Not Born Yesterday

jargon, ignorance, hypocrisy and dissembling: why johnson's aged care strategy is a disaster waiting to happen

Introducing some sleight of hand

With enormous fanfare, Health Minister Alan Johnson last year announced the Social Care Reform Grant. It would, he said, revolutionise the care of old people. Indeed, he told the media on 10th December 2007:

"The fact that six Cabinet Ministers have signed this protocol demonstrates unprecedented cross Government commitment to this objective. Today I am announcing an investment of over half a billion pounds through a Social Care Reform Grant, to support the transformation of Social Care over the next three years."

The Minister went further. This would mark the first step towards

"...21st Century social justice with an active and empowering state, rather than one which is paternalistic and controlling. Being healthy, staying well, and living independently, the right to self-determination and equality of citizenship - all essential elements of an equitable and progressive society."

It was stirring stuff. But New Labour ministers love all this 'epoch-making breakthrough' rhetoric - and few more than Alan. Earlier this year, he famously remarked in another 'major' speech,

"Ten years ago,we started the work/life balance debate"

a claim roughly akin to Spike Milligan's in relation to Hitler's downfall - except that the great old Goon was joking, and the pompous Mr Johnson wasn't.

Still, it was a big story and so perhaps the Secretary of State felt entitled to his hour of glory. He might have felt entitled to it - but he wasn't, and he isn't.

My Great Aunt Lizzie was fond of saying that 'fine words butter no parsnips', an Edwardian phrase now largely forgotten which means 'nice idea - where's the money coming from and who's going to do the work?' Events have moved on apace since Mr Johnson promised that the budget for this grant (SCRG) would be 'ringfenced' - a sure sign in itself that he felt anyone might try and steal it for some other purpose at a later date. The Brown administration now being effectively bankupt, somewhere in his Bunker Gordon would be fuming about £520 million of ringfenced money - if he thought there really was that much at stake. But he knows there isn't. And like all politicians, he knows that people are forgetful.

Time to examine all this in more detail.

History & Politics

Far from being 'on the ball' regarding the demographic Aged Care time-bomb, New Labour caught onto the problem very late. Scan the Party's website for 1997-2001, and you won't find a single reference to aged care, residential homes for the retired, geriatric medicine - or indeed any other form of words you put in.

What they did spot early on, however, was the chronic lack of any funds for real investment in the sort of bricks and mortar that would be required to modernise education, social welfare, geriatric care and the NHS. From early on, therefore, the 'idea' was hatched that they should put value upon people being treated at home. As early as December 1997, Blair said:

For example, we will introduce a nurse help-line to provide advice to people in their homes 24 hours a day, 365 days a year.

Rather like his promise to have a pc on every child's desk within a decade, this promise also faded like a reassuring dream in the cold light of morning. But in the eyes of those running the New Labour Project, it set a precedent: the future is virtual - service wherever you are...and variations on this messily trodden trail of bullshit.

In point of fact, it didn't set a precedent at all: it merely followed a convention already established by the Thatcherites with their approach to the collapse of proper mental health care in Britain. 'Care in the Community' was their little bit of cynicism - soon to be followed by more Orwellian brand names that meant almost the diametric opposite of what they set out to do.

Such an approach lies at the heart of the SCRG. As does an obsession with the kind of quasi-management consultancy jargo-bollocks we have come to expect from all those not actually engaged in having to make and sell something.

Before the SCRG there was a National Service Framework to be established as the foundation stone for a new Tower of Babel. There would be milestones on the way (bit of a mixed metaphor there) and in the absence of nothing remotely substantive to give to the old folks, a Medicine Management Booklet for helping them remember to take the tablets. Below is a corker from the documentation of the time - around 2006/7:

'Progress on social service transformation will be monitored by the independent regulator against the outcome-focused metrics set out in the National Indicator Set'

Bags-I get to play first with the Indicator Set's metrics. A little later, the National Institute for Clinical Excellence (NICE) - a price-controlling accountancy exercise thinly disguised as an upholder of standards - realised it too had little to offer the reform programme, having already condemned tens of thousands of Alzheimer's sufferers to years of expensive and degrading idiocy by denying them the right to have Aricept. So it tossed in a recommendation for - get this - 'Dementia Care Mapping' in order to assess the scope of a problem they had helped create in the first place. It was a sort of 'We won't do anything for these vegetables, but let's find out where they are'. (The UK is in the bottom third of countries in Europe in terms of the percentage of dementia patients receiving anti-dementia drugs).

