Introduction

The problem here addressed is that of an ageing population - how this can be cared for within a framework of distribution that is generally seen as just, and that may therefore be expected to remain stable in the long term.

The Changing Age Structure of the British Population

The scale of the problem - as it already exists, and as it may be expected to grow in future - can be seen in Table 1.

Older people have ceased to be an insignificant share of the population. Looking ahead into the next century, their numbers can be expected to increase still further. At the moment, there are about a million people over the age of 85. By 2040, there may be 2.5 million.2

The Pressure on Resources

The problem with all this is that, since few over the age of 65 remain in the working population, there has been and will be - other things being equal - a greater demand for public welfare provision. This pressure on resources is increased still further by the facts of mortality. Medical advances during the past few generations have largely eradicated the fast causes of death. Most people nowadays die slowly, from illnesses that cannot be cured but that need to be alleviated at high and rising costs. Even before they become terminally ill, older people frequently lose the ability to look after themselves, and so must be admitted to various kinds of long term residential care.

To give an example of the scale of increased pressure on resources, in 1992, there were 555,000 long stay care places in the United Kingdom. By the end of the century, according to current projections, a further 87,000 places will be required; and by 2050, a total of 1,300,000 places will be required.3 Despite a trend in the past generation towards the private supply of long term care, it is expected that significant numbers of these places must continue to be provided or paid for out of public funds.

The costs may be enormous. According to the Institute for Public Policy Research, the percentage of gross national product spent on long term care can be expected to rise from 1.8 per cent in 1995 to five per cent in 2031.[Note 4 Compare this with the six per cent of GNP now spent on the whole National Health Service. Assuming that the bill for long term care is to be paid mostly - as at present - by the taxpayers, we may be facing the prospect of an increasingly heavy tax burden on every new generation of workers. In 1990, there 3.4 people of working age to every pensioner. By 2031, the ratio may have changed to 2.7 to one.5 According to a still more alarming projection, by the year 2050, 75 per cent of the population will be looking for support to the remaining 25 per cent.6

The Need for Serious Thought

Of course, all this may be a pseudo-problem. The science of the 20th century has enabled increasing numbers of people to stay alive longer. The science of the 21st century may well be able to delay or even abolish the physical and mental declines now associated with ageing. It may be that most people now under the age of 40 will be able to remain active and productive into their 80s or even later. Perhaps we shall look back on the present worries with the same amused contempt as we now look back on past worries about mineral depletion and the drying up of investment opportunities.

But none of this is certain. The great advances now often predicted may happen, or they may not. If they do, they may not come in time to solve the problem described above. Therefore, it is necessary to consider what approach we should take to the problem as it currently appears to us. To ignore this duty, unpleasant as it may be, is to put our own futures at risk. It may be that, if we prefer not to think hard about the problems of an aged population, our children or grandchildren will be forced to solve it themselves with measures that range between the second best and the barbaric.

Brutal Suggestions Already Made

Indeed, these measures are already being proposed or even tried. Writing in 1987, Daniel Callahan argued for the cutting off of public health and long term care for people after a certain age. In his scheme, there is to be a deliberate refocussing of resources on younger generations. If the old have assets, and wish to sell these to finance their own continued existence, that is to be their business - that is, assuming the resultant inequality of life expectancy between classes will be tolerated by the majority. Though brutal, this approach would certainly limit public spending on health and long term care.7

Similar suggestions have been made independently. See, for example, F.J. Sharpless, writing to The Times in 1995:

Sir, The humbug and hypocrisy underlying Alan Smith's argument (letter, August 5) is obvious. To suggest that a person's National Health contributions should entitle one to unlimited nursing care and comfort costing insured workers and taxpayers 400 a week is patently absurd. I am an octogenarian and know full well such expectations are actuarily and morally indefensible. Furthermore, to imply that elderly people sitting on inflationary profits took out a mortgage or bought a house primarily to benefit heirs whilst relying on the Social Security Department to keep them in old age is an insult to them.8

Such schemes have nowhere yet been adopted. However, they are not entirely fanciful. Already within the NHS, a system of informal rationing has begun to emerge, with age as one of the criteria. In January 1995, for example, a survey showed that the old were suffering systematic discrimination. Researchers found that older victims were being denied life-saving drugs. Only two thirds of those over 74 were given clot-busting drugs on admission to hospital, compared with nine out of ten of those aged under 65. The drugs have been shown to reduce the death rate after a heart attack by a quarter if given within four hours after the onset of symptoms.[Note 9

