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Florence Mahon spent a decade running around after peers at the House of Lords. As head housekeeper, she was responsible for problems such as cleaning up messes or sorting out broken lamps, until ill-health forced her to retire in her 50s.
Her eyes gleam a little as she talks about which of their lordships she liked and which ones she didn’t. “I didn’t want to go,” she says. “I hate being retired.”
But arthritis wrecked her knees and she has health problems that mean even walking to her front door can be a struggle. Mahon found herself sitting alone in her flat almost permanently, unable to walk to the shops or meet friends. Making her bed was a two-hour epic.
Today she is making a journey that she couldn’t have done four years ago: a trip to her GP to pick up a prescription. The 67-year-old’s life has been transformed by daily carers who help with what is known as “personal care” – 45 minutes helping her take a shower, get dressed, have some breakfast, and see how she’s getting on.
It’s a reason to get dressed. A spark for her confidence. The care package and an electric wheelchair have “opened up my life completely”, she says, even if leaving her flat means dosing up on painkillers.
The care is not something she could afford on her parliamentary pension. If she lived anywhere else in England, Mahon would be working out if she could make her money stretch to pay someone to come perhaps once a week. As she puts it: “Do I have a carer or do I pay my rent?”
But she is lucky enough to live in a London borough where she doesn’t need to choose. Hammersmith and Fulham is the only English council where, as in Scotland, personal care is free to anyone who needs it.
Free home care was introduced here 10 years ago, and the borough’s leaders are convinced that it is popular, and helps the NHS.
The health service has been hit by social care’s “cannonball of inefficiency”, as Sir David Pearson, who led the government’s social care taskforce during the pandemic, described it to the Observer. Ambulances are queueing outside emergency departments because no beds are available on the wards – yet one in seven people in hospital were fit to leave last week but couldn’t as they needed care, either in their own home or a residential home.
Mahon’s health means she often needs overnight stays in hospital. “The longest stay I’ve done recently was 48 hours, but before it would have been weeks,” she says, as we reach the bus stop. “The fact I’ve got this care package means they know somebody’s here, so they’re more content to send me home.”
And Mahon believes the fact that she is more active, happier and less isolated makes her less likely to need healthcare in the first place.
There is data to back up Hammersmith and Fulham council’s belief. The number of people in residential care in the borough has fallen by about half in the past decade, from 789.4 residents per 100,000 people to 329.8 per 100,000 in 2023, below the London average of 453.7. The borough also has far more people receiving home care – 7.5 people per 1,000, well above the second placed London borough of Tower Hamlets with 5.7 and nearly double the London average.
What about the NHS? Older patients are vulnerable to yo-yoing in and out of hospital, and lying in a hospital bed can leave them more frail. The authorities measure this by examining how many people are still at home 91 days after discharge. In Hammersmith and Fulham, it is 95.7% – the fifth highest in England and well above the 85% average.
Could this be part of the solution to our social care crisis? On the 10th anniversary of the policy, the council has commissioned researchers at Aston University to examine whether there is a more direct impact on health outcomes. The results could form part of the picture for Baroness Casey, who has been asked by Wes Streeting, the health secretary, to lead an independent commission to examine how to reform adult social care.
Reforming care has been on the agenda for most of the past 75 years, but rarely sees much action. The old and infirm were swept away into workhouses or almshouses by the Poor Laws until the National Assistance Act came into force in 1948 alongside the National Health Service. But it set up a split between the NHS and social care that has persisted – the NHS was born free at the point of use; social care was separated and means tested.
Care for older people in 1950 looked very different to how it does now. Then, only 10% of the UK population was over 65 – 5.4 million people, most of whom lived near family and were unlikely to survive common diseases of old age, such as heart disease, strokes and cancer.
Now there are 13 million over-65s, or 19% of the population, and average life expectancy has reached 79 for men and 83 for women.
But living long does not necessarily mean living well. The UK’s healthspan-lifespan gap – the time someone can expect to live with disease, as Florence Mahon does – was estimated at 11.3 years last year, just behind the US with 12.4.
