TACKLE INCOME INEQUALITY AND POVERTY TO REDUCE PRESSURE ON THE NHS????????? ?

? Chris J Perry MA CSW???????????????????? ???????????????????????????

?The crisis in Health and Social Care deepens despite repeated attempts to resolve it. The most recent of which was the Health and Social Care Act 2021 which was intended to:

i)?????????????? sort out the under-funding of social care;

ii)????????????? remove the need for people to sell their houses to pay for their care;

iii)??????????? promote joined-up service delivery;

iv)??????????? replace the competitive model with a collaborative one.

Sadly, it was a quick fix component level response to a whole systems problem which would simply “kick the problem on for a few more years”. There seemed little point putting more and more money into the first aid camp at the bottom of the cliff without building a fence at the top. Radical reform, cultural change and re-structuring was required based on a whole systems approach. And unless Government did something about the widening income inequality and increasing poverty the additional money would simply not keep pace with increasing demand.

Since then, of course, the cost-of-living crisis has deepened. And clearly the Act has not sorted out the under-funding of social care.

The proposed cap on the amount which can be spent on care home fees would favour the rich in that people who did not have sufficient savings would still have to sell their house to pay for their care. And the Act did not address the anomaly whereby someone with cancer gets free terminal care whereas for someone with Alzheimer’s Disease or dementia their care is means tested. Looking after someone with Alzheimer’s Disease or dementia is extremely stressful due to interrupted sleep, fear of wandering or leaving a gas tap on, not being recognised by someone one loves, the guilt at letting them go into a care home.

The reward to lose up to ￡86,000 of their inheritance.

The “Integrated Care Systems” and “Integrated Care Partnerships” introduced by the Act are very costly, bureaucratic and cumbersome and appear more concerned with:

i)?????????????? preserving the current configuration of local government and NHS Trusts, and;

ii)????????????? protecting the purchaser / provider split and commissioning, to promote the mixed economy of care;

than the provision of integrated care. The mind set has not changed.

Change must be led by research into cause and effect.

Successive Governments have tried to get health, social services, police, education and housing to work together, from joint funding in the 1970s to the pooling of budgets. They have had the tools to tell them things are not working but have lacked the tools to put them right leading to repeated re-organisation. And none has grasped the nettle of different geographical areas, different funding streams and different lines of accountability, which have been the main impediments.

There is just as much empirical evidence in respect of organisation, management and leadership as there is medicine, social policy and social work and yet this is rarely applied in practice. For many years, until the late 1980s, Brunel University received Department of Health funding to apply “organisational analysis” to health and social care including “the stratification of work and organisational design”. The Tom Peters Group has studied cultural change, customer care, motivation and leadership. And applying his unique whole systems methodology to a hospital in Holland, Christian Schumacher (the son of the author of “Small Is Beautiful” and author of “God in Work”) was able to achieve a 30% increase in output with higher morale and lower sickness levels.

Social Service and Health Service Managers are extremely lucky in that the majority of their staff are working in their chosen vocation, it is what they want to do. It should therefore be possible to arrive at a situation whereby they can say, as many sports people do, aren’t I lucky I am doing what I want to do and being paid for it. Why then is morale reportedly so low?

It often appears that staff are doing excellent work despite the system, instead of the system helping and supporting them in their work.

People in Health and Social Care are working in some very stressful situations but which can be very rewarding if they see the outcome of their work and the improvement they have brought about in people’s lives. Unfortunately, many hospitals are still organised on the discredited production line model with, for example, some nurses just taking blood, not knowing why, the results or outcome for the patient. The use of Agency Staff also distracts from the continuity of care. Agency Staff are very expensive, with money going on travel, board and agency fees. It should not be beyond the wit of managers and trades unions to manage without them until there is no work and they have to apply for permanent positions and the savings shared in higher salaries for permanent staff.

The changes of the last thirty years have added to the cost and fragmentation of services.

Prior to the creation of NHS Trusts and the demise of Area Health Authorities my counterpart in health managed nine hospitals, five of which were regional, community services and the Family Practitioners Committee (GPs) all with a management team smaller than is now found in every NHS Trust. Prior to the 1995 local government re-organisation health and social services in Wales had common geographical boundaries, with several joint All Wales Strategies, although housing was a District Council responsibility and Health and Social Services did not have common funding streams or lines of accountability.

