3/ The care system in the United Kingdom: formal provision for older people
    

The formal care provided to older people by public, voluntary and private sector organizations and agencies across the United Kingdom has, as Chapter 2 suggested, radically changed in recent years. These upheavals are set to continue and, in combination with predicted demographic changes, are providing major challenges for social care agencies and organizations. There are currently some 10.8 million people in the United Kingdom over the age of retirement: 3.9 million men over the age of 65, and 6.9 million women over the age of 60.(1) The Royal Commission established to examine the funding of long-term care services estimated that the cost (in 1995) for this industry was £11 billion: £7 billion from the state (NHS and social services) and £4 billion from older people themselves and their families. The Commission—using a model developed by the Personal Social Services Research Unit (PSSRU)—estimated that these costs would increase (at 1995–6 prices) to £14.7 billion in 2010, £19.9 billion in 2021, and £45.3 billion in 2051.(2) Almost half of all social services expenditure is on services to older people, and between 900,000 and 1.2 million people work in the social care industry in England (two-thirds of whom work in the independent sector, mainly in residential and nursing homes).(3) The formal care of older people is big business.

With the vast sums of money now required to provide the range of social care services for older people, many Jewish agencies and organizations have become increasingly integrated within the overall UK system. As such, what affects the United Kingdom as a whole also affects the Jewish community, and so providers need to understand the overall trends, systems and government policies that are likely to set the scene for how care is delivered and financed over the next decade. This chapter provides much of this information by detailing the current UK system of formal care provision for older people. The first part of the chapter examines demographic projections noting, in particular, the rapid increase in the number and proportion of older people over the next half century. The second part details the different types of care currently provided in the United Kingdom, setting out the national picture as a basis for comparison with provision that is specifically Jewish (see Chapter 4). The final part attempts to navigate some of the key New Labour social care legislation and initiatives that are shaping the future of social care services. This information is complex, but sets the scene for the changes the government is seeking to make. These changes include the imposition of national minimum standards for residential and nursing homes and alterations in how long-term care is funded. The government has also expressed interest in 'mainstreaming', i.e. encouraging the provision of services in general settings rather than by specific religious or ethnic minorities for their own communities. In combination, all these changes have important long-term implications for Jewish providers.

Demographic projections

Over the last century, the number of people in the United Kingdom has increased from just under 40 million to around 60 million. However, during this same period the number of people aged 60 or over has grown fourfold, from 2.87 million in 1901 to 12.2 million in 2001. Moreover, the number of people aged 80+ has increased elevenfold so that in 2001 there are almost as many people aged 80+ as there were aged 60+ in 1901 (see Table 3.1).

Table 3.1 The changing number of older people in the UK over the last century(4)

Population (thousands)
	60+	70+	80+	All ages
1901	2,876	1,066	218	38,237
1911	3,434	1,298	251	42,082
1931	5,314	1,962	376	46,038
1951	7,890	3,399	730	50,225
1961	8,973	3,954	1,017	52,709
1971	10,512	4,599	1,263	55,515
1981	11,020	5,438	1,485	55,089
1991	11,713	6,174	1,824	56,388
2001	12,201	6,765	2,481	59,954

With the increases in population over the last century and the high current annual expenditure on long-term care for older people—currently representing some 1.6 per cent of gross domestic product (GDP)—the government is unsurprisingly concerned with establishing likely future demographic trends. In terms of the overall population of the United Kingdom, this is likely to remain fairly static for the foreseeable future, increasing to 61.77 million in 2011, 63.64 million in 2021, and 64.1 million in 2051. Nevertheless, with rises in standards of living, advances in medical technology and the impact of the increase in birth rates after the Second World War and during the 1960s and early 1970s (the so-called 'baby-boomer' generations), the proportion and actual numbers of older people are expected to increase throughout the next sixty years (see Figure 3.1).(5)

Figure 3.1 is drawn by indexing each of the age bands at a figure of 100 for the start year of 1999, so that the percentage change of each group can be compared. It shows how the numbers of individuals aged 75–9 will increase by a factor of 1.5 from 2001 to 2061; those aged 80–9 will more than double; but the most dramatic increases will be in those aged 90+, whose number will increase almost fourfold.

