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The trouble is, of course, that most of today's pensioners did not sow nearly enough during their working lives to cover the costs of looking after them in their dotage. If only the NHS were a proper insurance-based service, as it was originally intended to be, then they would have a point. But it isn't - which is why we are in this mess.

There is, as we all know, a very much better way of looking after the elderly than simply shovelling money in the direction of strangers, in the hope that they will look after them.

I am thinking of the most effective social security system ever devised by man or nature. It is a system that still operates in most primitive societies, but one which is on the verge of collapse in modern Britain.

I mean, of course, the family.

In almost every way, I would much rather live here than in a mud-hut village in Africa.

But I reckon that the very old in the Third World, looked after by their families in communities bustling with life, have a much better time of it than a great many British OAPs, sitting around in care homes stinking of urine, watching afternoon television and counting the days or weeks until that rare visit from their young.

There is more on this in The Welfare State We're In in the chapter on pensions. The section starts on page 299 with Octavia Hill's comments on pensions to a Royal Commission the late 19th century.

There are several ways of dealing with that minority of the elderly who need prolonged special care in old age:

- care at home or in an institution, paid for out of savings, insurance, mortgaging the home (and getting an annuity) or (if going into a care home) selling the home.

- care by the family or paid for by the family.

- care at home or an institution paid for by other taxpayers.

The apparent attraction of the last one is undermined by several factors:

- people come to rely on it but then find that, like most services theoretically provided by the state, it is rationed and not always available to those that need it. (This results in elderly incapable people living dreadful, lonely lives at home. They sometimes effectively starve themselves. It is quite possible for them to break a bone and then be unable to get help, causing them to die in dreadful circumstances.)

- children come to think that their parents are the state's problem, not their own. Their way of thinking about the issue - and thus their behaviour - changes.

- people come to think it is not worth saving and amassing capital because it could all go on the cost of a care home and, if they have no capital, the state will pay for the care anyway. So why bother saving?

- some people are likely to cheat or else legally take measures to avoid paying for their own care. They will hide their assets or give them away so that their children get their money while the state pays for their care. Or, to be more accurate, other people will pay for the care of their parents.

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Mr Wanless previously wrote a report for Gordon Brown which helped the Chancellor justify a massive increase in spending on the NHS. But Mr Brown has also greatly increased means-testing - precisely what Mr Wanless is now implicitly criticising.

I was telephoned by Radio 2 this morning and asked my views on means-testing. I said I was against it because it discouraged work and saving. Pity, said the researcher. We have already got Niall Dixon of the King's Fund to oppose means-testing. We are looking for someone who is in favour of it. I don't envy her searching for such a person. Mr Brown is the greatest proponent of the idea (having been very much against it prior to being in government). Unfortunately Mr Brown will not be making himself available for debate on the issue.

One of the difficulties of the Wanless plan, from what I have seen of it so far, is that it involves co-payments between individuals and government. Having experienced for myself the bureaucratic nightmare of trying to get state help for the care of an elderly person, I fear that organising such co-payments would be the mother of all bureaucratic hells.

One alternative would be for people to take out insurance with one of a wide range of private companies, mutual societies, trade unions and so on. In an ideal world this would be voluntary. Given the realities of British democracy, it would probably have to be compulsory for any politician to get it through.

BBC News story on the subject here.

The King's Fund report and supporting material here.

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One of the more telling clips in the film was a fresh-faced Tony Blair boldly declaring in 1997 that he did not want a Britain in which old people needing care had to sell their homes. Well, that is precisely what, after nine years of his rule, we have got. It was all blather and lies. It was aspirational and wholly misleading. The programme could have made a lot more of that if it had wanted to. It could have repeated that clip after every case of a disabled person whose home had been sold. It would, quite justifiably, have highlighted the chasm between what Mr Blair has said and what has actually happened. It would emphasise the failure of his administration in connection with the elderly.

I feel that the distinction between medical and social care is anyway absurd. If someone cannot look after himself or herself and needs a lot of help, that is the overriding fact. If you were buying an insurance policy against that eventuality of needing care, you would not choose a policy that only paid out if someone arbitrarily decided that your problems were primarily 'medical' not 'social'.

It was refreshing, incidentally, to have a serious BBC programme pointing out a gross deficiency in the welfare state and in the NHS as run by this government. It made a very welcome change from the regular failure of the BBC flagship Today programme to do anything of the sort.

Here are some of the cases highlighted by Panorama. The reporter was Vivian White who did an excellent job.

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It seemed to me that there was a series of related, possible drawbacks:

1. The more money that is given by the government to the hospices, the more the government will want to dictate how the money is spent, the nature of the care, the nature (and cost) of the training and how teh care is delivered. The more money given, the more the independence of the hospices could be undermined.

2. In consequence the morale of those within the hospice movement could be undermined. We have already seen how the morale of doctors and nurses in the NHS has been damaged. It would be a pity for the same to happen to those working in the hospice movement.

3. At present, those working in the hospice movement are universally admired and respected. They receive esteem which, I think it is fair to say, is greater than that received by those working in the NHS. They receive it partly because their work requires great qualities of character - patience, outstanding bravery and sensitivity for example. But they also receive admiration because people somehow understand that those working in hospices are working largely as an act of philanthropy. They are not just doing a job. These are charity workers with a powerful philanthropic drive.
The more the state may come to fund and dominate hospices, the more this huge respect could be endangered.

4. The more the government comes to dominate, the worse the service is likely to become. At present I suspect it is terrific. But if the government were in the driving seat, the same might happen to the quality of care as has happened to the quality of medical and social care in the NHS.

