The writer is a Research Fellow at the Mossavar-Rahmani Center for Business & Government, Harvard University, and author of ‘Extra Time: Ten Lessons for Living Longer Better’
In Japan, I’ve watched a humanoid robot dance with a human physio, leading enthusiastic elderly people in a morning exercise routine. In Holland, I’ve visited old ladies in their homes with a nurse who brings her dog to cheer them up. In America, I’ve been to a care home where the residents run the library — whose shelves display books they’ve written themselves. As every rich country grapples with growing numbers of people living longer, getting frail or being crippled by loneliness, an important part of the answer lies in keeping people independent for as long as possible.
A care system which promises us all more meaning in old age would be far more attractive than one which sounds like a last resort to manage decline. In the UK, the debate about social care has taken off again, with chancellor Rachel Reeves ditching a long-delayed plan to “cap” certain care costs. This has alarmed those who feared the cap was the only game in town. But Reeves’s instinct is right.
To fix social care requires bigger thinking, about both funding and the approach to those with disabilities. The only way to untangle what currently feels like a monstrous Gordian knot — with underpaid care workers, desperate families, GP shortages and clogged hospitals — is to change the narrative. Elderly social care should be framed as a positive investment for the whole of society.
In a working paper I have published with associates at Harvard’s Kennedy School, we recommend a series of practical policies to improve outcomes for people over 65 in both health and care. Unnecessary or prolonged hospital stays, for example, can condemn people to become dependent on others too early because of bad food, disturbed sleep and physical deconditioning. Intensive rehabilitation can pay for itself — it has enabled two-thirds of people in some American hospitals to return home after a fall or operation. But it requires staff to change from a mindset of “doing to”, to “doing with”.
Similarly, loneliness is not always cured by shunting people off to a day centre. In Norway, campaigners are using peer-to-peer technology to get elderly people sharing meals online. There is a widespread assumption that older people don’t want choice or control. But they do — and more should be allowed to spend their own allocated care budget and employ relatives, as Germany is doing.
Above all, we argue that the UK needs a coherent funding system to replace one which is opaque, arbitrary and unfair. In care homes, families with assets are effectively cross-subsiding those eligible for state help. NHS Continuing Health Care budgets are the subject of court cases from people desperately battling to prove a “primary health need”, of which there is no strict legal definition.
In some ways, the UK’s system looks not dissimilar to Germany’s 30 years ago. Both Germany and Japan have gone on to craft social care insurance funds which are transparent, predictable and sustainable, and have created a sense of social solidarity. Everyone pays in — including pensioners — and everyone benefits.
These schemes go far beyond the cap on care costs proposed in 2011, which Reeves has just stopped. The worthy aim was to set a maximum amount that anyone would have to pay for their personal care over their lifetime (excluding daily living costs). But politicians never implemented it, partly because it would protect relatively few families, and partly because the Treasury has been reluctant to raise taxes without any commensurate improvement in quality of care.
One political challenge in countries with “pay as you go” welfare systems is the belief among many older people that they have paid enough tax to cover their costs in old age (sadly, many haven’t). Another sticking point, especially in the UK, is housing. The desire to pass on a home to the next generation is strong and legitimate, and has led successive politicians to promise that no one should have to sell their home to pay for care — but it may not be sustainable to ignore the value of most people’s largest asset when assessing their wealth.
Labour will have to find more funding, not least because it risks bankrupting employers with its pledge to raise care staff wages. But reform is not simply a dry technical exercise: it must bring the public with it. That means setting out a vision for a better old age which can give people meaning — as Atul Gawande argued so powerfully in his book Being Mortal. How we treat our elderly and disabled is the ultimate test of a civilised society.