Where should the cost burden for care of the elderly lie in society - with the state or individual

[mids2019]

I was watching an item on a politics show about the long standing problem of funding elderly care. There was some woman who was strongly critical of the funding middle as her mother had to swell her house to find care home fees. Could one argue that the parent had no need for her house with regrettably a very small chance of return so it is fair for that a set to be used in paying for free instead of the tax payer picking up the cost? It was an elephant in the room during the interview but the person losing the most in the scenario was the daughter who ultimately would inherit less but obviously this was not said.

I don't think there is a simple answer hence successive governments pushing this into touch but where should the cost burden lie, the state of the indiividual?

I think this subject is really co.implicated by the fact that we have universally free healthcare yet a private model for social care. There really is a sinking here. Hospitals will in future not be able to fill in for shortcomings of social care and there are many cases of the elderly taking up beds in hospitals as they can't be discharged without an adequate care package and I wonder if these cars packages are materialistic because of cost? We also get the situation where specialist nursing care is free yet caring in a care home is not so how do we square that circle?

Brilliant question OP, I have been thinking about this a lot.

We are drifting into a situation where we will have a high tax state funding… basically just health and social care. Everything else suffering as a result.

It’s a huge problem. I agree an insurance type system sounds good but given so many can barely afford life as it is, I’m not sure how it would work.

I fear we are failing to invest in the future because we are putting all of the country’s resources into supporting people at the end of their lives - how much should we be spending to extend the lives of the elderly, particularly if it’s a low quality of life.

It is a big issue, but I think it's the elderly today who are most distressed and/or annoyed about paying because they didn't grow up/or old with these payments being a thing. My dad was quite irritated and kept asking (rhetorically) what did he pay his stamp for - not unreasonably as my mum's mum just got free care in the 80s and he'd never really been told much different, especially when he could have done something about it perhaps - eg/insurance - he was always planning financially for eventualities.
My Mum paid around 2k per month for 4x calls per day - this was after my dad passed and I never worried her about it. It's an extortionate sum really and eats up cash fast - plus as we're 'oop norf' then house prices don't and won't last long. Unfortunately, if in a home the elderly may then need to move to a cheaper place when cash runs out, and moves themselves are detrimental to their health.
Having said that the care system is obviously unsustainable and also pretty unfair with councils charging differing amounts, some care homes and/or companies providing less than basics too - it all needs an overhaul and we will need to put in money. I think my generation at least (and below) recognise the necessity of this and won't be as disappointed or angry as we expect to pay anyway now. I'm happy to put into any scheme/insurance whether I ultimately take out or not, and I'm surprised if people are not wanting our elderly citizens to have a decent life at the end years and not want to do so, or want some repayment if not needed - I do appreciate that times are hard and it's a worry to find more though. Preferably reform to the system will be phased in but again money is needed today - be nice if millions weren't wasted/not claimed by public services, some important folk, and some large companies but realistically they are and they're going to continue to be so it's down to us the general public to fund it / probably ultimately via wage packets and/or insurance schemes.
There will always be some unfairness but there is all through life so not much can resolve that. Would definitely prefer the overhaul and improvements to be clearly started and seen and shared alongside any public payment.

There have been wars since World War Two.

The current system, as others have pointed out, is unfair and inequitable. We need a fair system which recognises those that have worked hard and paid into the system for years and those who have not (perhaps out of choice). I would advocate for the insurance system.

Not wars in which “most people” have been involved. Wars in which people who have chosen the forces as a career have been involved, yes. And there are some veteran specific services (not saying they are enough, but there is at least an attempt to cater)

Yep my dad died early 22 just shy of his 95th birthday. Despite joining the army as an apprentice at 15 he didn't see any active service until he was sent to Palestine in 1946.

I think it's fair that you should exhaust your own finances first before the state steps in. Why should the taxpayer pick up the bill so that your family can inherit?

In my family when my grandparents were ailing they moved into one of their children's homes and a carer was hired for them. All the children contributed towards the cost of a carer.

There’s an inherent contradiction between wanting a “state based system” like insurance and wanting a difference between those who have paid in and those who haven’t.

The NHS isn’t perfect and can be a postcode lottery, but it will treat you whether you have paid £0 or £1m in tax over your lifetime.

A lot of care home costs aren’t that variable. It does cost a certain amount to build and maintain a home, feed the residents, provide sufficient care workers etc. The marginal cost difference of having a spa pool on site and doing outings to local castles rather than the local library (or anything else you might think of as luxury rather than basic) isn’t going to be huge and residential care costs will be high, however it is done.

I don't know what the answer is but keeping people alive in extremely poor states for years isn't affordable now and is certainly unsustainable going forward. I'm planning on popping my clogs with my first serious illness as I don't have any money or family to provide care and I'm not going to be able to cope in some grotty care home. Doctors insist on forcing people to remain alive though, so get an Advance Directive in place if this isn't what you want for yourself. Encourage your relatives to do the same as well because I can't see the care industry improving.

