Care and society.
Care is a wonderfully rich word that denotes health, emotion, quality, and thoroughness each one of which contributes to clinical outcomes. Care is the focus of two recent reports about people aged more than 65 years: Families caring for an aging America (National Academies of Science, Engineering, and Medicine, Sept 13) and Social care for older people (King's Fund and Nuffi eld Trust, Sept 15) Together, these reports address diff erent aspects of the worldwide challenge to provide dignifi ed, compassionate, quality care to older people in an era when population ageing outstrips economic growth. The need for elderly care aff ects all societies. In the USA, more than 17*7 million people provide care for a person aged 65 years or older who has limited physical, mental, or cognitive function. In the blurred boundaries between individual, family, and societal responsibilities, carers are the unrecognised heroes who improve quality of life for those they attend, relieve strain on social services, and reduce the likelihood and duration of acute hospital admissions. In doing so, carers may incur considerable personal costs. An American woman in her 20s can expect to spend 6*1 years (10% of her remaining life caring for an older person, with tasks that might range from housework to legal surrogacy to end oflife care. In the process, she risks deteriorating physical and mental health, isolation, and fi nancial loss from diminished earning opportunities plus an estimated US$5000 out of pocket expenditure annually. Families caring for an aging America gives several recommendations for the next US administration to address, which contain identifi cation, support (including payments) data collection, and research. There are also lessons for employers regarding fl exible family leave. Health professionals should note that only a third of carers surveyed reported being asked their opinion about a patient's needs and many were inappropriately excluded from discussions about care because of misinterpreted patient privacy laws. While the USA moves towards greater support for older people in need of care, the UK is in retreat. 6 years of budget cuts mean that the expenditure on social care for older people has fallen by 9% and the number of people receiving care is down by 26% from 2009 to 2014. More than 1 million peopled aged 65 years or older are estimated to have unmet social care needs. The dedication of 6 million unpaid carers disguises the fact that a system long on the verge of breaking, is now broken. The outlook is bleak, with continued austerity, increased ageing, fragmented community care, and post Brexit uncertainty over the future of 266 000 foreign born careworkers, 28% of whom are from the EU. Deteriorating social services have a direct eff ect on the NHS and are associated with increased hospital admission rates and delayed discharges (the latter estimated to cost PS820 million per year) An obvious solution to a shared problem, recommended by the 2014 Barker Commission on the Future of health and social care in England, is integration of health and social budgets. An attempt to do this via the Better Care Fund had limited success, because more generous budgets and attitudes were needed. In Japan, where 30% of the population is aged 60 years or more, mandatory public long term health insurance was introduced in 2000, fi nanced by a 1% tax. The goal was to increase the independence of older people and relieve the burden on carers. By 2030, Chile, China, Iran, and Thailand will also have 30% of the population older than 60 years and each will need workable solutions that refl ect the fi nances and values of society. In China, a pilot scheme of community outreach to support carers is already underway in Xiamen. Four issues require immediate attention. First, end the marginalisation of carers and provide greater recognition and support, with particular attention to reduce the disproportionate burden on women. Second, improve access to information about services to support older people and their carers. Third, generate evidence from objective carer specifi c outcomes in clinical studies, including studies of interventions directed at those they care for. Fourth, recognise that the artifi cial partition of social care from health care in the UK threatens the quality and sustainability of both. They are interdependent collective responsibilities that should be fi nanced jointly through taxation, and accessed on the basis of need. The degree to which a society cares about older citizens refl ects its mores. In rethinking the centrality of carers, an opportunity exists to embed care more broadly within social attitudes. The Lancet N at io na l A ca de m ie s o f S cie nc es E ng in ee rin g, a nd M ed ici ne
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