As a result, local authorities in England received more than 2 million requests for adult care support in 2022-23 and they spent £23.7bn helping 858,720 people last year.
“There are two big issues,” said Pearson, a former director of social services for Nottinghamshire county council and former president of Adass, the body representing social services directors. “The first is the state of the current means-tested system, which is characterised by 131,000 vacancies in the workforce, three times the average of other sectors in the UK, and waiting lists for care.” The latest figures from Adass show 430,000 people were waiting for an assessment or care in 2023.
“The second issue is who pays, and about 50% of people pay for their own care,” Pearson said. “The two issues get quite conflated, in my view. If inadequate amounts of money are just spread more thinly, that will not help the quality or quantity of care in this country.”
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Only people with less than £23,250 in savings are eligible for free care, a fact that comes as a shock to many who assume they or an ageing parent is entitled to help at home. Since a homecare package of an hour’s help a day can cost £10,000 a year, people choose cheaper options. At least 5 million people act as an unpaid carer, according to the latest census, though Carers UK believe the number could be twice that. Adult children, often women, drop out of work to look after a parent, or it’s left to an elderly partner to cope, leaving them at risk of injury.
At Mahon’s GP surgery today, Hammersmith and Fulham’s leader, Stephen Cowan, has come to meet her and discuss why the council introduced free personal care.
He says he was convinced by disability campaigners before the 2014 local elections. “They said ‘care is essentially a tax on your disability, because if you have to pay for care you’re not really enabled’. They educated me: if you’re not disabled you don’t know. And if we live long enough, we’re going to become disabled too. So when we won, we thought we could do it through efficiency savings. Now it’s a cornerstone of what this Labour administration stands for.”
Yet his homecare budget has doubled in the past 10 years, as has the number of people it helps – up to 3,016 from 1,384, at a cost of £31.5m compared with £13.9m in 2015. Is this why, after 10 years, no other council in England has introduced this policy? They may ask why they should pay to help the NHS when their budgets have been slashed.
Ben Coleman, formerly the council’s deputy leader who was elected as Chelsea and Fulham MP last year and sits on the health and social affairs select committee, says Conservative governments imposed heavy cuts on local authorities.
“Over £50m went out of Hammersmith and Fulham’s budget in real terms over the last 10 years. And obviously we have a growing elderly population as well. So it becomes more difficult to offer all services, let alone free home care. It’s a problem facing every country in the world, every developed country.”
The conundrum for Labour is the “who pays” question. Some people never need care. Others only need a little. People with dementia may need years of care costing hundreds of thousands of pounds.
The effect, as Sir Andrew Dilnot told MPs at the health and social care select committee this month, is “like standing in the middle of the road with a lorry driving towards you, and the best you can hope for is you die before the lorry hits you”.
There are a number of solutions, according to Simon Bottery of the King’s Fund, a health and social care charity. He said: “You can make the means test more generous, raise the threshold, bring more people into the system. You could have a lifetime cap on the amount people pay, as the Dilnot commission recommended. Or you can have a Scandinavian model – essentially an NHS-style, close-to-free care at point of need.
“And then there is a social insurance model, like Germany and Japan, where everybody gets access to publicly funded care, but they’ll often have to pay towards the full cost.
“England is an outlier because we sort people into two groups – people whose needs are high and assets are low enough. And everyone else is out of the system entirely.”
These questions and proposals are not new. They have been addressed by the Griffiths report in 1988, the Sutherland report in 1999, the Wanless review in 2002 and the Dilnot commission in 2011.
“I wish the Casey review well,” Pearson said, “it’s terribly important that we reach a realisation of all this. But we know what the options are – unless we say there is something more radical we want to do.
“We’ve been close to implementing the solutions before. The issue is a political one. Within governments, there’s always been a debate between people who want to do this and the Treasury. I understand that Casey wants to be answerable to the prime minister, which is a wise move because it would take a prime minister to say ‘we’re going to do this’. At the end of the day, I think a government will have to act with determination and courage, and say what the benefits will be for the public, other than just the cost.”
