UPDATE: One of the major domiciliary care providers, featured this year in a Panorama investigation, has just  been told by York council it’s contract will be finishing this year. Read the story and some very good comment here:

Original comment:

In the last few years more we have been subject to more and more stories in the media about how elderly people are being failed by the Care system. Stories about how ever greater numbers of elderly people fall outside the welfare system, and are entitled to no financial help at the end of their working, and tax paying, lives. We are told this problem will get very much worse with an estimated 1.7 million additional older people in the UK by the year 2026. UN figures estimate that by 2050 one in every three people in developed countries will be of pensionable age. This means that every pensioner will only have two tax payers to fund their health and social care costs, for perhaps several decades.

So change is needed in the way care for older people is funded, but there is no agreement on what it should be, or legislation to make it happen.

Meanwhile, over the last twenty years providing care has become big business. The Community Care Act of 1990 sought to enable people with care needs to remain in their own communities for as long as possible through the provision of individualised care packages, or ‘people-centred care’. This is a very laudable notion, and better than what went before which focussed on various kinds of large scale institutional care arrangements.

But the problem is in the execution. The new individualised care was not to be provided by the NHS, but by private enterprise. In the rush to privatise everything, bundling up the care ‘burden’ of the state , and selling it off in contracts to private companies was deemed the most cost effective way to provide this new, and more expensive, community based care.

In 2005 (latest figure available) 367,000 people were in receipt of care in a given week. Seventy three per cent of it was delivered privately. Back in the 1980’s it would have been seventy odd per cent delivered by the state.

Neo-liberal theory has it that competitive markets for goods produce the most efficient outcomes. A competitive environment reduces waste and inefficient practice, and so gives better value for money. Conversely centrally managed state run operations, such as the NHS, will be wasteful as there is no incentive to be efficient. Additionally civil servants are more expensive to run, as they expect fair pay and conditions, and have unions to help them achieve such. So our government to farming out the care to those in need to the private sector – to save us all a big chunk of money (theoretically).

The private sector, driven by the profit motive will be efficient, but the key question  is, efficient for whom?

It’s not efficient for the people receiving the care, the real people with real health issues, perhaps facing terminal degenerative illness or just the increasing frailty of old age. Somebody receiving home care in the past would have got perhaps an hour or two a day of help to do a whole range of things, from shopping to bathing. They would see the same carer most days and build and ongoing cooperative relationship with them. The carer’s presence would materially improve their well-being, the social aspect alone could be good for them.

What might that person get today? With care probably delivered by a private company, whose motivation is to do so as cheaply as possible by employing staff at near minimum wage, and then overworking them, somebody receiving care today may get 15 minutes of ‘contact time’ (the current business term) with a carer. That carer will be strictly limited in what she/he can do in those 15 mins for health and safety and other reasons. No lifting, and no administering of medicines is allowed for example. Worse still, a cared for person might have a constant stream of different carer’s visiting; no continuity of care is possible. This is because it’s efficient for the private company so send whoever is free at any given time. Their prime concern is not the quality of care given, but how cheaply it can be given, whilst still maintaining their contractual obligations to the local authority. Overall many people receiving care get a raw deal; they are just a unit to be serviced in order for the care company to get paid. People in need are commoditised into production units which have a monetary value to profit driven companies. They have become like parking meters or paving slabs; local authorities have to sub-contract out provision of their maintenance to the cheapest tender. So whether it’s an uneven pavement or a person in dire need, half a job can be done, and a fee is extracted.

It’s not the care workers fault. They typically don’t get paid for travel time, which may account for half their hours. In fact technically they may not even make minimum wage on these grounds, although legally any shortfall would have to be made up. Workers are de-motivated as they cannot offer a quality service within the time-frames they are given, staff churn is very high. A report by the Home Care Association in 2004 stated “The reduction in the length of visits specified by care managers may reduce job satisfaction for workers further impeding recruitment and

retention.”. (UKHCA, 2004).

Who are these private care companies?

Due to mergers and acquisitions many providers have conglomerated. Most operate franchise schemes were anybody with a lump sum can buy a territory and make a healthy profit. These are marketed as ‘make a lot of money quickly’ schemes on various websites. At the top of the pyramid are the big hitters that own these businesses as part of an overall  investment portfolio. They may also own construction or tech companies, anything that turns a good profit. One provider, Carewatch, was recently bought by an asset management company for £37 million. Making a business out of caring for people in their own homes is clearly very profitable. Although try telling that to the lowly paid and stressed out workers on the ground, or the care receivers who often don’t get the quality of care they are entitled to.

So as we all get older, we can increasingly look forward to our care needs being given over to large businesses that exist to make yet more millions for themselves. About 45,000 people a year are forced to sell their homes to pay for their own care-home based care, money which mostly ends up going to these large businesses in care home fees. As does the money from the in-home (domiciliary) care operations. Older people today must be feeling really short-changed by their own government. You can work all your life, pay tax and NI for 50+ years, and as you relax into retirement it’s all taken back off you, and given to already rich men in big business. It would be especially galling if, like many, you bought your council house in the Thatcher years, as a nest-egg or inheritance for your children. Only to find you now have to sell it to pay for your own care provision, which would have been provided free by the state back when you exercised your right to buy. Being a property owner has a downside, unless you are also wealthy.

The state (NHS) was considered too wasteful to provide cost-effective care. But the current system is failing people in need. If every penny of the millions in profits the private care companies are making was ploughed back into care provision how much better things could be! Quality and quantity of care could be vastly enhanced. Right now, while old Mrs. Smith sits alone waiting for her 5 minute care visit to come and dress her for the day, the younger Mr Farquar, asset manager, is heading down to the Bentley garage to look at his next car, part funded by the lifetime assets of old Mrs Smith.

How can that be right?

Surely it must be time to look at taking the financial profit out of providing care, and organising it in such a way that people get the level and quality of support they deserve. If not-for-profit care provision was widespread (it’s a minor player today) that might just be possible. Whatever the solution, the status quo is unjust and unsustainable.

This is a long post, but I felt it worth saying as it potentially affects us all. Any comments welcome.