Eventually, a field-test project in Lincolnshire established the need for:

• early intervention for old age conditions
• streaming to specialist care in crisis situations
• early transfer to the community for rehabilitation in intermediate care
• multidisciplinary assessment prior to care home placement
• partnership working across health and social care.

To be fair, the Lincolnshire Report was excellent, but once again made recommendations in a fiscal and economic vacuum. And it set out little beyond what any care worker could have told the project managers before they started.

One family's experience

For example, 'early intervention' (a blinding glimpse of the obvious) did not sit well in the reality of this comment from Dementia UK:

'Only a third to a half of people with dementia receive a formal diagnosis, meaning many people do not receive the support they need. Only 31% of GPs surveyed felt they had enough training to diagnose and manage the disease.'

My own experience of this area suggests that, if anything, this observation was being kind to standard practice: in the case of my father, the GP denied his (very obvious) senility, and then refused point blank to commission a brain-scan for Alzheimer's because 'it probably wouldn't show anything' - a cavalier prognosis if ever there was one.

'Streaming to specialist care in crisis situations' also applied in Dad's case, because a hip injury to my mother left her in hospital and him wandering about. Social services stuck him in a 'community care centre' - aka, a hostel for the severely disturbed - until my brother and I came round to rescue him. The only thing to be thankful for is that his Alzheimer's condition ensured he'd forgotten all about it within a few days.

'Multidisciplinary asessment' and 'partnership working across health and social care' are two more pretty phrases saying little more than 'let's deal with this in a coordinated manner as opposed to making a complete Horlicks of it'. Again, our experience was that social workers and NHS staff spent the entire time at each others' throats: the first lot said he was a medical condition, and the latter that he was social. Neither knew where to start - so they didn't.

What all these observations boil down to once again is the obvious material-world problem: money. GPs, care home owners, social workers and NHS administrators were all busy defending budgets - having lost the plot entirely, viz: the treatment of a sick patient in need of help.

When is money not really money?

Now of course, the Johnson Plan (it wasn't his, but let's keep going) is supposedly trying to put an end to all this - so what's my beef? Well, it's twofold actually. First, how - eight years into the life of a 'reforming' Labour Government - had the whole bunch of bananas got into such a parlous, cynical, anarchic mess? And second, where was the cash going to come from to sort it out?

The answer seemed to overlap the two questions: eight years of fine words in Parliament alongside cash starvation in the real world was going to need one mother of an investment now - but there was Big Al rolling up, and holding folding to the tune of five hundred and twenty million smackers. Whoopee.

Except we mustn't whoop before we weep. For while Alan Johnson unveiled 'half a billion pounds' (as he put it in one interview), there were two catches right from the start:

1. It was over three years, 2008 - 2010. and

2. It is very much back-loaded. This year, in fact, there will be a mere £85 million applied to this gigantic problem. And basic maths proves that this is only about 16% of the budget.

Keen students of the British electoral system will also have spotted that for at least the third year, there is every chance - in fact, bordering on a 100% chance - that it'll be the other Party's problem.

You see, the thing with pure, undiluted cynicism is, you almost have to admire the sheer elegance of it.

However, there's more. Ploughing through the original launch pack in December last year, one finds this small point in the second to last paragraph:

'the £520M includes some NHS resources'

Ahaa. Very informative - up to but not including the 'how much?' issue. So I emailed (and then rang) the DoH. "How much?" I asked. And after some ring-a-ring-a-roses, this is what I discovered: £257 million of the 'new' money for this huge initiative is rather old, dog-eared money snaffled from the already hard-pressed NHS budget. In Year Two, the NHS coughs up sixty per cent of the total.

Will the money be well-spent?

Wouldn't it be nice to just write 'yes'? Sadly, I can't. At best, the strategy is unsound on a number of levels; at worst, it's just more of the Care in the Community scam.

Let's rewind to somewhere near where we started. We can see some signs of what was in the minds of those behind all this in stuff like

'.....helping more people stay in control of their own lives by ensuring 30 percent of people receiving care from social services do so at home.....'