Wales went from 8 County Councils and 37 District Councils to 22 Unitary Authorities at colossal expense when had they made the County Councils the Unitary Authorities there would have been immediate savings on the cost of democracy and year on year savings as District Departments were merged and some with County Departments. The coterminousity of boundary with health could also have been preserved.

Similar, re-organisation in England and the splitting of Childrens and Adult Social Services together with the re-location of other responsibilities has also added to the cost and fragmentation.

There are now 24 County Councils, 181 District Councils, 58 Unitary Authorities, 36 Metropolitan Boroughs and 32 London Boroughs in England and 22 County Councils in Wales, 223 NHS Trusts and 43 Police Authorities. All serving different geographical areas, with different funding streams and different lines of accountability.

These 619 organisations could be merged into around 120 Unitary Authorities – based on the 1974 County Council, or Police Authority, areas - returning the NHS and police to local democratic scrutiny within central government direction and, in many cases, taking out a tier of local government. This would remove the need for the “integrated care systems” and save millions on the cost of democracy, and management, whilst making services more democratically accountable.

?In 1974 there were 120 Social Service Authorities – now there are 172 – Children’s and Adult Services have been split into separate departments in England – increasing the number to 322 with many responsibilities removed and placed elsewhere.

Smaller geographical areas, less responsibility and less directly managed provision.

Prior to 1980 the majority of care homes were provided by Local Authorities under Part III of the 1948 National Assistance Act. Margaret Thatcher extended choice by enabling people to have their fees in private and voluntary care homes paid by the then Benefits Agency subject only to the availability of a place and a means test. This led to a rapid growth in privately run “care homes” and the cost escalated to billions which Sir Roy Griffiths termed the “perverse incentive” as the money was not available for home care and it was thought there were people in residential care who neither wanted nor needed to be. The money was transferred to Local Authority Social Service Departments, by the 1990 National Health Service and Community Care Act which had to carry out an “assessment of need” and “verification of wishes”. What had been an “open-ended entitlement” became a “cash limited allocation” with Social Service Departments charged with “managing the market”. The majority fixed their “contract price” below the cost of their in-house provision (so much for the level playing field) which hastened the demise of in-house provision and meant that private and voluntary homes struggled financially and had to subsidise local authority placements from the fees of private residents. Currently 10% are in financial difficulty and under threat of closure.

The 1990 Act included the funding for Nursing Homes, which had previously been a Health Authority responsibility, so that for the first time they became means tested although the nursing element was subsequently disregarded.

The money transferred from the Benefits Agency was also available for home care. Prior to 1990 there were very few private domiciliary care agencies and those there were, were very expensive. Domiciliary Care Agencies grew like topsy and the imposition of the purchaser / provider split brought the prices down and with prices the wages.

This transfer from public to private sector provision has continued under its own momentum, un checked, ever since so that there is very little public sector residential or domiciliary care for older people left. And even Children’s Homes and Fostering Agencies are increasingly in the independent sector and no longer directly managed,

There are probably very few people still working in health and social care who remember when most provision was directly managed and Local Authorities bought into specialist independent provision if it would better meet the needs of their client and grant aided the voluntary sector.

Even the nature of social work itself has changed.

In the late 1960s and early 1970s social work was regarded as a valuable resource in its own right and social workers seen as “agents of change”. Since then, social workers have been increasingly regarded as “gate keepers” assessing the eligibility for practical help and rationing of services.

The Seebohm Report which led to the establishment of Social Service Departments in 1971 recognised the value of social work and saw social workers as the key resource. There was a wide debate at the time as to whether they should be called “social service departments” or “social work departments” as they were in Scotland. However, The Seebohm Report did not create the “one door to knock on”, it promised, as a multi-disciplinary / inter-agency response is often required in differing combinations depending upon the desired outcome. This was subsequently recognised with the establishment of Area Child Protection Committees and Child Protection Procedures (post Maria Caldwell), Mental Health procedures, the creation of “Community Mental Handicap Teams” (now Learning Disability), and Youth Justice Teams etc.

