Options for care system changes will not be sweet

ANDREW MCKIE

‘THIS land is not the sweet home that it looks”, as that quintessentially English poet WH Auden put it in In Praise of Limestone, though he wrote the line in Italy.

Scholars argue about whether the poem is actually set there, or whether he was thinking of the Pennines, but I wasn’t thinking of it in geographical terms. Bits of it make old Wystan look prescient: neither the independence nor the EU referendum left us with “the historical calm of a site / Where something was settled once and for all”, even if some people would like to characterise the UK as “A backward / And dilapidated province, connected / To the big busy world by a tunnel”.

But I prefer to read this mysterious poem, which I don’t pretend to understand, as an allegory of the human body: indeed, later on he points out that “we have to look forward / To death as a fact”.

We’ve all had to confront a good deal more of that than anyone would want in recent months. Now that we may – though perhaps only temporarily – be emerging from the crisis, there is a natural tendency to look for where mistakes were made, and what we can learn.

In some quarters, there’s an unpleasant partisan touch to this: nationalists inclined to congratulate themselves about Scotland’s supposedly superior handling of the coronavirus, or unionists desperate to characterise the distinctions as SNP weaponisation of a health emergency for political advantage.

Not only do both positions – fortunately, taken only by a minority on either side – strike me as unfair and unhelpful, it also seems likely that any national or international comparisons will be meaningless until we know more about the disease (such as whether immunity is built up or how, precisely, it spreads), as well as the role of external, uncontrollable factors: population density, demographic make-up, proximity to transport hubs and all the rest of it.

But it’s not premature to start to look at some things where we can all agree that improvement is called for, not least in the event of a second wave of the disease returning in the winter. And one area where it’s clear that neither Scotland, nor the UK as a whole, has covered itself in glory is the care home sector.

A couple of months ago it was suggested that Scotland had done uniquely badly, with percentage figures twice as bad as England’s. That may have been misleading. The numbers no longer seem quite so conclusively different for the component nations of the UK, which vindicates Mike Russell’s position a couple of weeks ago, when he told a Commons committee that while we would need to learn where we’d gone wrong, we need more information before setting up inquiries or drawing conclusions.

Even though the numbers are terrible, they may not in fact end up worse than those for many other countries, considering the UK’S larger outbreak overall. They do, however, draw attention to the many problems that attend the care sector, and the urgency of addressing them. Unfortunately, it’s also clear that there are no obvious, and certainly no popular, solutions to those questions.

Like the pensions crisis, which no political party has yet had the courage to tackle (which is why the state pension is 40 per cent of all welfare spending, and public sector pension costs have nearly tripled in just over a decade), everyone has been aware of this for decades. We have an ageing population, a falling birthrate, and rising life expectancy and medical costs. You don’t need to be Euler to see the general direction of the arithmetic.

Yet while the Scottish Government has promised to investigate, and the Westminster Government a year ago undertook to fix “social care once and for all”, the fact is that the closest thing to a real proposal was suggested by Theresa May, which brought her headlines about “dementia tax”, the widespread desertion of her own supporters, and a thoroughgoing drubbing at the polls.

Whether you regard care homes as part of general social care, or as a subset of the health system, the money will have to come from the public, either in the form of direct personal contributions, or through general taxation, or by means of some form of private insurance market. And it won’t be cheap: the system is already chronically underfunded, in part because it is largely under the control of local authorities and so, unlike the NHS, did not receive the guarantees of protection that Westminster and Holyrood provided for hospitals.

But, as the shunting of patients out of hospitals into care homes (which certainly made matters worse) demonstrates, each sector is intimately dependent on the other. Without the care sector, the NHS would be swamped. But most care provision across the UK is set at severe or critical levels, and involve direct contributions – Scotland’s apparently more generous terms are only a couple of thousand pounds different on total assets from the other nations.

There is no particular reason why it should not be locally administered and not directly under central government (Holyrood or Westminster) control; it’s often forgotten that most of the NHS, except for hospitals, is administered this way. But care homes are not now particularly attractive for private investors, and the sector has as a result fallen in productivity and resources alike. That can’t continue.

The Tory solution, having abandoned calls for people to pay more directly, but with a cap, isn’t clear, though some favour encouraging a private insurance market, and others free central care, topped up by payment for the “hotel” aspects. Labour (and quite a few Tories and Nationalists) at one stage favoured a National Care Service.

All those suggestions will cost a lot more, either as a direct bill to the users or as an increase in general taxation, which would be particularly unfair on the younger part of the population who, burdened with student loans and unable to buy a house, would have to fork out more so that the boomer generation don’t have to cash in their extensive assets, which hardly seems equitable. Something must change, but none of the options for homes will be sweet.

It’s clear that there are no obvious, and certainly no popular, solutions