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TX: 21.01.08 - Social Care Around the World

PRESENTER: PETER WHITE

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WHITE
Now if there's one thing to have emerged so far from our season on care in the UK it's that almost everyone is agreed that the current system isn't working. So given that much of the developed world has the same problem of a rising population of elderly people is anyone else dealing with it any better than we are? Today we're casting our gaze a little further afield and examining the care of elderly and disabled people around the world.

Professor Julian Forder of the University of Kent has been looking at the social care systems in a number of countries, in particular as part of his contribution to the Wanless Report on Social Care commissioned by the King's Fund and we'll be hearing from him in just a moment.

First though, Jane O'Brien reports on the way things work or perhaps don't in the United States where she spoke to Suzanne Hamburger who cares for her husband. And if you think the criteria to get help are tough here this may surprise you.

HAMBURGER
I have promised him he would never have to go to a nursing home and he reminds me of that promise sometimes. It's scary thinking about it because it will be very expensive. You know we'll just have to keep cutting back and reducing our lifestyle. Parkinson's patients their vocal cords become very weak and sometimes they become almost unhearable and they mumble a lot. In his exercise class the teacher gives him some exercises to do make their voice stronger. Can you do your A, E, I, O, U? Do it real loud, remember like you do it in class.

MR HAMBURGER
A. E. I. O. U.

HAMBURGER
I'm going to keep him at home by using up his retirement income. When his is gone I'll start using mine. The government provides no help at all, except income tax deductions for medical expenses, that's the only thing. Until you get bone poor and then they will give you Medicaid but you have to have almost nothing left. And that leaves the woman in really bad shape when the patient dies because then they don't have anything.

O'BRIEN
How long do you think you have before you've used up all your assets?

HAMBURGER
If I have to go to 24/7 care to keep him at home - oh I can't even add it up in my head - that could be substantial, that could be like four years and we'd been done.

O'BRIEN
Susan is one of an estimated 38 million people looking after a chronically ill or ageing relative. According to Suzanne Mintz, president of the National Caregivers Association, such people provide almost all long term care services in America.

MINTZ
It has been estimated that the market value, a conservative market value, for family care givers services is over $300 billion a year.

O'BRIEN
Do these people get any government support at all, how bad does it have to get before the safety net, if there is one, kicks in?

MINTZ
There really is no safety net in America, we're supposed to pull ourselves up by our boot straps. And depending upon where you live there are more or less services because those services are state based or county based but there is no true safety net at all.

ACTUALITY - CHURCH CHOIR

O'BRIEN
Singing with the church choir offers Suzanne Giegel [phon.] a brief break from the stress of looking after her husband her suffered a catastrophic stroke more than a year ago. The medical bills have put her into enormous debt and the financial burden is now so overwhelming that lawyers have advised her to make an appalling decision.

GIEGEL
I really may have to confront the issue of divorcing him. Pretty much everyone in our family believes that this would be a devastating blow to him because his dementia is not so severe that he wouldn't know what was happening, I mean he would know what was happening. But his dementia is severe enough that he wouldn't understand the logic or the financial reasons why, he would simply be hurt at a time when he's so vulnerable already. And I feel pretty vulnerable, I feel very alone much of the time. And I suspect I have more support than some people.

O'BRIEN
Separating their finances through divorce is the only way Suzanne can protect her own financial future and qualify her husband for Medicaid, which would pay for his long term care. But even that could take time.

GIEGEL
I've re-financed my house and taken out every penny of equity in it. I'm going to start selling. I don't want to sale my home. I think - even for Medicaid eligibility if we stay married I would be allowed to keep my home and one car. But I couldn't have - I mean the amount of assets I would be allowed to keep is minuscule. And this is all consistent with the idea that Medicaid is intended for people who are destitute, which I'm not and I don't want to be, I don't want to get to the point where I'm bankrupt to pay for his care.

ACTUALITY
How are you Dorothy?

Yeah I'm here.

You're here? Like both of us, huh.

I'm just happy to be out here.

Yeah, you're looking good today, are you feeling better?

I do but ...

O'BRIEN
Ninety-one-year-old Alda Bart [phon.] chats with fellow residents at the national Lutheran home in Maryland. In the absence of any government support charities and churches are pretty much the only option for people like her who can't afford to grow old.

BART
Well my husband was sick for 42 years, he wasn't able to work for over 20 years before he died and we used up everything we had saved of course. I am Lutheran, I was brought up Lutheran all my life, so I knew about the home and also knew they had what they call a trusteeship where I could come into the home by turning over my assets to them. The first year he died I came out and put in my application and they said fine they would see to it, there would be no problem for me to come in, let us know when you're ready and we'll bring you in. So I've now been here 15 years and I'm very happy.

O'BRIEN
Where would you be if you couldn't be here?

BART
I don't know I guess I'd have to be getting help with my rent, like I was before, even while my husband was still alive we had to ask for help, we had to swallow our pride and ask for charity. I don't have any of those worries now, for which I'm very grateful.