Figure 3.1 provides the best estimate to likely future demographic change. However, the relatively long period it covers makes it highly prone to error. The graph is calculated using known birth rates, and estimating future death rates based on assumptions about life expectancies for different age groups. It is, however, almost impossible to calculate the likely effects on life expectancies of events such as future wars and diseases, as well as changes in medical technology and standards of living. Thus, a more realistic time period for the examination of demographic change is the next ten years. Figure 3.2 shows how numbers of people aged 75–9 will remain fairly static (or even decrease) over the next ten years; individuals aged 80–4 will increase by up to 30 per cent; those aged 85–9 will decline in number until 2004 before increasing again; and those aged 90+ will increase steadily until 2006, dipping slightly up to 2009 before increasing rapidly in 2010 and 2011.

An increase in the number of older people in the coming decades does not, of course, inevitably imply that there will be a corresponding rise in numbers requiring long-term care services.(8) One of the major debates in policy circles relates to changes in healthy life expectancy, defined as 'the years of life a person may expect to live free of some chronic health condition; or sometimes a related health state such as institutionalisation; or until the first occurrence of some crucial health event'.(9) For policy planning purposes, what matters most is the length of time that people are chronically ill (otherwise known as the morbidity rate), rather than their actual age.

Research from the PSSRU shows how there has been an average increase in life expectancies for men at 65 of 1.7 months for every year from 1980 to 1998; for women the figure is 1.2 months. For men, the average age by which they can no longer manage daily tasks on their own (such as bathing or showering, or getting to the toilet) has increased in line with these higher life expectancies (i.e. by 1.7 months for every year from 1980 to 1998). The age by which they can no longer manage to climb stairs on their own has increased by 1.5 months per year, to go outdoors unaided by 1.3 months, but the age at which they identify the onset of a long-standing limiting illness has risen by only 0.4 months. For women, their ability to manage daily tasks on their own has increased by 1.2 months per year (the same as their increase in life expectancy), to use stairs by 0.6 months and to go outdoors by 0.5 months, while the age at which they are likely to report a long-standing limiting illness has increased by 0.6 months. These figures suggest that older people are likely to have more years of mild and moderate levels of disability, i.e. to have a long-standing limiting illness or the inability to go outdoors unaided, than previous generations (who tended to become ill younger but also died earlier). In terms of severe disabilities (unable to manage daily tasks on their own), improvements in healthy life expectancies have kept pace with the dramatic increase in life expectancies witnessed over the past twenty years. Overall, men can expect to live to 74, 16 years of which will be with limiting ill health; women can expect to live to 80, 20 years of which will be with limiting ill health.(10)

Related to the predicted rise in the number of older people will be a decrease in the proportion of those of working age to the rest of society. The basic state pension and the state earnings-related pension scheme (SERPS) are both funded through contributions of the current workforce, rather than from savings throughout the lifetimes of those who are now retired. Thus, a relative decline in the percentage of working-age people, in conjunction with an increase in the percentage of those above retirement age, has important implications for the funding of older people's services (see Figure 3.3). The number of people of pensionable age is estimated to increase from 29 per cent of those of working age in 2001, to 42 per cent in 2061.

Different types of care

Most older people continue to live in their own homes and do not require any formal long-term care. As individuals become older, however, they are increasingly likely to make use of informal or unpaid care from spouses, relatives, friends and neighbours. About 5.7 million people in the United Kingdom provide some type of informal care, mostly for older people. Most of these people spend 4 hours or less per week providing unpaid care, although some 800,000 provide care for 50 hours a week or more. Sixty per cent of carers are women, with the largest type of care being that provided to parents or parents-in- law, mostly by people aged 45–64.(12) Nevertheless, nearly 1.6 million carers are over the age of 65 (and 400,000 are aged 75 and over), with 40 per cent of these individuals living in the same household as the cared-for person.(13)

For those requiring more formalized types of care, there are several different services provided in a range of care settings in the public, private and voluntary sectors. The 1999 Royal Commission on Long Term Care identified seven types of settings for formal care, although categories do overlap (see Table 3.2).

The most important services provided by the organized Jewish community are: domiciliary care, day care centres, sheltered housing and institutional care, especially residential and nursing care homes, which account for the lion's share of spending on long-term care for older people in the United Kingdom.

Table 3.2 Care settings for older people(14)

Care setting	Definition
Care at home (domiciliary care)	Personal care and practical help provided to older people in their own homes
Adult placement	Placing older people with selectively matched carers in carers' own homes
Day care	Including NHS day hospitals, local authority and independent sector day centres
Sheltered housing	Individual housing within a setting that offers varying degrees of monitoring, protection or support; either owned or rented; including very sheltered housing or housing with extra care, and retirement communities/care villages
Institutional care	In an institutional setting, either a residential or nursing home, provided by the public, private or voluntary sectors
NHS continuing care	In nursing homes, hospices and hospitals
NHS acute services	In NHS hospitals

Domiciliary care
There are currently some 600,000 people in the United Kingdom over the age of 65 receiving domiciliary assistance from a local authority (see Table 3.3). Domiciliary care may include help with tasks such as washing and bathing, occupational therapy, community nursing and chiropody.