Between the implementation of the 1970 Social Services Act and the 1974 Local Government Re-organisation, Social Service Departments flourished and benefitted from considerable growth.

The undoing of much of the public sector was down to the philosophy of the Thatcher years and more particularly, in respect of Health and Social Services, to Sir Roy Griffiths and his mistaken belief that people were motivated by and could be controlled by money. This led to the introduction of the contract culture and internal market with the purchaser / provider split which Sir Roy thought would create a level playing field to facilitate a mixed economy of care thereby forcing quality up and prices down. It has subsequently been proven to have had the opposite effect and led to over-prescription taking away the ability of carers to react in situ to changing need. It also led to greater fragmentation with different components of a “package of care” bought from different providers.

Unlike Freddie Seebolm, Sir Roy Griffiths appeared to have little understanding of the nature of social work. A consequence of which was that Social Workers were deployed on the “purchasing side”, assessing the need for specific services (often responding to “presenting problems” rather than the “underlying problem”) which led to several social services departments providing “minding” rather than “mending” services with an ever-increasing workload of dependent people.??

Brought up in the days of Florence Hollis, who described social work as a “psycho-social process”, I have always considered social work to be about the use of relationship, and various therapeutic techniques, to bring about change. Social Workers need to begin where the client is (I personally dislike the term “user”) and convey empathy with their client’s perceived problem. Taking a social history, itself a form of catharsis, and identifying the underlying problems before providing help in:

·?????? decision taking and problem solving – asking open ended questions to get the client to list and consider the options. Trying to avoid jumping in to fill silence. Prompting, if necessary, by repeating the question and waiting;

·?????? dealing with ambivalence, denial or depression – asking open ended questions to weight options, give insight or trace previous turning points in the client’s life – again making a good use of silence;

·?????? coming to terms with reality – looking at what their client can do and how he / she can compensate for what they can no longer do.

·?????? removing the emotional blocks to recover – by lowering anxiety through a better understanding of the total picture.

·?????? lowering or increasing anxiety to improve functioning – this was “key” to my work as a social worker, manager and agent of change. Too high a level of anxiety or too low a level of anxiety will impede functioning. In the 1960s the NSPCC would usually increase the level of anxiety, through threat of consequence, believing it would improve functioning and the FSU (Family Service Units) take the opposite view and provide support to reduce the level of anxiety to increase functioning. Neither were able to measure where the level of anxiety was to start with. I would consider this at depth both when working with clients, supervising staff and managing organisations. Anxiety is an intrinsic part of culture and one needs to optimise the anxiety level, not too high and not too low, of an organisation for it to work both effectively and efficiently.

·?????? Improving motivation; open ended questions to consider what the client does well, agreeing achievable targets and giving praise when they are achieved – without appearing patronising.

·?????? understanding and bringing about change in behaviour; open ended questions about their past during social history taking. open ended questions about their behaviour, what they hope to achieve by it, how they think other people might see them, and why other people react as they do. Further open-ended questions as to how they want other people to react and how they might do things differently to achieve this. Giving insight.

·?????? budgeting and negotiation with creditors; asking the client (or clients) to write down and prioritise their expenditure against income. Look at ways of increasing income or reducing expenditure and prioritisation. Negotiating re-payment by instalment with creditors. As a social worker I always found that people were far more willing to pay instalments via me than direct to a rent collector for example.

·?????? improving inter-personal relationships; discussion with each party as to how they see the relationship, how they feel about the other, and what they would like the relationship to be. If they wish to continue. Seeing both parties together to help them repeat the positives of what they had said individually. Open ended questions as to what they each (themselves – not the other) might do differently to improve matters. Follow up interviews as required.

·?????? Involving friends and relatives in physical care – gaining acceptance of the need for help, asking who might be able to help, permission to approach them and discuss difficulties, see response and what they might do, test this is genuine and not just as a result of the visit, do they really have the time etc. Agree who is to do what and when with all concerned.

·?????? changing external factors in the environment etc etc. This can involve a whole range of things from “care proceedings” in respect of children, to the provision of aids, adaptations or rehousing. To negotiating with creditors, employers, the police or local authority. Or helping to find work or sheltered placement.

