aside, to find solutions to our shared problem.

First thoughts on Dilnot.

First thoughts on Dilnot.

The Dilnot report on social care funding comes out today. This is an essential part of the complex changes needed to make Hospital care and End of life care work, and of removing a great deal of the fear from old age . Here is Dilnot on BBC Radio 4 Today.

Everyone knows that we need Dilnot. That is why there is agreement to work across parties to make this work.

This is an interesting challenge to the press. – Where is the conflict? What can be said to make this an “interesting” story from the media point of view.

I would suggest that what the press can and should be doing is taking up the challenge of showing people clearly why something that many members of the public will not instinctively take to is in fact in their very best interests.

The press need to help with the process of driving whatever modifications are needed, but also they need to help us to “love Dilnot”.

My own journey towards “the Dilnot solution” began around 12 years ago, when I began to be a full time carer for my mother. A very respectable conservative voting friend took me on one side and advised me to “lose” her limited assets, so that they would not be swallowed up in care costs if mum eventually went into care.

His position showed me that the manifest unfairness of the means tested system we still have are so great that the “respectable” and “prudent” line of action is to take steps to evade payment.

When I looked at this more closely I could see that he was the tip of a very big iceberg of overpriced rented properties for the elderly, and clever financial advisers that are all based on the premise of getting rid of your money before you have to pay care costs.

The cost of all this activity becomes apparent when you see what it is like within a cash starved care industry, where the quality of care is often very far from being what anyone wants. We are also seeing (if we look carefully enough) the cost of this evasion in the quality of life being lived by that elderly lady living out the end of her life in a house several doors down the road from you.

Dilnot is not perfect, any more than its predecessor, the White Paper on Social care produced by Labour in 2010 is perfect. It is the product of the government that we as voters have empowered. It is something that may change a little over time, but if it does not, then I think that we can live with it.

I have not yet read the report, but from hearing Dilnot’s very clear interview on Radio 4 Today  I would suggest a number of key things that Dilnot is getting right.

Raising the Means tested threshold.

 Raising this from the ridiculous £23,000 to £100,000, is something that the Joseph Rowntree Foundation has been campaigning for, over many years.  This is a realistic aspiration for people to have this level of “wealth” to pass on to their children. Some people will fall below this, but it will no longer be “respectable” to try and fall below this more generous figure.  (questions- how does this work with couples?)

Capping the contribution

I was pleased to hear Dilnot say this should be at £35,000 . (We have been hearing a lot about £50,000 – not sure where the pressure for this figure is coming from).

Capping the contribution from the individual does two things. It immediately takes away the fear of unlimited costs, and it makes it possible for the insurance industry to offer some kind of sensible packages to cover this known risk.

This is actually very similar to the proposals I put forward about 7 years ago now.

Recognising costs at home and in care

An anomaly in the existing system is that you can do what I in fact did with mum. You can spend years caring at home. Reach the point where it is no longer possible to buy in enough help to make that viable, and then end up spending £100,000 on residential care costs.  Dilnot’s cap applies to Care in the home and care in a residential home. 

(questions – how do we set the minimum needs thresholds for care provision, – how does this work with the localism agenda)

Hotel Costs.

With all the talk of Care costs, it is important to know what is covered and what is not. The fear is that you get a shift to disguised care costs, being called hotel costs, as has happened in Scotland.  Dilnot addresses this by setting a cap on Hotel costs, at £7,000 which is the minimum income anyone would get from the state.

(questions – is this going to satisfy care providers – what about people who want “a luxury care home” – Will some homes be able to opt out, and will that then put pressure on families to pay “top ups”)

Is it fair to pay out for people who do not need help

Dilnot does mean that rich people will get state help with their care costs. Some will see that us unfair. Dilnot was quick to point out that this works on the same basis as the NHS.  If we are worried about fairness then that is what the tax system is there to do.

Today is only the start of discussion. It is also perhaps the start of a better way of doing politics, and a better way of making our society work for us.

Will it make care any better?

The first tweet I saw on Dilnot is the question will Dilnot make the quality of care better. My answer is yes it can. At present the care funding system is so problematic that most of us just simply avoid thinking about a problem that we cannot deal with and will not go away. The Dilnot framework gives us something we can work with to create a care system that we all "own". We will all have a vested interest in  making the whole system work better for us. 

Lets do it.  

Let’s use the opportunity.