`WE'VE PUT HER IN A HOME'

Entry to an old people's home is usually for life:

Andrew Gimson examines the perverse incentives

which encourage permanent incarceration

`THE solution to my mother's problems is that she should die,' Mr Green, as we may call him, said. Extraordinary to relate, his mother was not at the time suffering from hypothermia. Nor did she have the misfor- tune to be incarcerated in some peculiarly brutal old people's home, ripe for exposure in the press. Her troubles were deeper than could be removed by the gift of a five- Pound note, less susceptible than most stories written about the elderly to moral Indignation. It was only a question of where she should live. Helping people like Mr Green's mother find somewhere suitable to live consumes billions of public money, but not much of the energy of politicians or journal- ists.

In September 1985, Mrs Green mere, a lady in her mid-eighties, had a severe fall. She suf- fered a brain haemor- rhage and was in a coma for five days. When she came round, she could not talk or recognise people.

The NHS, having suc- ceeded in its emergency role of saving life, transferred her to a geriatric hospital for 'rehabilitation'. Dur- ing the next six months she was well looked after, received daily occupational therapy, became mobile and able to dress herself, and was taken off a catheter. But Mr Green and his wife found that the medical excellence of the hospital was not matched by an ability to deal with next of kin. They attended two case conferences with the specialist and the ward sister, at which the latter pair gave the impression of wishing only to know what property their patient had. On finding that she owned a house, they decided she should be looked after at her own expense, and left the Greens to decide how, offering no help or advice.

When she had her fall, Mrs Green was living in the same house as her son and daughter-in-law. If it were now sold, to pay fees at a private residential home of £150-200 a week, the husband and wife would have nowhere to live. So although Mr Green works full-time, and Mrs Green part-time (neither in a well-paid job), they decided they must look after Mother at home. She came home for two trial visits, on the first of which she did not know where she was, on the second of which she became wildly over-excited. Then she came home for good. She did not always recognise her daughter-in-law, could not wash herself, could not dress without supervision, had to be encouraged to eat, certainly could not cook, was unaware of any need to go to the lavatory, but was said by the experts to be capable of living by herself. The consultant said she had reached a plateau and might live for another five years, or ten.

The Greens receive many kinds of assist- ance from the state. Every three months, Mother is allowed two weeks in a county council-run old people's home. On two days a week, she goes to a day centre. A home help comes three mornings a week. Butall these services have to be fought for. The social worker attached to the case has not called since Mother came home last May. An occupational therapist is the only professional to have given them useful advice about how to look after a chronic invalid at home. They also get various financial benefits in addition to the state pension. These are horribly confusing: no wonder many benefits are never claimed, especially as old people have not yet grown accustomed from youth to extracting every possible penny from the state. Among other complications, entitlement fluctu- ates. For example, after six months the Greens became eligible for Attendance Allowance of £20.60 a week, but then old Mrs Green had to spend four more weeks in hospital, whereupon Attendance Allow- ance lapsed for another six months.

The intention here is not to discuss how much Nanny State ought to provide, but to observe that the way she provides is more subversive of self-help than it needs to be, and also, paradoxically, that she is believed to provide more than she . does. Her embrace is not so wide as many people suppose. Many who imagine that if they become infirm, they will be housed at public expense, find this is not so. It must be galling for them or their families to realise that if they were poorer, they would, in this respect, be better off. Their thrift tells against them. If you are old and have less than £3,000 of capital, you can claim Supplementary Benefit of £125 a week or more to pay fees at a private home. In 1978, 7,000 people were drawing a total of £6 million to pay such fees. Since then, during years of supposed austerity, the cost has risen by approximately 8,333 per cent: the DHSS provides no up-to-date figures, but the Audit Commission esti- mates, in its report Making a Reality of Community Care (HMSO, £9.60), that 85,000 claimants, 80,000 of them elderly, are now costing £500 million a year. An undersecretary at the DHSS has called this sum, which seems to result from an obscure change in the rules, 'a small leak in the system'.