Otherwise, there have been repeated allegations in recent years, which have been denied by Ministers, that the more expensive drugs are being withheld from older people, and that hospitals operate age bars for admission to specialist coronary-care units. A survey in 1991 found that one in five coronary-care units had an upper age limit for admission between 65 and 75 and two in five had an upper age limit for treatment with clot-busting drugs.10

At the moment, it is enough to reveal these facts for there to be popular demands for change. But what is to happen if the pressure on resources becomes insupportable? For a while perhaps, the large and growing bloc of older voters may be able to maintain the flow of resources to their own needs. But let the problem become great enough, and the stronger and more active may lose faith in the mechanisms of liberal democracy.

Ad Hoc Solutions

With regard to long term care, the Government currently has a policy of gradual withdrawal of public provision. As said, people have for some years been turning increasingly to provide for their own long term care should they ever need it. Otherwise, the private sector has been encouraged to provide long care services to local authorities. This is, however, only a partial solution to a problem that has not yet fully revealed itself. Already, local authorities are coming under severe pressure to pay for long term care; and in many cases the elderly are being forced to sell all their assets - their houses included - before being accepted as eligible for public assistance. Only those who have assets worth less than 16,000 qualify for public help in paying for their long term care.

The Government is preparing a White Paper for the latter part of 1996, which will address the general problem of long term care. This will probably suggest a scheme of topping up long term care insurance policies. It will seek to ensure that those who take out special insurance cover when young will be protected from losing their houses and other assets if ever their need for long term care when old should be greater than the sums insured.

There is, however, no evidence of serious thought behind these measures. In the first place, the Government seems to be acting because it wants to save money now, and because there are Ministers in the relevant departments whose particular strengths and weaknesses enable the current structure of retrenchments. Change the Government, or change just some of the Ministers, and the pressures on spending may change considerably. Otherwise, let those who are already old organise more effectively to lobby for their rights, and the pressure on spending will be transferred to some other area - defence, perhaps, or transport infrastructure - where the resistance to cuts may be less effective. For, at the moment, the emergency - assuming it will ever come - is still some while away. The careers of almost everyone now in politics will have ended long before action absolutely has to be taken.

In the second place, the proposals likely to emerge in the White Paper - whatever the pressure behind them - are already perceived as defective. Any topping up scheme will be administered by central government. At the same time, it is local authorities who do and will provide the long term care. Between these two, there may be room for endless ambiguity and personal disaster. At the moment, eligibility for care varies from one authority to another. It is easy to imagine future situations in which an elderly person is declared eligible for local authority care by a central government body, only to be refused by the local authority concerned. According to David Robinson of Scottish Provident,

Harmonisation is going to be very difficult to achieve, but it's something that a lot of effort must be put into. If the scheme is rushed in any way, then it will be subject to frequent change, the whole thing will be a mess and people won't have the confidence to provide for their care anyway.11

Surely, we cannot a solution to what may be a vast problem that is guided by little more than the desire of governments to cut their budget deficit, and the competitive lobbying skills of the relevant special interests. There must be some other way forward.

Towards a Stable Solution

All this being said, we come to the reason for this paper, which is to suggest a more principled approach. Since the emergency is still at least a generation before us, we have time to sit down and try to form a civilised consensus on how health and long term care for the old is to be provided.

We say "consensus" because this is not a problem that can be solved by the ordinary political process. It might be that a Conservative or Labour Government can arrive at a particular solution - only for this to be undone by the next government. Of course, we have had a period of one-party rule since 1979; and many Conservative measures - privatisation, or trade union reform, for example - though bitterly opposed at the time, have become in their basics part of the new consensus. But we cannot assume that these conditions will continue into the future. We cannot risk having this problem treated during the next 30 years as the problems of the steel industry were treated during the post-War era - nationalised, denationalised, renationalised, privatised.

Indeed, where these matters are concerned, it may be preferable to have a wrong but stable solution than to have one that is right but uncertain. At the moment, for example, large numbers of old people are living less comfortably than they once imagined would be the case. Those who entered the working population in the 1940s and 50s did so in an age of welfarism that promised to look after them from cradle to grave. Just as they did not have to provide for their own health care or the education of their children, they would not have to provide for their own retirement. Certainly, they would have to pay for it. But the coordination of resources would be managed by the State. Therefore, when the real value of old age pensions began to shrink after the mid-1970s, millions were caught who had not made any additional provision.