Indeed.
This is the debate that the commons should be having, not assisted dying which would actually affect very few people. The big question for our generation and the boomers is "at what actual and human cost comes increased length of life".

im pretty sure it's Ricky Gervais that brings this up in his recent show that the doctor was saying that if he cut out x,y and z he could live longer. But the point Ricky made was that it wouldnt be years in good health such as his 20s, he'd be living longer at a time of his life when he was likely to be in poor health and frail and why would he want to do that !

American research has shown that while people have an increased life expectancy, the additional years are generally spent in very poor health.

@SheilaFentiman exactly. If people want to pool risk and have the state and/or insurance pay for care then they also have to accept some people will pay a lot less in and get a lot more than them out of the system.

As a fairly high earning, healthy, child free woman I have paid a heck of a lot more towards the NHS than I get out. But thay may change and even if it doesn't I do not begrudge it.

This is not an all or nothing situation. I think you need to break the costs down for example:

There are the basics that should be paid for by the person e.g.

• food and drink
• toiletries and sundries e.g. soap, shampoo, toothbrush, toothpaste etc.
• clothes
• entertainment/sport etc.
• contents insurance
• car, transport etc.
• mobile phone

There are basics where the person should, depending on the circumstances, pay all or a fair proportion of costs e.g.

• the building they live in, along with buildings insurance and ongoing maintenance costs
• utilities such as gas, electric, water, TV licence, council tax, broadband etc.
• cleaners, cooks etc.
• admin

Then there is care which can range from companionship to full 24/7 nursing as well as specialist equipment. This can be split into two elements the equipment/ supplies and the caring staff costs.

In most cases the staff costs are the most expensive element. NMW is going to be £12.21 per hour but on top there is Employer NI and pension contributions, liability insurance and admin costs (payroll etc).

I would not be happy at having to pay increased insurance for a future care home as I would rather be dead. If this were to be a plan then opt in euthanasia too please linked to opt out for the insurance.

@ByMerryKoala

You're right that just a conversation isn't enough. From the conversation, you can make an Advanced Decision (Or Advanced Decision to Refuse Treatment) which is a legally binding document. It's a conditional agreement that says "In X circumstances, I want Y to happen"

You can change them as long as you still have capacity to make decisions, but if you lose capacity then doctors have to follow those instructions.

I don't know what the answer is but keeping people alive in extremely poor states for years isn't affordable now and is certainly unsustainable going forward.

If a person is unable to stay alive without life support, then this is reasonably clear cut and can be covered by expressions of wishes in LPoA documents etc.

But a lot of cases are less clear. My dad had dementia. Otherwise, his health was decent. Left to his own devices (without my mum, and later, the care home) reminding him to eat and drink, to wash and do his teeth, he would have effectively died of self neglect (hunger, thirst, infections from dirty broken skin). He was in a poor state in the sense of not having awareness of his surroundings towards the end, but what alternative was there?

Similarly, my MIL survived a stroke, to the extent that she came off life support, and there were encouraging early signs that she would recover speech etc. But they didn’t pan out and she died within a year.

Appreciate this isn’t “years” that you mention, but it is still a difficult one.

Imho it has to be funded through taxes. How we raise taxes fairly is another matter. But at the moment we have so many variable outcomes that nobody really considers fair.

If the burden of paying is left to fall to the individual eg through insurance, what happens to those that don't bother to invest in it? Do we just leave them to suffer? And if insurance isn't optional then how is it different to a tax?

I agree that we need to look at whether we are keeping people alive longer than those people themselves would wish given the extent of their suffering.

I also think it's a very fair point about the cost of care for younger adults too, which can be lifelong. I used to work in a service for disabled (primarily autistic people with LDs) adults. All moved in there in their 20s and each placement cost over 100k a year despite us, staff being on barely more than min wage. If we don't think care should be funded by tax, who should be paying for this?

I'd say it rests with the individual but there should be a safety net if the individual can't support themselves.

I think the problem is that just because we CAN keep people alive for a very long time doesn't mean we SHOULD. I've only been in a very few care homes and the residents were... alive. That's about all you could really say for them. Mostly immobile, bored, sometimes confused and sad, many with poor eyesight and hearing. Lacking in dignity, unable to care for their basic hygiene needs without help. No-one wants to go into residential care. It's the running joke isn't it- be nice to your kids or they'll put you in a home? Was it not maybe better when instead of having a cocktail of pills 4 times a day to keep Granddad just about hanging on to life until 90, he passed away peacefully in front of the fire at 80?

Chest infections usually affect stroke and dementia patients. These are invariably treated with courses of antibiotics until the next one occurs, ad infinitum. Perhaps instead of aggressively treating these, people would rather be placed on end of life care and pain/symptom relief until nature does its thing. That's what I have in my Advance Directive. Antibiotics were a wonderful discovery, but are being used to extend life even in the instance of individuals having no meaningful life. Humans aren't meant to just exist. It's cruel, pointless and extremely expensive.