·?????? arranging practical help and support – both voluntary and paid

Underpinning this work is a thorough knowledge of “human growth and behaviour”, the importance of the first five years and Freudian Theory of the ID (animal instincts) Super Ego (developed conscience) and the Ego (arbitrator), the conscious, sub-conscious and unconscious, and the maturation process. Social Workers also have a grounding in psychology and sociology and an understanding of prejudice. Social Workers also make use of “transference”, “transactional analysis” and use such techniques as “a systems approach to family therapy” etc etc

These are the “generic” (not to be confused with “generalist”) skills of social workers. They then need the specialist knowledge of their areas of work whether it be working with people with specific disabilities or illnesses, mental illness, older people, youth justice, domestic abuse and marital counselling, parenting skills and child protection, fostering and adoption, registration and inspection, homelessness or work with adult offenders. And a detailed knowledge of the legislative framework in which they work, the law and resources available on which they can draw.

It is then important that social workers are engaged on the work which interests and motivates them as social work is a vocation.?People may be attracted to a job by the salary but once in post the motivation is job satisfaction and recognition of a job well done.

In recent times it has concerned me that in child protection the emphasis appears to have been increasingly on “safeguarding” rather than understanding and bringing about lasting change. Doctors can indicate whether or not they consider an injury to be non-accidental, the police can bring a prosecution or temporarily remove the perpetrator, but it is for the social worker to determine what caused the incident, the likelihood of it recurring, and if it might what might be done to ensure that it doesn’t. All too often case conferences are held to decide whether a child should be returned home when none of those present are able to say what they have done to bring about change in the situation, to warrant even consideration of a return home, and the discussion solely around the additional safeguarding measures required to reduce risk.

Despite the success during the 1970s and 1980s of policies of diversion and alternatives to custardy, which saw crime rates falling, residential care and custardy is still being used for young people who offend. We know the solution lies in minimising adverse peer group influence and fully occupying the young person throughout their waking day on activities which interest and motivate them. And that such establishments reinforce offending and establish a pattern of offending for life. Creating Criminals. Nor can parents be held accountable for the behaviour of young people during adolescence. They may be responsible, but if they have not got a good relationship with their child when he or she reaches adolescence, it is too late. They can’t go back and re-live the early years. Adolescence is a time of rapid change as the young person tests the boundaries of acceptability and tries to establish an identity independently of his/her parents. It is also a time of optimism and insecurity when peer group support is essential but which can also have an adverse effect on behaviour due to “egging on”. This is why it is so important to give young people responsibility, reward positive contributions and to invest in work with parents of the under-fives as a long term preventative measure. Housing estates and shopping precincts need to incorporate theories of defendable space.

Structural change in Society

In the 1940s, 50s and 60s it was unusual for both parents to work and school hours were from 8-45 to 4-15 pm during which children were not allowed off the premises. Children either left school at 14, 15 or 16 and went into apprenticeships, where they had one to one supervision from an adult, or went into sixth forms where the same school attendance rules applied and they were often given responsibility as prefects. Now it is the norm for both parents work, of necessity (if they can), and schools turn out at 3 pm or earlier. Older children go to six form colleges, where they are not given responsibility for the younger children as prefects or confined to the campus and sometimes only have to go in two or three days per week. It is a wonder there is not more anti-social behaviour and vandalism.

A multi-disciplinary / inter-agency approach

As stated earlier very rarely can social workers work in isolation and a multi-disciplinary approach is often required. Therefore, there is a need to remove functional divisions along patient / client pathways by the creation of multi-disciplinary, inter-agency, whole task, right-sized teams aligned behind outcome with access to all the resources required to achieve their goals. Communication is best within groups and worst between groups. Therefore, these teams need to operate out of a shared base at the focal point of the community of interest which they serve. This does not mean the dreaded open plan offices. (employers found during the pandemic that they got greater output from their employees who were home working free from the distraction and interruptions of open plan offices). These teams need to be able to “plan, do and evaluate” their own work which completes the “learning cycle” of “constant improvement” and enables them to gain the satisfaction derived from seeing the outcome of their interventions.