O'BRIEN
In the meantime millions of Americans are facing a bleak future. The number of 85-year-olds is expected to double in the next decade. But without affordable long term care the attraction of living longer seems increasingly limited.

WHITE
Jane O'Brien ending her report from the States which made for some pretty stark listening. Professor Julian Forder was listening too. Julian, are things really there as tough as some people seem to be suggesting?

FORDER
I think to some extent yes. It's certainly the case that people really have to impoverish themselves before the public system kicks in and provides that safety net. On the other hand it is true that for people that have no money at all there is a safety net and it does work to protect those and spending levels through the public sector are quite high, higher than you might expect.

WHITE
Well yes I saw that, that they're actually comparable with ours. So what happens to the money - does that mean that people when they do get it get more - more expensive care or is healthcare more expensive in the States, where does that money go?

FORDER
Well the comparisons involve a number of assumptions but essentially in the States it's something like 1.3% of GDP and in England about 1.5%, so we're a little ahead. But as you say because the safety net kicks in only for very low income people it's explained perhaps by the fact that most of the Medicaid programme that was commented on just before funds nursing care, full time nursing care and not so much care in the community.

WHITE
And that's a more common option in the States isn't it?

FORDER
It is, absolutely, although the balance is changing - they're doing much more community based care now.

WHITE
Well are we moving the other way - I mean we've been talking a lot about means testing on this programme, are we moving to that kind of system because at the moment that equivalent amount of money in this country, when your help kicks in, is around twenty one and a half thousand, not three thousand quid?

FORDER
Yes, I mean I think that's right, although I'd say the underlying philosophy of the systems are pretty much the same - they're safety net systems, they're means tested, public support only kicks in when people's assets and income fall below certain thresholds. It's just that our thresholds in England are quite a lot higher than they are in the States.

WHITE
So if we had another system, I mean at the moment philosophically, you're saying, our system is the same even if the amounts are different?

FORDER
That's right, it's means tested, it's not universal.

WHITE
With the presidential race well underway how up the agenda is the issue of social care and is there any appetite for change?

FORDER
I don't think it is actually that high up the agenda. I mean listening to some of the primaries coverage it hasn't been mentioned that much. The only exception really is Hilary Clinton has talked again about tax breaks for people who have moderate levels of income, who are above those minimum thresholds for support, like the people in your piece.

WHITE
Julian, thanks for the time being. Well at the other end of the spectrum is Denmark, the Scandinavian model of cradle to grave provision or so we tend to assume. But could that be about to change as well? Journalist Lena Venakild [phon.] has been reflecting on how their system is likely to work for her.

VENAKILD
Denmark is often held up around the world as an example of best practice when it comes to social welfare. Here we spread the butter thinly across anyone who needs social care - from cradle to grave. I'm on maternity leave and until my latest offspring turns one in September I get a generous cheque from the state every month. My daughter's school is free and is of a high standard. My cousin, who has learning difficulties, has her own apartment. She gets care and support but also has independence and the chance to go to work. And my grandmother, who's 90 and still living at home, gets help to get dressed and washed twice a day for free. I'm not sure how this compares to England but I do know our [indistinct word] get a pretty good deal.

Of course the price has been higher taxes, I pay nearly half of my wages to the government. In return I expect to get the help I need for free when I'm old. But this might change. Our model is being challenged for many reasons. The last post-war generations are exiting the labour force just as the economic burden of care for the elderly and the ill is growing. So we have less young to do the work and pay the tax. In November last year our liberal conservative government was re-elected with a small margin. The key issue was tax, tax versus welfare. The government is keen to negotiate the welfare reform - more money will definitely be allocated to care. But those in power are also suggesting that we might have to get used to less in the future. This might be hard to accept in a country where we've almost spoiled with welfare. So I wonder when I'm old and need that care myself whether Denmark will still be as good an example to the rest of the world.

WHITE
That was Lena Venakild.

So Julian Forder will we still be looking to Denmark as the sort of bastion of best practice in years to come?

FORDER
Well I mean it certainly is at the moment, as was mentioned it's a universal system - people pay practically no charges for their care. But I think, like all systems perhaps, it faces some challenges - there's rising demand that you see from an ageing population, people want more choice particularly the baby boomer generation, there is problems with recruiting enough people with workforce issues. So I think it will remain a very much one system that we look up to because of that universality, the broad coverage, the high quality - something like 25% of older people in Denmark get some form of help, which is way above us. But they spend a lot more as well - it's about half as much again as we spend.

WHITE
So choice - lack of choice is the one chink in the armour as it were, is that choice between kind of community care and residential care or just who you get to give you the care?

FORDER
Yeah, they've done a fair bit of work recently to improve choice, they give you choice of providers, so you can actually choose a private provider rather than the state provider. And they're also experimenting in some local authorities with cash payments which we have ...