Table 3.3 Number of people in the UK receiving domiciliary care(15)
 

Form of domiciliary care	Number of recipients
Home care	610,000
Community nursing	530,000
Private help	670,000
Meals	240,000

Of the approximately £11 billion spent on long-term care in 1995, £2.7 billion went on home care. As outlined in Chapter 2, government policy in recent years has been to keep people within their own homes for as long as possible. This is because most older people want to remain in their own homes (see Table 3.4), but also because supporting people in their own residence is generally considered to be more 'cost effective' than placing them in institutional care. The Royal Commission calculated typical costs per person for home care in 1999 at £6,188 per year (calculated at local authority rates of £8.50 an hour, 14 hours' help per week). This is approximately a third to a half of the annual cost of residential or nursing homes.(16)

As part of the drive to keep people out of institutional care there are grants available to help older people adapt their own homes. Under the Housing Grants, Construction and Regeneration Act 1996 older people can apply for a 'disabled facilities grant' for the installation of minor alterations, such as grab rails in bathrooms, as well as major changes, such as stair lifts or the construction of a downstairs bathroom. These adaptations can be enormously beneficial in improving the quality of life of many older people, although there is evidence of very long waiting lists for social service assessments and of reluctance by authorities to fund expensive changes (see also Chapter 9).(17)

Table 3.4 Preferences for formal and informal care(18)

	Gross personal income per annum
	<£6,000	£6,000– £11,999	£12,000–£19,999	£20,000+	All
Type of care	%	%	%	%	%
Relatives in your own home	19	16	13	8	15
Relatives in their home	4	3	1	-	3
Professionals in your own home	19	21	19	25	21
Nursing or residential home	12	11	11	12	12
Mix of family and professionals in your own home	42	45	55	53	47
Other	2	2	1	1	2

Day care centres
Day care centres have evolved rather piecemeal, with 'little co-ordination between service providers, and great disparity in the level of provision between regions'.(19) Day care services can be defined as offering 'communal care, with paid or voluntary caregivers present, in a setting outside the user's own home. Individuals come or are brought to use the services which are available for at least four hours during the day.'(20) About 260,000 people currently use day care services, which are provided in a variety of different settings, including generic day centres for older people, dementia-focused centres and day hospitals (including psychiatric day hospitals for older people). Local authorities provide approximately three-quarters of day centre places in England and Wales, with voluntary organizations providing the remainder.(21) Day care centres are vital tools in providing quality of life for individuals who may be suffering from loneliness or conditions such as Alzheimer's disease or other forms of dementia. They are also important in providing respite for carers.

Sheltered housing
This is grouped accommodation that has some communal facilities such as a common room or laundry, a warden, and an alarm system to alert the warden in case of need. Schemes range from those accommodating fewer than 20 individuals to those with more than 100. The origins of sheltered housing date back to almshouses, although from the 1960s local authorities and housing associations increasingly provided them, attracted in part by large government subsidies. Since the 1970s, very sheltered housing schemes have also been developed. These are designed to meet the requirements of older people with care needs greater than those that can be accommodated in ordinary sheltered housing. These schemes tend to have more communal facilities, such as specialist baths for disabled people, twenty-four-hour warden cover and meals (provided once or twice a day). The boundary between very sheltered housing and residential care homes is often difficult to define. Five per cent of people aged 65 or over live in sheltered or very sheltered housing (see Table 3.5). There has been an increase in the average age of residents: in 1984 only one resident in ten was aged 85 or over, compared to almost one in four in 1993.(22)

Table 3.5 Provision of sheltered and very sheltered housing units for older people, England, 1997(23)

	Local  authorities	Housing associations	Other public sector	Private	Total
Sheltered housing	282,114	169,586	2,225	44,558	498,483
Very sheltered housing	7,134	9,873	1,034	–	18,041
Total	289,248	179,459	3,259	44,558	516,524

Recent government advice has not been encouraging with regard to the construction of new sheltered housing, including very sheltered housing. The Housing Corporation—a non-departmental public body that funds and regulates Registered Social Landlords in England—has declared that new specialist housing schemes for older people will only be approved if evidence of housing and care needs can be clearly demonstrated. There seems to be a greater desire to remodel existing schemes, rather than fund new schemes, as is clearly evidenced by the rapid fall in the construction of new dwellings for older people from 1989 to 1997 (see Table 3.6).