?Social Workers need to be given the time and resources to do the job for which they were trained. A room to themselves in which to carry out diagnostic thought, write their reports and letters, make telephone calls and receive their clients in order to make a differential use of office and home-based interviews is essential. The client should not be kept at arms-length in impersonal interview rooms but invited into the heart of the business into a room which reflects the personality of the social worker. When I was Director of Social Services in South Glamorgan these teams were based in resource centres (providing day care etc), family centres or integrated family centres and schools to bring professionals into day-to-day contact with those with whom they were working. There was a communal staff room where all involved might off load when returning from a stressful situation by just involving those there for similar reasons and not disrupting everyone else. This also acted as a catalyst to team building and the mutual understanding of each other’s role towards common shared goals. All too often professionals are inadvertently working against each other.

?There is so much which could be done to improve the effectiveness and efficiency of health and social care. A complete change of culture is required to liberate the dedicated, conscientious staff, who struggle to do a good job despite the system, rather than the organisation supporting them in their work – making it easier: not more difficult.

?This requires structural, leadership and cultural change.

?Since the 1990 National Health Service and Community Care Act the “contract culture” has led to:

i)?????????????? a “minding” rather than a “mending” service with social workers increasingly used to assess the eligibility to specific services, rather than using relationship, various therapeutic techniques and counselling to resolve problems;

ii)????????????? providers being left with little discretion to respond in situ to changing need;

iii)??????????? greater fragmentation with different components of a “package of care” bought from different providers, and;

iv)??????????? “self-funders” (a dreadful term) being waived away denying them an “independent verification of their wishes” and their families the help and support they need.

There is a wealth of empirical evidence on the “social determinates of health” which have demonstrated the correlation between income and demand upon the NHS.

The costings in this article are at a 2021 price base to correspond with the 2021 Health and Social Care Act receiving Royal Ascent and the money the Government of the day invested in it.

At just ￡7,430 (￡9,568 with pension credit) Britain has one of the lowest State Pensions in the western world. The national living wage is ￡18,278 and average earnings ￡30,212. The definition of poverty is less than 60% of median household income.?Many older people live alone.

Over the last decade the rich have got richer and the majority poorer – ref the BBC 2 two-part series “The decade the rich won”. As a result of this widening income inequality there are now 3.9 million children being brought up in poverty – 2/3rds of whom have a parent in work. These parents are no more able to increase their income than are older people who have no earning or borrowing power. According to a report by the Paris-based World Inequality Lab, 2020 saw the steepest increase in billionaires’ wealth on record, whilst the majority got poorer. Children brought up in poverty are less likely to do well at school, more likely to have health problems, making a demand upon the NHS, and have a shorter life expectancy.

According to Philip Alston, special rapporteur on extreme poverty to the UN, Government Ministers were in a "state of denial" about poverty. During a twelve day visit to the UK in 2019 he said that despite being in one of the world's richest countries he had encountered "misery". Quoting figures from the Joseph Rowntree Foundation, he said that more than 1.5 million people were destitute at some point in 2017, meaning they lived on less than ￡70 a week or went without essentials such as housing, food, clothing or heating. A fifth of the population, amounting to 14 million people, are living in poverty, Prof Alston said. And the situation is now much much worse.

In contrast the pay of Chief Executives at businesses on the?FTSE?100 index surged 11% on a median basis during 2017 while average earnings failed to keep pace with inflation. And this trend has continued. There was widespread concern during the 2009 banking crisis that whilst the majority suffered austerity those the public were led to believe had brought about the crisis prospered. For example. as a result of the crisis the share value of the banks fell, but after the Government bailed them out share values rose and half the money paid to RBS, for example, went straight out in bonuses which were related to share values.

Perhaps it is time to legislate to restrict the pay of the highest paid Director / Employee of a company (including the banks and utilities and Chief Executives and Chairmen) to an agreed multiple of the lowest paid and bonuses to an agreed percentage of profits (not related to share values or multiples of salaries) and shared pro-rata amongst all who contributed. They could still have their million-pound salaries provided they pay those on whose hard work they depend proportionately. Clearly, this would not apply to people who get royalties from record or book sales or patents or fill theatres etc but to all those who are appointed to jobs in pre-existing companies, and especially those who circulate around major companies creaming off millions.

