3 – What aims should we have for social care for older people?

Even before the impact of Covid, the long-term trend of increasing life expectancy had begun to falter. Covid will put this into reverse for a while and who knows what being a poorer country will do in the medium term? But even if over the next decade the numbers of very old people do not substantially increase, we need to much better understand the necessary role that social care for older people will achieve in our society.

I have already rehearsed the argument that nationalised industries do not have the sensitivity either to meet local and individual needs or enable the provision of necessary personalised care.

The big contradiction for social care is that the main outcome we want from this service is for it to maintain and develop the independence of the older people it serves. Yet doing so increases the likelihood that it will create greater dependence rather than independence. Social work and social care have grappled with this issue for decades – how do we offer help whilst ensuring that service users maintain and develop independence?

If you talk to nearly all older people (including me) that is what they want. They want to maintain and develop their independence and they would like everything around them to work with them to achieve that aim. That goal exists both for currently independent older people and for those with a wide range of care needs. We all want to take as many decisions about our own lives as we can, and we want to continue to make those decisions for as long as we can. And when we do need some help we want that to be a part of our independence and not to create dependence. And when we need a lot of help we want that to be a part of our independence as well. This is not easy, but it is what older people want.

For our society to help this happen goes way beyond the responsibility of social care.

Some of this is nearly all to do with the way in which we organise our housing. Housing is a universal need. But kitchens, bathrooms and most aspects of accommodation are designed for younger people. Climbing onto chairs or steps to get food from kitchen cabinets, getting out of baths, have the potential to cause catastrophic incidents which gravely threaten independence.

Moving into a house in your 60s will usually mean that for the next 3 decades you are likely to have to have large scale adaptations to meet the different needs of aging on at least two occasions. Making these adaptations can be so difficult that they are frequently put off until a fall forces a move.

But if they became normal we could develop industries that, because they were doing it all the time, could do so much more cheaply and easily than at the moment. This is not only a matter for social housing but also for owner occupiers.

Housing is an important factor in creating independence – but so is the NHS. The majority of people in their 60s have some kind of long-term condition. If the NHS was dedicated to increasing the capacity of older people to self-manage those conditions, it would help maintain independence for much longer. Later in life people may need assistance in managing a wide variety of co-morbidities. Better self-management of your long-term condition means increasing independence. Exacerbations and extended stays in emergency beds often have catastrophic consequences that detract from that independence.

Readily adaptable housing and personalised, coordinated NHS health care would both lay the foundations for better and longer independence.

Most care of older people is carried out by relatives and friends. The extended family may now be extended over 100s of miles but for most it still provides much of their care. And the nature of this interaction of care through relatives, friends and community allows it to be constantly renegotiated more easily than any formal contract. To say “Thanks so much for coming to see me twice a week and bringing my shopping, but for the next few weeks could you just come the once.”  is easier and normal within personal relationships.

Our society just would not operate without those interactions of negotiation and generational reciprocity. Most care is delivered by informal carers and we need to enhance and support that care better than we do. As a society we need to enhance those relationships as much as we can.

And for many, for most of their lives, this network of adaptable housing, person-centred NHS care and friends and relatives will work. There will be sufficient care to maintain their lives and their independence.

But for others this will not be enough. Many will need help at home, and some will need to move into residential care. One of the problems for the current set of services is that sometimes this movement between informal and professional care takes place through large transitions. And large transitions compromise independence.

Organisation of the delivery of professional care – whether at home or residential – needs to link much more organically with the experience of informal care.

What do I mean by this? Most people who receive domiciliary care also receive informal care. Most people in residential care (up until the Covid crisis) also receive care from relatives and other visitors. ALL of this is care – professional and informal. And all of it is essential to the person receiving it. The smaller the transition between the different forms of care the better for the service user.

At present we make too strong a distinction between professional care and informal care. Of course, there has to be strong regulation of professional care which will be different from any oversight of informal care – but we tend to overemphasise professional care as being a separate care experience. What we need to do is emphasise the continuity and relationship between these two different types of care.

For example, in the next few years there will be considerable technological advances in health monitoring. The ability to apply remote medical tests whilst in their own or a residential home, will be vitally important for older people. It will transform their health and health care. We will need this to becpome a part of the role of carers and their capacity to look after service users. The transformation will be that care resulting from these advances will have a much more positive impact if both professional and informal carers can play a role in using them.

We need to develop organisational models of professional social care that better relate to informal care.

In next week’s blog John Copps from Mutuo will work through how the mutual organisational form could play a role in delivering professional social care in such a way as to develop these stronger organic links between informal and professional care.

2 Replies to “3 – What aims should we have for social care for older people?”

  1. The debate is being had in sanitized terms … the debate is more complex than much of these “linear aging” discussions about people wanting to remain independent suggests. Real life when our health and faculties fail is different from the rational world of independent aging we envisage while we are well.

    Many older people come to be in residential care because they have an underlying health condition and it has become so serious that not only can they no longer look after themselves but it is no longer reasonable or possible for their family or even other professional carers to look after them in their own homes , albeit that most of their care might is what the legislation terms “social care”. What real tangible information is there about how and why older people come to be in residential care? Too often it is towards the end of life, all other options are closed or closing and it follows a hospital admission (not necessarily a fall) or other serious medical intervention.

    The silent element of the debate is about having informed conversations with individuals about how they would like to die at a stage when they are still capable of having that decision – before things reach the stage of GPs prescribing medication that prolongs the quantity of life, but not the quality and when comorbidities affect mental faculties. This is the real crisis in social care.

    1. You are quite right Liz. We do need to spend time and effort in talking to people and listening to them about their death and how they want to die, but we also need to spend time and effort in talking and listening to them about how they want to live.

      At the moment we base our actions on assumptions are made about both living and dying and they are often wrong.

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