During the past decade, increasing numbers of people have realised that they must provide for themselves in old age - that the State may not be willing or able to keep its promises to look after them. Many others, however, have failed so far to take these precautions. They still believe that the financial crisis of the British State that began in the 1970s can be overcome, and that the value of pensions, as a proportion of average earnings, can be restored. Perhaps it can. Perhaps it cannot. Whichever it be, it would be useful for people to know with fair certainty what they can expect.

And as it is with pensions, so it is with all other provision for the old. Even the Callahan scheme, unpleasant as it is, has advantages over the current uncertainty. At least if people really knew for certain that they would receive no public care after a certain age, they would mostly set about providing for themselves - or, at the worst, considering in what degree of suffering they would choose euthanasia.

It is to achieve this certainty that consensus is needed. We need to secure as wide an agreement as possible on what is to be done. The three main parties must help in drawing up the solution, and must endorse whatever policies and institutional framework emerge from this. Equally, there must be agreement across the generations. It is no use to find ourselves with a set of institutions that are rejected as illegitimate by either of the constituencies involved, and are maintained in place only by some kind of strength - by the voting power of the aged, or the natural power of the young.

The Rawls Test

However, before the specifics can be discussed, we need a means of discussion that will allow all the parties to the discussion to set aside their immediate interests and to arrive at conclusions that can be given general approval, without regard to age or financial status. One way of doing this is to apply what is called the "Rawls Test".

First published in 1972, John Rawls' A Theory of Justice is generally regarded as one of the most important texts in moral philosophy of the past half century, and as one of the foundation works of modern social democracy. Its basic theme is how to derive rules of conduct for individuals and society as a whole that will be accepted as fair in the long term. For Rawls, the criterion of acceptance is justice:

Justice is the first virtue of social institutions, as truth is of systems of thought. A theory however elegant and economical must be rejected or revised if its is untrue; likewise laws and institutions no matter how efficient and well-arranged must be reformed or abolished if they are unjust.12

Without justice, a society is merely a collection of individuals brought together for their own protection and advancement. Wealth may be created in such a society; but there will be no universal agreement as to its distribution. This will be a matter of "political bargaining or... the calculus of social interests".13 Such a society cannot be called well-ordered in the long term. But

a society is well-ordered when it is not only designed to advance the good of its members but when it is also effectively regulated by a public conception of justice. That is, it is a society in which (1) everyone accepts and knows that the others accept the same principles of justice, and (2) the basic social institutions generally satisfy and are generally known to satisfy these principles. In this case while men may put forth excessive demands on each other, they nevertheless acknowledge a common point of view from which their claims may be adjudicated.14

It is plain that this last sentence is particularly important to our discussion of provision for the old. We may face just such a situation, where old and young alike put excessive demands on each other - the old for ever greater levels of provision, the young for the right to keep the whole of what they earn for themselves. If this conflict is to be resolved on any basis other than force, we need to stop arguing solely with regard to our own personal interests, There is obvious need here for this "common point of view from which their claims can be adjudicated".

Rawls seeks to provide this with his concept of "the Veil of Ignorance". Briefly explained, this is a thought experiment. We are asked to imagine that we were looking into a society that we were about to enter, but without knowledge of our position within it. We should also be ignorant of our intelligence, our strength, our tastes, our ages, and of all the other things that distinguish us as individuals and that give us individual interests separate from the common interest.

Thus there follows the very important consequence that the parties have no basis for bargaining in the usual sense. No one knows his situation in society nor his natural assets, and therefore no one is in a position to tailor principles to his advantage.15

In this "original state" of ignorance, we have only a comprehensive knowledge of the social sciences. That is, we know everything worth knowing about politics, economics, law, sociology, and so forth. With these limitations and advantages, we are then equipped to decide on a set of rules which will maximise our chances of doing well when we enter into society. Perhaps the most obvious rule will be some kind of equality. If there are to be inequalities and hardships, these will be accepted only because they are necessary for the common good. They will not be accepted because they are favourable to any specified individual or group - because we who must decide are prevented from knowing if we shall personally benefit or lose from any such arrangements.

Since Rawls argues his case very closely over several hundred pages, here is not the place for giving any kind of full description of what he does with his Veil of Ignorance, or of how he seems to make justice and equality synonymous. Indeed, his grand theory of justice has been effectively attacked from both left and right. However, it has many virtues in helping us to think about long term care. It establishes criteria of fairness that are formally distinct from any single set of interests.