How many people can realistically afford care insurance as well? People can't afford housing, food and bills let alone insurance for something which very well may not happen. Premiums would be huge as well because people who pay privately subsidise those on council funded care. Costs will skyrocket which is what's happening with veterinary care now that surgeries have figured out that they can charge a bomb because the insurance companies will pay. It's happened with American healthcare too.

People are living with much more complex needs and issues and for far longer than they were 100 years ago.

Pre-antibiotics many elderly would be killed off with pumomia, in winter, now they are treated and survive with an ever growing cocktail of drugs.
Mean while the body gets frailer and more help and caring is needed.

The whole picture needs looked.

@Needanewname42 I supplied historical context and then went on to look at the whole picture!

The bit you missed is 100years ago frail people were wiped out.

Medical advances mean people are surviving longer they aren't necessarily much healthier than they were in 1924.

No, @Needanewname42 that isn't the bit I missed out. You could go into a million different details about how the situation is different now to 100 years ago, my point was that the state has only started intervening to support the lives of individuals (regardless of age) within the last 100 years. That was the very specific point that I was making. It is a new thing, a bit of an experiment still perhaps.

Sorry for the long post:

I just got today my mum's invoice for December for her care home in Germany.

She is wheelchair bound after a bad broken hip but has some limited mobility in the way that she can move around in her wheelchair herself.

She pays €86/day for her care which is help with getting up, getting dressed, using the bathroom, shower and then to bed again in the evening.

She pays €18/day for food. That means 3 meals a day, afternnon coffee and cake plus unlimited water, tea, coffee, juice.

There is a monthly cost for the room (€700), which is furnished and has a hospital bed, bedding, towels and includes laundry 2x a week.

She pays an admin charge which goes towards general run of the house, kitchen and cleaning staff, the fact that the home organises the GP visits, ensure that prescribed medication arrives and is given to her, order non-prescribed medication and supplements, organise emergency trips to the optician or audiologist, they schedule physical therapy sessions with an outside provider (that is covered by her health insurance but they sort out the appointments), they provide auxillary staff for activities, offer a library, newspapers, magazines.

Even if I would be local and able to pop in every couple of days I wouldn't be required to do these errands, the charge is the same for each resident.

From her own funds she has to pay extra for telephone, she has her own newspaper subscription (her choice), any treats, toileteries, hairdresser and podiatrist each month plus clothing when required.

The care home is part of a health foundation which also runs a major hospital, two other care homes and a geriatric rehabilitation center. It's non-profit but is required to have extensive funds in reserve as they are restricted how to take on loans.

She is mentally very fit, with nearly 87 the decline of short term memory is normal (I have access to the tests they did with her after the accident and the head of the care staff discussed it with me as well), is annoyed about the fact that she now needs medication for the permanent nerve damage in her hip.

Until early this year she was living absolutely independently in a first floor flat with no elevator, did all her errands and shopping, cleaned communal areas. Then one stupid movement caused her to fall and this is the result.

Reasons for care can come quicker than you think, it's not always the frail, stroke or dementia patients living in care homes.
No typical family home would be suitable unless you convert it to be used with a wheelchair.
I prefer not having an inheritance than knowing she would be sitting in her flat with noone to look for her outside paid carers 3x a day.

People's families supported them into older age 100 years ago, but most families live far apart from each other now. I don't think people expected to live into their 80s and 90s either. Only the rich achieved those types of ages.

I don't agree with cradle to grave provision, even if it existed, which it doesn't.

People over 65 are the wealthiest groups in our society. They have not fought in wars and they have not worked any harder than people today. Many of them have worked very little, and some none at all. Some have been retired for as long as they ever worked.

Most of that wealth is NOT earnt wealth, it is down to the rise in their assets, particularly housing. This has not been taxed. Most of it exists because of government policy such as quantative easing.

Inheritance tax needs to be paid on more estates - it allows us as a society to collect that asset rise that has not been taxed in order to pay for the services that were used by those people.

Whilst dementia is an illness, it is an illness of old age - yes there are rare early onsets, but it is mostly about getting older.

Social care is about providing replacement care for the things you can't do any more due to age. The older you get , the more likely you are to need it - it is predictable that an 80 year old is more likely to need help getting dressed than a 30 year old.

Care homes provide housing, food, and social care. This should be paid for by individuals and their assets.

Nursing homes provide care for specific medical needs that would normally be beyond an individual to do for themselves, even if young and well.

It is up to a family to choose - they cannot keep both assets for their inheritance and expect someone else to both pay for and carry out their relatives' care.

If you have neither assets nor family then you get basic care provision, which you pay for through your benefits , with minimal left over.

We also need to be more rational about health services provided to those do not want extension of their lives or are not benefitting from it.