There is a positive and significant relationship between directors' pay and employees' average wage in Japan.

Widening income inequality and increasing poverty are the great social evils of our time.

The salaries of the superrich often run into millions as do their bonuses. For example, it is thought that Bob Diamond, a former Chief Executive of Barclays, took ￡125m out of the bank for his own personal use during his five year tenure whilst making 30,000 people redundant before moving on to pastures new leaving counter staff over worked and customers queuing for service.

The “unacceptable face of capitalism” was evidenced again during the 2022 energy crisis. Gas was in short supply due to the war in Ukraine, but instead of the multi-national companies distributing pro-rata to previous demand they sold to the highest bidder adversely effecting the poorer countries and people on lower incomes in the richer ones whilst making excessive profits themselves.

The introduction of another tier in-order to take profit out of the system when the utilities were privatised under the Thatcher administration made matters even worse in the UK. These energy companies are purely billing companies: they do not produce any gas or lay or repair any pipes. And yet their Chief Executives are paid as follows: EON ￡1m, RWE ￡3.6m, Orsted ￡1.7m, Centrica ￡4.5m, SSE ￡1.6m, Uniper ￡1.6m, Scottish Power ￡1.15m, Drax ￡2.7m, EDF (which made a loss) ￡1m. How can these salaries be justified? Before privatisation there would have been one public sector Chief Executive for Gas and one for Electricity. The Chief Executive of Birmingham City Council is paid ￡186,000 for arguably greater and certainly more complex responsibility. ?

It is difficult to believe that there are people worth so much more than people working in the public sector. It is often said that such high salaries are required to stop the talent going abroad. Could it be that the mind set of these individuals is wrong in focussing on profit above service? ?In which case let them go abroad there are many people here able to do just as good or better job for less money and do we really want a society motivated by greed? The performance of the Water Companies leaves a lot to be desired, for example.

And such high salaries may prove counter-productive in making the job that much harder and the organisation less, rather than more, productive.? How must a low paid employee of the National Grid feel turning out at 2 am in the early hours braving horizontal rain to climb a ladder to restore electricity knowing his Chief Executive is most likely warm and dry with his ￡6.5m salary in the bank. To quote Charles Handy from the “Age of Unreason” “The leader must remember that it is the work of others.?The vision remains a dream without the work of others”.?What must these high salaries and wage differentials do for motivation, output and morale. Interestingly, those who contribute most to society by discovering new medicines or inventing new technology are not in the main paid such high salaries. ?

Between them these “billing companies” made over ￡30billion in profit during 2022.

If one added the excess profits of the produces to those of the retailers and allowing for commercial consumption it would have gone a long way towards avoiding crippling price increases for the 28.2 million households in the UK. However, unlike much of Europe, the British Government chose to borrow money to help households, which will have to be paid back through income tax, rather than imposing a windfall tax – or better still taking the utility companies back into public ownership.

And given that most of the UKs electricity is generated in house it is hard to see why these prices also soared. There is absolutely no logic to linking gas and electricity prices.

According to several recent surveys public opinion would favour the utilities (retail), NHS, social services and education being not for profit or in public ownership.

So, what impact does this widening income inequality and increasing poverty have on the NHS and social care?

There were 1,047 excess winter deaths caused by living in cold damp homes in England in December 2022, this is up from 768 in December 2021. Figures for the whole of the winter period were not available at the time of writing. National Records of Scotland figures showed?24,427 deaths?registered in Scotland between December 2022 and March 2023: 11 per cent more than the previous winter and the highest since 1989-90