5. The more money given by the government, the less that charitable donors are likely to be willing to give. People like to feel, when they are giving money, that they are filling a vitally important human need. They don't like to feel they are just helping the government with its finances. The more the government is involved, the more people will feel the hospices are just part of government spending.

6. At first, the amount of care provided by hospices would probably be sustained or even improved by the deployment of government money. But we have already seen in other areas of the NHS that provision is at first increased only to be decreased later. This has happened in the provision of GP services, for example. Care for the elderly in their own home and provided by government falls well short of what is needed after much was promised. The number of care home places has actually fallen at a time when the number of elderly has increased. The same kind of thing could happen to the hospice movement.

A member of the audience who works professionally in this area of 'palliative care' said that the discussion about financing was about to become obsolete because the government was in the process of deciding, through its agency NICE, that hospice care is something that the NHS should finance. So it would become entirely a matter of government finance. I don't know how much truth there may be to what he suggested. It seemed to be news to the Tory spokesman on the subject.

In any case, I fear that the hospice movement - as an independent, excellent, admired charitable movement - may be under threat.

For the time being, however, I suspect it remains mostly funded by charitable donations and the hospices are, I expect, among the most worthwhile of charities to support.

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The comments in (1) still apply ; the application of tickboxes is variable to say the least. They write what they want.

(3) The standards have to be measured. This forces towards things which are quantifiable. Quality of Care, Happiness of Patients etc is not quantifiable. Forms and Records are. So they require more and more forms and records, which makes less time available for the job of actually caring. Inspection is usually about 70-80% looking at records and forms, and has been done without viewing any practice at all. This is like OFSTED inspecting a school without ever seeing a classroom or child.

(4) They can say and do what they like. The complaints route is all to them and their above levels, and they will ignore the ombudsman, basically. There is a tribunal, but the burden of proof is on the complainant, not on CSCI. A variation on OFSTED is you always get the same inspector, so if you make a complaint the same person will come back effectively wanting revenge. So no-one complains, though I know no-one who thinks any of them are competent.

(5) Like any quango, the main aim is to increase its reach, budget, areas of control. Much effort goes into this. There is a laughable punch up going on where I live between SSD & CSCI, which involves them refusing to invite each other to meetings etc. (for the benefit of the children, doubtless). This is because both want the power and money that comes with "child protection"

(6) Because they don't have to pay for anything, the requirements extend endlessly as a back covering exercise. It is always in their interest to demand more staff, more targets, more forms, more systems. This increases costs, which most users cannot afford and SSDs will not pay. So care home owners sell up and quit, or they focus purely on meeting the targets. You get the impression that as long as the forms are okay they don't care about what is actually happening.

The worst cost increase is staffing. They are demanding minimum levels of staff training, which is fine, except someone has to pay for it at some time. Care Homes are run to some extent on cheap employees to do mundane jobs. Having everyone at NVQ3 (another rule ignored for public care homes and schools) racks up employment costs spectacularly, let alone training costs. At the same time, they want more staff (except for Local Authority provision).

(7) As a carry-on from (1), LAs are dodging the targets by redefining care homes as "rented accommodation with 24-hour support". This way most of the regulations don't apply. So they dodge them (something Private orgs aren't allowed to do), even though the practice is identical. To be fair, there's nothing actually wrong with the homes, they just don't tick the boxes.

(8) It repeatedly reorganises at great expense. Originally it was done by SSD. Then they all went to work for NCSC (late 2002). Two weeks after NCSC started, they were told they would be converted to CSCI and CHAI (early 2004). Now they are going to be OFSTED and CHAI. Imagine the money wasted !

The glossary:

IME : In my experience

LEA : Local Education Authority ; run public sector schools, pretty
badly. It's worse than you can possibly imagine.

SSD : Local Authority Social Services Departments ; roughly
divided into "Children & Families" and "Adult" divisions, though they
are trying to combine this back and add control over education. Yet
another bureaucratic turf war. Also responsible for Child Protection,
but are squabbling with CSCI over this at the moment. Both sides want
the clout.

DfES : Department for Education and Science. *Also* squabbling for power with NCSC/CSCI/CHAI, over who has control of Residential Mainstream and Special Schooling.

NCSC : National Care Standards Commission, monitoring Residential
Accommodation, Hospitals, Fostering, OAP Care, Residential Schools,
Sheltered Housing and all sorts of other similar stuff. Typical Blairism Monitoring and Targets organisation. Basically a "OFSTED for Care Provision".

Later (announced 2 weeks after opening !) split into :-
CHAI : Commission for Healthcare Improvement
CSCI : Commission for Social Care Improvement

Which does the same thing. Not quite sure where the split is. I think
CHAI does Hospitals, CSCI does the rest but wouldn't swear to it. I
*think* that CSCI are going to be subsumed into OFSTED, this is one of
Gordo's red tape reductions. I'd bet my life savings the same people
will be doing the same jobs .... it's a joke.

Incidentally, as far as I can tell despite all these switches the same
people (literally) do the same jobs in the same way, they just change
the name and bring out masses of new initiatives and reprint all the
stationery.

OFSTED : Office for Standards in Education. Quango for schools
monitoring. Infamous.

NVQ : National Vocational Qualification.

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I looked at several other homes during her initial 12 weeks. I was appalled: many were dirty, smelt awful and the patients were left to sit and stare into space. We have more compassion for animals in this country than our elderly. If I could have had her living with me, then that is what I would have done rather than subject her to this.

My dad is also in a nursing home; at just 56 he had diagnosed a degenerative brain disease. Thankfully his experience has been better and the home is wonderful. The catch is that he is 35 miles away in Milton Keynes, as that was the nearest place that could care for him.

Debbie Stokes,
Watford

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