Time and again care workers protest they are “thrown under a bus” in this crisis. What an irony that bus drivers are victims too, as Monday’s official statistics show the low paid are at more risk of death than better-off work-at-homes. Care workers will not be surprised at their “significantly raised rates of death”: they are far more likely to die of coronavirus than NHS doctors and nurses, who die no more frequently than the general population, partly due to better protection.
Boris Johnson praised “the incredible bravery and hard work of our NHS and care workers” in Sunday’s address; last week he admitted to an “epidemic going on in care homes, which is something I bitterly regret”. Care workers will expect that regret expressed in hard cash once the crisis ebbs. To save the NHS, 15,000 patients were tipped out of hospitals on 17 March into “the community”, mainly care homes, with no testing, or, in some cases, having already tested positive. Care homes and community care workers were left defenceless. As one NHS leader told me: “If they’re lucky, homes will have one nurse who had a course in infection control 30 years ago.”
The government knew about, but chose not to be “alert” to, deaths in Spanish care homes. In later inquests and inquiries, families’ anger at lonely care home deaths will not evaporate, with a strong suspicion that many died gasping for breath without enough morphine or tranquilisers. Some complain about GPs staying well away – though others tell of GPs heroically taking on neglected care home patients. Within just the first month of lockdown, an additional 11,000 care homes deaths were reported, according to a Financial Times survey.
Will the care home body bags – of staff as well as patients – finally prompt the political crash trolley to resuscitate social care? The promised green paper has been kicked into the Westminster long grass. Hope rose when the health secretary, Matt Hancock, appeared with a Care badge at one press conference, but it was never seen again.
The call for “parity of esteem” between NHS and social care rings out louder than ever in this crisis, with NHS promises never again to call care workers “unskilled”. Having worked in a care home, I can testify to good care workers’ remarkable qualities. Yet a fully trained nurse in a care home is paid massively less than an NHS nurse: no wonder they are hard to hire. A plan from Andy Burnham, the mayor of Greater Manchester, for a National Care Service would blend the two careers together under the same NHS Agenda for Change training and pay. But equalising them into a single force with people moving seamlessly each way needs money – and a change in professional attitudes.
Local integrated care systems can happen, where councils are treated as equal partners. It happens in places – such as Salford or Oldham – where both services are commissioned together, wards interchangeable with care beds. But the obstacle, as ever, is austerity forcing both sides to tussle over puny funding. Besides, for as long as most care homes and services are profit-making, bonding them with the NHS will always be a viper’s nest of contradictions. Add to that the brutal truth that caring for those with dementia in their last years always lacks the status and glamour of heroic life-saving in university hospitals.
Optimists look at the great leap forward in this crisis as the two sectors are thrown together as never before, breaking through professional iron curtains showing them to be utterly interdependent. But that was oiled by “whatever it takes” cash. Those 15,000 put into the community and care homes arrived as NHS-paid patients. Ian Hudspeth, an Oxfordshire council leader and LGA lead on community wellbeing, points to the £4,000 they cost in an acute bed, £1,200 in a care bed or £400 cared for in their own homes: if they always arrived with an NHS endowment, those “bed-blockers” would be easily discharged. As it is, he says councils are £10bn out of pocket in this crisis, only compensated with £3.2bn by government.
Here’s yet another wicked care issue: families didn’t protest when those thousands were transferred to care homes as they were still registered as NHS patients, not needing to not pay care home fees. But families might have kicked up a fuss if the usual means-testing had landed them with a steep bill.
All the wicked issues in care come back to money – and until that’s resolved there’s no easy path for this “integration”. Unlike the NHS, care was never free: with so much wealth accumulated in old people’s property, few think younger generations with less property should pay via their taxes. But whatever system of payment – Burnham suggested a lump sum paid on retirement – care absolutely must be free at the point of use by the time old people need help, or the two systems will never meld.
Here’s that other wickedness, the Tory privatisation of care: in 1979, 64% of care homes were NHS or council owned, most others charitable, but by 2012, 94% were private or for-profit. Many are now teetering on the edge, costs rising as they are forced to isolate patients better – and each death means lost income. Ros Altmann, a former Tory pensions minister, castigates the big care firms “bought up by hedge-funders at knockdown prices, loaded with debt, tripling their money”. They know homes can’t be allowed to collapse. “But,” she rightly says, “don’t bail them out, take them over.” That would ease a host of problems.
No wonder Hancock doesn’t wear his Care badge. He wouldn’t be able to account for this ramshackle array of 11,000 mostly private homes. Soon the NHS really will be overwhelmed by its gargantuan waiting lists. Can the public be kept clapping for broken social care when the NHS will again dominate the headlines?