There are two million older people living in poverty in Britain - many of whom, prior to the abolition of the “default retirement age” in 2012, were forced into retirement and condemned to spending the rest of their lives in poverty. There was no other group of people who could be treated in this way. Just imagine if people were denied employment on grounds of race, gender, religion or disability. And yet, until 2012 it was perfectly legal to deny employment on grounds of age. Research has shown that redundancy has a more long-term debilitating effect than either bereavement or divorce – forced retirement was like redundancy only more so as there was no hope of re-employment.? There was little wonder that there was so much depression amongst older people. And if they retired before April 2016 they are not entitled to the new State Pension either. The Government, in its wisdom, has reduced the income of retired people further by stopping the free television license and recently suspending the “triple lock” for a year. The “triple lock”, whereby the State Pension increases each year by which ever is the greater of prices, earnings or 2.5%, was introduced in 2010 to reverse the 30 years of erosion since the earnings link was removed. Prices are about the cost of living: earnings are about the standard of living and quality of life. As the economy grows so too do the expectations and necessities of life. For example, very few people had a fridge in the 1950s: it would be very difficult to live without one today. Between 2000 and 2010, when the “triple lock” was introduced, earnings went up by 41.7%, pensions linked to RPI increased by 32.4% and CPI a mere 26.6%. Low interest rates, over the last decade, have meant that lifetime savings have not kept pace with inflation. Banks need to have a re-think in respect of the interest they pay to savers (and charge on mortgages) taking into account their high salaries, bonuses and profits.

It is therefore hardly surprising that 80% of the expenditure of the NHS is on older people. The Netherlands with the highest state pension in Europe spends 60% of its health budget on older people. Rising food and fuel prices, being essential items, will hit the poor disproportionately. And this has been compounded by the freezing of the personal income tax allowance and thresholds.

Occupational Pensions have also been eroded, due in part to Gordon Brown’s 1997 tax raid on pension funds, with “defined benefit” schemes being replaced by “defined contribution” ones” and many of the “defined benefit” schemes which have survived going from “final salary” to “average salary”. Over the last 50 years the index linking has gone from earnings to RPI to CPI – even for pensions in payment. Auto-enrolment into pension schemes has done more to reduce the demand for “pension credit” than it has to increase income due to the small contributions made. ?

An estimated 1.3million older people in the UK suffer from malnutrition costing the NHS ￡19.6billion per year. There are five main causes of malnutrition: lack of money; lack of motivation; incapacity; lack of support and social isolation. How can one of the richest Countries in the world allow its older citizens to virtually starve to death or die from hyperthermia during the winter?

So, what might the outcome have been had the Government used the ￡57.5b, it committed to health and social care, differently to pump prime radical reform based upon a “whole systems review” by:

a)??? bringing all services together on the 1974 County Council, or Police Authority, areas in-order to achieve shared geographical areas, common funding streams and common lines of accountability: returning health and police to local democratic scrutiny within central government direction and taking out a tier of local government, making collaboration easier and saving a minimum of ￡1b on the cost of democracy and senior management.

b)??? removing the purchaser / provider split and specialist commissioning, replacing it with a statutory, voluntary, private sector partnership.

c)??? Freeing up social workers to practice their skills in using relationship and various therapeutic techniques to resolve problems and reduce the demand for state funded long term care.

d)??? making other requisite organisational, leadership and cultural change to:

i)?????????????? liberate professionals and organisations working directly with people from the “straight jacket” of the “contract culture” enabling them to respond in situ to changing need, innovate and develop (the “contract culture” has meant that the private and voluntary sectors have been micro- managed – the voluntary sector was renowned for innovation and development which the statutory sector was only too pleased to grant aid);

ii)????????????? ?remove functional divisions along patient / client pathways by the creation of “whole task, right sized, multidisciplinary, inter-agency teams”, co-ordinated by the most senior employee from the lead agency in each team, with “key workers” at case level – these teams should be able to “plan, do and evaluate” their own work which completes the learning cycle of constant improvement;

iii)??????????? these teams to operate out of a “shared base” as communication is best within groups and worst between groups – this does not mean in “open-plan” offices as professionals need a room to themselves for diagnostic thought, report writing and in-order to make a differential use of home and office-based contact –? a shared staff room to enable catharsis after stressful contact and facilitate team building;

iv)??????????? move from a “constraining management culture” to an “enabling leadership culture” recognising that staff are working in their chosen vocation and the role of management is to train and enable, and;

v)???????????? agree a strategy with the Trades Unions to end the use of agency staff to save money and ensure greater continuity of care.

any savings from these changes be used to improve the quality and quantity of services and improve salaries.