WHITE
As we are, yes right.

Meanwhile in Germany they've had the same debate that we've been having here, they just started it a bit earlier and have got a bit further with it. Just over 10 years ago they thought they'd found the answer. We asked our Berlin correspondent, Tristana Moore, what had changed and how things are now.

MOORE
Ursula is washing her husband in their small bathroom in East Berlin. Valdemar is 83-years-old, he has a pacemaker and he's recently contracted Parkinson's. Luckily his wife is fit enough to look after him.

URSULA
His heart is better now but not his legs, he can't stand up properly so he has to stay in his wheelchair. I try and walk a bit with him so he doesn't get stiff. I have to be there for him day and night. He takes water tablets but they make him go all the time. I always have to be around to wash him, dress him, to do the cooking. He's like a king, he's served from behind, from in front, from all sides.

MOORE
Valdemar gets £500 each month in benefits. Back in 1995 a long term care insurance system was introduced, made up of equal contributions from the employer and employee. Medical experts categorised claimants as either needing residential care or community care. Valdemar is deemed to need the highest level of care. He's opted to get this benefit in cash as part of an allowance which recognises that his wife is looking after him. They also use the money to pay their daughter, a nurse, who often looks after Valdemar. On top of this another nurse pops in everyday and a physiotherapist drops by twice a week.

URSULA
We are modest and the help we get from the state is enough. We always say we're well. If you complain you don't get healthier and when you say that you're okay then it doesn't hurt that much. We're fine. I'm glad we get the extra help.

MOORE
Over the years more people here in Germany have been claiming long term care. The higher take up inevitably puts pressure on the system. So today, more than a decade after the old system was brought in, a new law is going through the Bundestag which will overhaul Germany's long term care insurance. Contributions will increase from 1.7 to 1.95% of someone's salary. And the extra money will pay for more support for people who need care as well as their relatives. Helga Walter is from the German Association of Elderly People BAGSO.

WALTER
We hope that with this new law, along with the new long term care insurance system and council services, that people who need care can stay at home for as long as possible before they die. That means more help from the insurance system and from volunteers who can visit, read, go shopping or go for a walk with people in need of care.

MOORE
The new law is expected to come into force by the end of the summer. Many carers groups say changes are long overdue. But groups representing disabled people argue that a change in attitudes is also needed. Hildegarde Gramatsky [phon.] is from the BSK organisation for the disabled.

GRAMATSKY
How disabled people are approached and how you talk to a disabled person, it's a question of accepting this person. I'm especially annoyed about the provision of care in care homes or hospitals where disabled people are often left in a corner where they don't belong and decisions are made over their heads.

MOORE
Back in their flat Ursula is telling Valdemar that she's popping out to the shops for a while. Please answer the phone if it rings, she says, and write down who it is, I won't be long. Valdemar complains - I was always in charge of shopping in the past. Things have changed now darling, Ursula replies in a matter of fact way.

WHITE
Tristana Moore reporting from Berlin. Professor Julian Forder that sounds quite a lot like Gordon Brown's idea of some kind of progressive universalism isn't it, it's the idea of us all - us making a contribution and the government making a contribution?

FORDER
Yes that's right, the insurance system in Germany involves essentially an entitlement which covers perhaps on average 60% of the costs of care and then people top that up using their own resources or rely on social security to top up if they're poorer.

WHITE
Yeah I mean you've talked quite a lot I think to the Labour government about this, do you think this is the kind of option Mr Brown might be quite attracted by?

FORDER
I think it is, I think because it balances on the one hand this idea that you get a minimum entitlement for everyone that's universal and doesn't penalise people for having savings. But on the other hand does give some flexibility and some incentives to people to contribute themselves.

WHITE
Are there other countries we should be looking to - I mean what about Asian models for instance?

FORDER
Well in Japan, for example, they too have an insurance system which is similar to the German one except it's funded, at least partly, out of general taxation rather than insurance premiums.

WHITE
And which - I mean which option would you favour, you've studied this quite closely, if you were trying to pick an option which one would it be?

FORDER
Well you mentioned the Wanless review earlier on and the recommendation that we made was for a partnership model which involves this minimum guarantee to everybody plus a top up. And I think that one has the balance of merit overall.

WHITE
So when this green paper finally gets published that's where you would expect the options to come down, if Mr Brown's still in a position politically to put it into practice.

FORDER
Well a lot of people say if you had a blank sheet of paper and you're starting afresh the Denmark system would be one to aspire to. But given the fiscal realities, the money available at the moment, then perhaps a mixed system, a partnership model, is a way forward.

WHITE
And just finally, where do you intend to be old and frail?

FORDER
Well if I could I'd go to Denmark, I mean in the sense that you get much higher level of care but then you have to pay a lot higher taxes as well and I wouldn't have been contributing if I hadn't lived there.

WHITE
Okay, maybe you'd better stay here. Julian Forder, thanks very much indeed.

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