'Disabled people rightly demand to live independently as equal citizens.'

The research upon which the 'at home' strategy for aged care is based isn't quoted specifically, but the main finding is repeated over and over again:

'The vast majority of people wish to remain in their own home for as long as possible'

Now, I hate to sound know-all about this, but anyone with an IQ above 70 looking after (or arguing with) an elderly relative will know that all old folks think they're perfectly capable of staying at home to look after themselves. But the reality is, most of them aren't. And if they were allowed so to do, they would be a danger to themselves and others. The vast majority of people want to live forever, but they aren't going to, so don't ask them if they want to.

My father will answer, if you ask him, that he wants to go back home. He'll tell you that ten times in twenty minutes even if you don't ask him. Mind you, Dad doesn't know where home is, and he's not that clear on what home is. You see, he thinks he's been in the home for nearly fifteen years, whereas it's nearer to being fifteen months.

I asked some people in the care home profession if they were aware of the SCRG 'strategy', and if so what they thought of it. Yes, they said - not only were they aware of it, they knew two things for certain about it:

1. It will put even more pressure on the private sector than at present - because caring offspring told their loopy folks will be visited four times a day at home will say 'thanks but no thanks'. This will drive prices up further - and thus cause even more hardship to those already paying through the nose to have their parents cared for.

2. To quote one senior care home manager "I'll give it three months before some old dear either blows herself up or gets run over while crossing the road naked".

The truth is, what the future holds under this plan is as many old biddies wandering the streets as there were poor disturbed souls jiggling and twitching up and down Britain's thoroughfares under Care in the Community. And the reason is, even the flea-bitten State homes there are cannot be maintained much longer. No money.

So no, the money isn't going to be well spent - because it's trying to replace a vital need for infrastructural investment that isn't going to happen: an investment that would cost thirty times more than the (real) new £270 million being applied to the problem.

There's also the issue of whether the In Home approach can be funded on this budget anyway. The plan calls for four visits a day by a social worker; Lord knows how many cases each executive will handle, but it's unlikely to be more than four a day at most. How can that compare with the ground they cover now - which is, on their own admission, woefully insufficient?

And efficacy. What happens for the eighteen hours when Mr or Ms Carer isn't there to stop 90 year-old Jethro from tripping over in the bath, gassing himself, or forgetting that he left his key in the flat at 1 am in the morning?

People with age-realted physical disability and dementia are not competent. It is at best delusional and at worst horribly cynical to suggest they are. After a certain point they need 24/7 care.

It is utterly risible for Work & Pensions secretary James Purnell to say

“Disabled people should have the same choice and control over how they live their lives as everyone else"

Physically disabled people should indeed be given that chance. But placing people over 75 with dementia into a group deserving of more liberty is cant of the highest order. Put bluntly, liberty will kill such people.

It's not as if the old and their carers aren't a deserving case. At present, dementia affects one in five people over 85 and one in 20 over the age of 65. Friends and relatives who care for the 700,000 who currently have dementia save the state £6billion every year. The annual economic burden of dementia is over £14 billion - more than stroke, heart disease and cancer combined - of which the majority falls to families....taxpayers.

Over the next twenty years, this is going to be a shared experience for all but a tiny, lucky minority of us. A huge proportion of those 'caring' for elderly relatives don't live with them. Even for those who do, this policy cannot possibly release them from their prison: a short, temporary relief each day is the best they can hope for - if, that is, the system doesn't collapse under the pressure of ludicrously unrealistic aims given the manpower available. (Only 30 per cent of 1.6 million people working in social care have a relevant qualification.)

It is inconceivable that those in charge of aged care strategy don't know these facts. The Government owes the families helping their old folks infinitely more than what's on offer. It owes the British people more honesty than this.

But then, the current Government (in fact, the current Establishment) owes the British people hundreds of billions of pounds in money wasted on everything from incompetent IT consultancy and foreign wars to greedy bankers and poorly negotiated EU budgets.

Copyright John Ward & Not Born Yesterday June 2008

The new Social Care Reform Grant is worth £85 million in 2008/09, £195 million in 2009/10 and £240 million in 2010/11. £247 million of this will come from existing NHS budgets.

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