e)??? work with Housing Associations and the Private Sector to develop extra-care sheltered housing with nomination rights and a base for the “multi-disciplinary teams” providing outreach on a “core and cluster” basis. It is possible to put just as much personal and nursing care into extra care housing as it is the more traditional residential homes, but the resident has their own home, front door, defended space and retains control over the essentials of daily living. The relationship between the resident and staff is also very different reducing the risk of abuse.

f)????? ensure that all older people have a “verification of wishes”, help in considering the alternatives before being admitted to a “care home” and their carers the support they need;

g)??? extend NI to all working people (as Government has ￡4.1b) with the State Pension only paid on retirement with phased arrangements – ie one day’s work – 4/5th pension (saving an additional ￡8.24b)

h)??? Raising the State Pension to 60% of average earnings to lift all older people out of poverty (3.8m older people live alone) or ￡18,127, which would still be lower than much of Europe and slightly less than the “living wage” (at a cost of ￡102b). This would absorb pension credit (￡4.9b - which only had a 63% take-up), housing benefit and council tax relief (￡20b), and the winter fuel allowance (￡248m). A minimum of 20% of this increased pension would be clawed back from people with other income through taxation (￡19b). Therefore, the NET cost would be ￡45,51b after the changes in NI and pension entitlement. Free prescriptions and bus passes (which encourage older people to get out and are effectively a subsidy on less profitable routes combating global warming) would continue.

i)????? Reconfiguring housing benefit. Currently someone on pension credit gets their rent paid whereas an owner occupier on pension credit doesn’t get anything towards repairs or maintenance. The wide variation in rents, from the medium rent of ￡495 per month in the North-East to ￡1,425 per month in London makes it impossible to totally absorb housing benefit in the increased pension. Therefore, it is necessary to retain a limited means tested housing benefit so that no individual has to pay more than ￡250 per month rent, or mortgage interest, (￡500 a couple) out of their new increased State Pension, at a cost of ￡5b.? ??

If this increased income, together with the other changes proposed, were to reduce malnutrition by 90% it would save ￡17.85billion. And given the correlation between income and demand upon the NHS there could be a further reduction in demand of between 10% and 15% as a result of lifting all older people out of poverty. This would save ￡34.85b on what would otherwise have been spent.

Given these changes and the higher State Pension there would no longer be a need to take capital into account when charging for care.

There are currently 416,000 older people in care homes, many of whom will be “self-funders”, and it is anticipated that the number might decrease by up to 20%, as a result of this radical reform based upon a “whole systems approach”, to 332,000. The average cost of a care home is ￡35,000 per year. (nursing care is already paid for) People would hand over their income up to the cost of the home, less their personal allowance of ￡24.90p per week, as now. With an increased pension of ￡18,127 the minimum residents could contribute would be ￡16,883 leaving a maximum of ￡18,117 for the local authority to find. (Currently people are deemed to have ￡1 per week income for every ￡250 of capital they have, including their house, between the disregard and full cost thresholds and this would no longer apply).?Some people with occupational or private pensions may, with this increased State Pension, be able to pay the full cost whilst still retaining their personal allowance. It has not been possible to find out exactly how many people have other income or how much it is. The only reliable figure we have is the 1.5m people claiming pension credit which, given the poor take up, is 63% of those who would require the full ￡18,127 – which is ￡8,559 per person less than now.? The best estimate (based on retirement income surveys) to totally disregard capital (including one’s house), given this increased pension, would be an additional ￡1.5b – at current pension levels the Government estimated its cap at ￡86,000 would cost ￡5.4b

The total cost of these proposals is ￡51.01b and the eventual savings ￡35.85b (plus that redeployed from organisation changes to increase output and effectiveness) giving a long-term cost of ￡15.16b. Therefore, had the Government chosen to use its ￡57.5b differently to pump prime radical reform based on a “whole-systems review” it would get ￡42.34b of its money back to increase provision and reduce the tax burden on working people with no need for the 1.25% precept on National Insurance (￡12b) or to raise the age of eligibility to the State Pension.

Chris Perry is a former Director of Social Services for South Glamorgan County Council, a former Non-Executive Director of the Winchester and Eastleigh Healthcare NHS Trust and a former Director of Age Concern Hampshire.