The money has fuelled an extraordinary growth in the number of private residential homes. To enter one with all or most of the cost paid by the DHSS, you do not have to prove that you are unable to manage at home, merely that you are poor. Indeed, it is far harder to draw the various allowances which might help you to stay at home. To do that, you have to prove a degree of disability. The upshot is that many old people enter homes who do not need to do so. Even someone like Tony Pittaccio, national secretary of one of the recently formed trade associations, the British Fed- eration of Care-Home Proprietors, agrees that '25 per cent of people in residential care homes today could be cared for in their own homes'.

A visit to Strafford Villa, a home for 21 people in Leytonstone, east London, con- firmed this view. The proprietor, Don Russell, a former social worker who set up the home four years ago, thought very few of his people had not needed residential care initially, but that five or six could now quite well live in flats, with staff from the home going in to provided services as needed. They would then, however, sacri- fice their entitlement to Supplementary Benefit. Since they have generally surren- dered, at the end of a trial month at Strafford Villa, the place where they used to live, they no longer have any way of leaving.

It is this which helps to make even a well-conducted residential institution so depressing. As Mr Russell says, 'We take people into residential care with the inten- tion that we should care for them until death.' They are places where people wait, and wait at the expense of a centrally funded budget which is not cash-limited. Local councils are able to 'make', or at least save, large sums of money by en- couraging people to move from private dwellings where locally funded services have to be provided for them, to institu- tions run by commercial proprietors, even though it generally costs less to look after someone, so long as they are fit enough, 'in the community' (as the jargon has it: there is a problem of terminology, as 'private home' has two meanings). A local author- ity can also transfer the institutions it funds itself to private management, so that eligi- ble residents can claim Supplementary Benefit to help meet the fees. The Audit Commission's report, cited above, contains a masterly exposition of 'perverse incen- tives' of this sort. Kent Social Services have just advertised for a full-time person to advise on such manoeuvres. The tendency is now to put more and more people into institutions, despite the fact that for many years the government has been trying to reduce institutional care: peak occupancy of beds was in 1954.

I'd like to empty this place,' Dr Gerard Bulger, a GP in the East End, told me as we entered a local authority-funded home. The debate about residential care of the old very often degenerates into nothing more than an argument between the sup- porters of private and public institutions, but both contain people who should not be there. In a typical home, the inmates sit comatose in a day-room, on a line of chairs running round the walls. In front of the inmates, like a row of tombstones, there is a line of walking frames. In a corner of the day-room there is a large colour television set. During one of my visits, the screen happened to be filled with actors in an American soap-opera. Their healthiness looked as grotesque as the inmates' inertia.

Dr Bulger explained that he had to make far more visits to patients brought into the local authority home than to patients en- joying the same level of fitness but living outside. People had more falls in residen- tial homes. They also tended to lose the ability to walk, because staff wanting, say, to serve lunch, lacked the time to let patients move themselves, so lifted them, or put them in wheelchairs. in newly admitted patients, a rapid descent into institutionalised dependence could be seen.

'What of old Mrs Green?' I wondered. Many of the services to care for her 'in the community' exist, but still her son and daughter-in-law bear an almost intolerable burden. In 1985, the Audit Commission had to add a caveat to its finding that many in local authority homes do not need to be there: 'In three authorities studied in detail about half of the residents in the author- ities' homes could have been supported in the community had the necessary resources been available' (my italics).

One reason why there may not always be enough money is that when the NHS shuts a mental or geriatric hospital, the money saved is hardly ever transferred to a local authority, to spend on care in the commun- ity. Indeed, it appears that quite often no savings at all are made. Since 1976-7, the number of in-patient days in mental hospit- als has fallen by a fifth, but costs have risen, in real terms, by 7.5 per cent. Meanwhile, local authorities which spend more on community care lose rate support grant: it would cost Lambeth or Croydon

ratepayers two million pounds if either were to spend one million pounds more on community care. How much more temp- ting it is to throw people into homes and let the pHSS pay, even if the cost to the public purse is far higher.

Another reason for shortage of money is that, as we are reminded ad nauseam, the population is aging. Over the next ten years, the number of people aged 85 and over will increase by an estimated 37 per cent.