At present, some of the main arguments and pressures on government come from people in their fifties who have elderly parents. These are the people who are complaining so about the rationing of health care and about the forced sale of assets to pay for long term care. To be sure, an argument need not at all be invalid simply because the person advancing it has an interest in its being accepted. But obviously, there are sectional interests at work here. These are people who can see the inheritances they have long been expecting melting away in fees to nursing homes, and who fear that they will themselves one day be in the same position.

Applying the Rawls test to the long term care debate strips out these sectional interests. It has the following effects:

First, it asks us to address long term care from the point of view of individuals who are trying to plan their lives yet who know nothing about their present ages or how their lives will subsequently develop.

Second, it puts long term care into a class of other goods which must be thought about in terms of a range of other goods which have to ranked in order of their relative merit - and thus traded against each other.

Third, it puts the issue of Government funding of long term care firmly in the context of what individuals want, and are prepared to pay for, rather than in the context of what any particular Government believes is politically acceptable and fiscally permissable.

Let us take these in order.

Cooperation not Competition Between the Generations

First, the central truth is that we can most of us expect to pass through each of the main age periods during our lives. In an snapshot view of society, there may be a competition for resources between old and young. But this disguises the fact that we pass from one side of the struggle to the other during the course of our lives. On the whole, we are not talking about a struggle between different groups of persons - as we are in Ireland, or the Middle East - but about ourselves at different times. This being so, we ought perhaps to see the problem as one of distribution not between groups, but within individuals. Most advanced societies have institutions that take resources from people while they are young and productive, and return these to them when they are old and in need of more than they can currently produce.

Thus there is room for the "common point of view" on which Rawls places so much emphasis. Since we can expect to be in different positions depending on our ages, we can start to ask what scheme of distribution between generations is the most just, in the sense of giving individuals the greatest chance of leading a good life. Because it prevents us from knowing what point we have reached in our lives, the Veil of Ignorance compels neutrality between age groups, having the authorities favour none more highly than the others. This does not mean that each ages group is to be treated as exactly equal in the distribution of public resources - simply that each age group is to be allowed that level of public resources that is most likely to allow an average individual to lead a good life.

Meanings of the Good Life

Second, this brings us to what is meant by a "good life". At a first glance, the Rawls test might seem here to break down into accusations of class bias. It is very tempting to define a good life in middle class terms. For the writers and most readers of this pamphlet, it seems plain that in youth and middle age we should be as unconstrained as possible in achieving our life goals. To this end, we should be allowed to keep as much of our earnings as possible. For us, old age is a period of rest and reflection on a life that is for the most part already fulfilled. The thought of spending years in the idleness of dependence and decline is at the least uninviting. And so for us, the distribution of public resources most compatible with a good life is one of relative scarcity for the aged. People should not be prevented from providing for themselves; but there should be little emphasis on providing for them. Death should not be put off as long as possible - for, beyond a certain point, this will impose costs that interfere with other goals. Emphasis should instead be put on achieving a "tolerable death" - that is, according to Callahan, a

death at that stage in a lifespan when (a) one's life possibilities have on the whole been accomplished; (b) one's moral obligations to those for whom one has responsibility have been discharged; (c) one's death will not seem to others an offense to sensibility, or tempt others to despair or rage at the finitude of human existence.16

Death must also not be

marked by unbearable or degrading pain.17

And that is all.

For poorer members of society, however, this might not be seen as an optimum distribution. For them, youth and middle age are times of unremitting labour. For them, life goals are measured in terms less of books written or houses bought and extended than of simply keeping body and soul together. For them, old age is a time of welcome rest from this. Their children have gone away. Their bills are lower. They at last have time to enjoy themselves. They are unlikely to consent to having this retirement shortened or clouded because the middle classes do not want their life goals threatened by the need to pour billions into publicly funded long term care for the old. They do not at all mind heavy taxes on the productive - of which they pay little anyway - to fund care of the old.

Until recently - and perhaps just about still - this objection might be fatal to the sort of Rawls test here outlined. Here we have groups of different people between whom there can be no "common point of view from which their claims may be adjudicated". However, continued economic growth is making the old class distinctions obsolete. Already, most people have reached what may be called middle class affluence - bearing in mind levels of employed income and ownership of the main consumer durables. There will surely come a time within the next generation when the overwhelming majority will, to a greater or lesser degree, have adopted middle class values.

