Friday, 11 May 2012

Losing sleep over social care

Having written once about social care, I went to bed last night knowing that it is more than a one-hit issue - in fact, every facet of the topic has in-built complexity, varied value judgements, and a strong undercurrent of morality to it. A divide and conquer approach is needed to tame this beast. Some of the questions we need to answer are based on the standard lines of cost, affordability, and level of individual contribution vs state subsidy. But some of the questions we need to post to ourselves have the potential to be uncomfortable indeed, and it was to some of these issues that I alluded in my last post. It is difficult to frame the discussion of social care without revealing one's own opinion. The current discussion about social care is not just framed by the realisation that it is becoming unaffordable, it is also framed by the understanding that it is something that we are not doing very well. Does that ring true? Do we offer our elderly the kind of care that they both need and deserve? It's really difficult to get away from the value judgements. There are two ends of the spectrum: at one end is the view point that our elderly have had long working lives, and should get all the help and support they need via the state. At the other end, is the view that one of the requirements of your active years is to ensure that one's subsistence can be afforded after retirement. Your views on where the state fits in to this scale will vary, but one of the important roles that society plays is to protect individuals from the vagaries of misfortune and catastrophe. Let me put this another way: on average, each of us will have to find £20,000 to cover care costs in later life, but 1 in 10 of us will have care costs in excess of £100,000. A strong parallel exists here with the NHS, which manages the risk of very high individual health costs, by central risk-pooling: we all contribute through our taxes, and the majority (in a financially-balanced health service) will put in a larger amount of money than we ever withdraw in the form of treatment. This cross subsidisation was one of the things the Britain voted for in the landslide Labour win of 1945. And the same must also be true of social care: it seems fair to operate the same kind of cross subsidy that ensures that individuals who end up, through no fault of their own, with exceedingly high care costs will be supported. But implicit in this value-judgement of fairness, there is also an assumption that there is a fair level of self-provision. Again, this operates on a scale: at the one end, we have the NHS model of social care, whereby we all contribute the money that we would otherwise save in anticipation of our future care costs, pool it together and operate a free-at-the-point-of-delivery and comprehensive social care service, from which people can opt out, but from which there is no rebate if you do not avail yourself of the state provided services. At the other end of the scale is a privately funded system, whereby you either afford your own care services, or you do not receive them at all. Surely no one wants this kind of set-up, but where on that scale do we want the level of cross-subsidy to be set? And this is where the current debate on social care is missing the point slightly: the issue of funding social care can only really be discussed in the context of the value judgements that we as a community wish to apply to the issue. Do we want to institute a revolution in social care, along the lines of the NHS, or do we wish to aim for more modest ambitions of satisfying unmet need where we can, but in an overall context of mostly private funding of social care? If like me, your head is beginning to hurt, then perhaps that merely indicates how far we still have to go.

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