But moaning about shortage of money tends' to be a convenient way of avoiding any reform which impinges upon some existing empire, whether belonging to a consultant, a bureaucrat, a public-sector trade union or a private proprietor. Where community care fails, it is often because the dozens of different organisations which provide it fail to work together. Nobody is in charge. Individual supplicants, like the Greens, find themselves dealing with too many different people. The placing of patients comes to be extraordinarily arbit- rary, often depending more on the force of personality of a social worker or GP, or on some unforeseen consequence of the DHSS regulations, than upon need. As in other parts of the Welfare State, it is the failure accurately to establish need which underlies other failures. Some receive far too much and others far too little.

Dr Bulger proposes a simplification. Hospitals should only look after people who are Hi(!); admitting patients at once, but also discharging them as quickly as possible. 'Residential' care — the institu- tions — should mostly be disbanded, but should in any case be run by the same people as look after someone in his own residence. At remaining institutions a 'rotating door' policy would operate: there would be no life sentences.

A model for the latter part of this scheme is the hospice movement. Visiting nurses help cancer patients to stay at home, but the hospice exists when all else fails. Readers disgusted by the assumption which may be thought to underlie this article, that the state should do everything, may be cheered by the thought of the work which is done by volunteers. And of course people should be encouraged (pious phrase) to make their own arrangements, independent of the state. The trouble is, as an elderly gentleman said who helped me with this article and has for many years taken an interest in the subject, it is 'virtually impossible to make a satisfactory plan'. Existing health insurance schemes do not provide for the cost of long-term nursing. Only about three per cent of people over the age of 65 live in any sort of communal establishment, though the fig- ure rises to about 19 per cent for those over the age of 85. Unless one wishes pre- maturely to commit oneself to in institution promising the terminal care which may never be needed — and most sheltered housing schemes, for example, certainly do not offer nursing, but ask sick residents to leave — then apart from arranging to be either very rich or very poor, and in either case on good terms with a reliable doctor, there is not much to be done. A demand for sheltered housing with nursing facilities attached is just beginning to be recognised by developers, but anyone who has had to look for such accommodation knows that it remains very hard to find.

It's very popular locally. The people feel comfortable there,' a relative of an inmate told me. He was referring to Blythburgh geriatric hospital in Suffolk. For all the bracing talk of community care, the knowledge that there is a good local hospital is consoling. Blythburgh used to be a workhouse. The administrator, Maurice Gilbert, told me that it was still `virtually a slum' when he first knew it, in 1949. It had been opened in 1746 as 'a house of industry' for 1,000 residents, men, women and children. He showed me a board headed 'Tasks of Work for Casuals', drawn up under the Public Assistance (Casual Poor) Order, 1931, as amended by the Public Assistance (Casual Poor) Amendment Order 1939: The task for each day of detention shall be:

MALES Eight hours' work in gardening or digging or pumping, or sawing or chopping or bundling wood, or carrying coal, or washing or scrub- bing or cleaning.

Each morning, the taskmaster would line up the men and allot them their tasks. The women also had tasks. By 1949, this was no longer so. The taskmaster had become the porter, and had laid aside his truncheon, dated 1836. Nor were the 'bread and water' cells, though standing, still in use to punish malefactors. The last long-stay patient went in 1970, having been there since 1910.

As Mr Gilbert showed me round the spotless wards, enthusiastically describing how much better everything had become, I did not quite agree with all he said, but it did occur to me that if I wrote an article describing only the failings of our Welfare State, it would be, at the very least, incomplete. From most reports, one forms the impression that everything has got worse and everyone is demoralised. This is not true. Nor is it true that every institution which does not fit some systematic vision of how to run a health service is bad. Institutions like Blythburgh are becoming less fashionable, as grammar schools once did, but whether to change them should depend on their inherent virtues, not just their compatibility with some new, perhaps transient orthodoxy. Yet the sight of those ever-so-sanitary day-rooms impels the thought that there must be a better place to live and die. It recalls the very old ortho- doxy that there is no place like home, one's own home.

I have just heard that Mrs Green has died, in hospital, as a result of a fall suffered while staying at the county council-run old people's institution.