Now the value of this discussion is to show that the needs of any particular group are not things solely in themselves. Their satisfaction always has a cost. And this cost is frustrating the needs of other age groups. We need, therefore, to set our priorities. We need to decide at which times in our lives we have the greatest claim and access to public resources. Imagine a world in which most people are able to live to about a hundred, but in which decay is still inevitable after the late sixties. Are we to put more public funding emphasis on the period before of after the late sixties? Are we to supply public health care - as at present, in theory - on the basis of momentary need? If so, there will inevitably be a bias towards the elderly, bearing in mind their greater need of expensive treatments and care. Or are we to ration public health care? If so, in most competitions between a person of 75 and one of 45 for a heart bypass operation, the younger person will win. So long as such a policy were guided by an overarching Rawlsian test of generational distribution, its effects need not be seen by anyone as unfair. They might well be seen as hard. But the policy itself would not have been framed in any auction of votes or display of power.

The Need for Plural Responses

Third, the above must be seen as only the direct public response. We have been discussing the intergenerational distribution of public funds. Fortunately, this is to be seen as a discussion not of the whole matter but of its most basic aspect. As said, economic growth is continuing to raise millions out of poverty and into something like middle class affluence. This being so, we ought surely to encourage the growth of institutions that will allow people to make their own additional intergenerational transfers - by investing in pension and insurance schemes.

Now, this brings us back to the value of certainty. As said, the generations now over the age of fifty have been comprehensively mistaken about the future. They consented in their youths - or were subjected - to policies that prevented them from providing for the future. They were kept guessing what level of care they could look forward to in old age. At the same time, they were deterred by high taxes and inflation from providing for themselves. This must not be allowed to happen again.

People must in future be made confident about how much or how little public support they can expect to receive. They must know where they stand in the long term. Welfare policy must not be made into a football between the main parties, with massive and destabilising changes made every half decade or so. There must be agreement. We have been trying here to outline a test of fairness for the provision of long term care. It is worth saying, though, that even an unfair scheme is better than one that keeps arbitrarily changing.

At the same time, there must be an end to inflation and high taxes on income. Whatever the wider economic benefits of this, its benefits for long term planning should be plain from the above. How it is to be achieved, and once achieved how maintained, are matters outside the scope of this pamphlet. A restored Gold Standard, an independent central bank, a new constitutional settlement to guarantee stability - these and many other suggestions can be made. But the point is to provide a scheme of public provision that is widely regarded as fair, and then to encourage individual provision to ensure that few need to rely absolutely on public funds in their old age.

Conclusion

It would be premature to say for sure what conclusions might emerge from the analysis here suggested. Some guesses and proposals can be briefly made. But far more work needs to be done on investigating all the possible options and what most people would regard as fair in as yet unknown circumstances. What we have tried here to present is a method of arriving at answers - a method of developing a scheme that might have to last for centuries and be able to incorporate only minimal changes once started.

1. Source: Peter Coleman, John Bond and Sheila Peace, "Ageing in the Twentieth Century", in John Bond, Peter Coleman and Sheila Peace (ed.s) Ageing in Society: An Introduction to Social Gerontology, Sage Publications, London, 2nd edition 1993, p.4 (projected figures only for 1991-2001).

2. Source: Neasa Macerlean, "Golden oldies", The Observer, London, 19th November 1995.

3. Source: Alan Pike, "Survey on Care of the Elderly (4): Relative savings of 15bn a year - About 6m people are carers", The Financial Times, 18th December 1989.

4. Paying for Long-Term Care (summary), Institute for Public Policy Research, London, 1996.

5. Source, John MacGregor, a former Transport Secretary, quoted in Anthony Bevins, "Tories prepare for Chequers brainstorming", The Observer, London, 10th September 1995.

6. Source: Sheila Waller, employee-benefits manager at Swiss Life (UK), in Paul Ham, "Goodbye to carefree retirement", The Sunday Times, London, 3rd December 1995.

7. Daniel Callahan, Setting Limits, Simon and Schuster, New York, 1987.

8. "Letters to the Editor", The Times, London, 12th August 1995.

9. Jeremy Laurence, "Elderly heart patients denied life-saving drugs", The Times, London, 9th January 1995.

10. Ibid.

11. Quoted by Paul Slade, "Storm clouds gather over long-term care", The Daily Telegraph, London, 16th June 1996.

12. John Rawls, A Theory of Justice (1972), Oxford University Press, Oxford, 1980, p.3.

13. Ibid, p.4.

14. Ibid, p.5.

15. Ibid, pp. 139-40.

16. Callahan, op cit, p.66.

17. Ibid, p.72.