Table 3.6 Number of new dwellings built for older people, England, 1989–97(24)

	Private sector	Housing associations	Local authorities and new towns	Total
Sheltered
1989	3,242	1,092	2,523	6,857
1993	808	1,442	202	2,452
1997	155	245	2	402
Other
1989	554	339	1,004	1,897
1993	179	724	57	960
1997	45	113	11	169

There is also evidence of the problem of obsolescent housing stock: properties that are difficult to let because, for example, they are studio apartments when what is needed is multi-bedroom housing. In 1994, 40 per cent of local authorities and 36 per cent of housing associations characterized between 1 and 9 per cent of their sheltered housing stock as 'difficult to let'. This problem is particularly acute in certain areas where 8 per cent of local authorities and 13 per cent of housing associations report that over half their stock is 'difficult to let'. There are also similar problems in letting very sheltered housing stock, with four-fifths of local authorities and housing associations describing between 1 and 9 per cent of their stock as 'difficult to let'.(25) According to the 1998 Audit Commission report, Home Alone:

The principle of community care makes it harder to justify tying resources to property rather than people. Sheltered housing must accordingly re-invent itself as provision for older people who prefer the presence of a supportive community or it must re-think the levels of need it is able to support. If it does not it will face serious questions about its relevance in a system which can deliver high levels of support in ordinary housing.(26)

Housing associations are also faced with government standards and legislation requiring 'best value', with organizations having to prove the quality of services provided, for example through in-depth tenant satisfaction surveys.

Institutional care
There are currently over 480,000 older people residing in residential and nursing care homes, i.e. about 1 in 20 of all older people. The Royal Commission on Long Term Care calculates that one in five men, and one in three women, aged 65 or over, will require residential or nursing home care at some point in their lives. Residential homes provide meals and personal care such as help with washing, dressing, getting up and going to bed. Nursing homes provide personal care and specialist nursing care; they must employ qualified nurses and have at least one on duty at all times. Dual homes are combined residential and nursing facilities and these are also legally required to employ qualified nurses. Sixty per cent of long-term institutional care is provided in residential homes, 33 per cent in nursing homes and the remainder in hospitals (see Table 3.7). The costs of institutional care in 1995 were estimated to be £8.3 billion.(27)

Table 3.7 Number of people in the UK receiving long-term institutional care(28)

Institutional care	Number of recipients		Totals
Residential care	Publicly financed Privately financed	205,000 83,750	288,750
Nursing home care	Publicly financed Privately financed	115,000 42,500	157,500
Hospital		34,000	34,000
All institutional residents			480,250

The median average length of stay in a care home is estimated to be 19.6 months: 11.9 months for those originally admitted to nursing homes, and 26.8 months for residential care.(29) The factors at admission that significantly raise subsequent mortality rates are (in order of statistical significance): having a malignancy (cancer); having high levels of disability (low Barthel score); old age; being a man; being admitted from a nursing home; being admitted from a hospital; having a respiratory illness; and being cognitively impaired.(30)

In response to the recommendations of the Royal Commission, the care home sector is presently undergoing a major transformation. The overall thrust of the change is to increase the levels of care provided in people's own homes rather than in residential or nursing homes, to alter the way that private individuals pay for care, and to improve and standardize services in homes. These changes are part of an overall drive by the government to 'modernize' delivery of social care services.

New Labour social care legislation and initiatives

In 1998 the government published its White Paper, Modernising Social Services, which, in conjunction with The NHS Plan (2000) and the National Service Framework for Older People (2001), sets out to build social services that 'promote people's independence', 'improve protection of vulnerable people' and 'raise standards'.(31) In particular, the government hopes to effect change in six areas: assuring standards of care, extending access to services, ensuring fairer funding, developing services that promote independence, helping older people to stay healthy, and developing more effective links between health and social services. This section of the report introduces some of the key (primary and secondary) legislation and guidance initiatives that have been, and are being, introduced by the current New Labour government. In particular, it addresses three areas of particular relevance to the UK Jewish voluntary sector: funding long-term care, regulations and standards and access to care and commissioning services.(32)

Funding long-term care
The report by the Royal Commission on Long Term Care, With Respect to Old Age, was produced following fears of the spiralling costs to the state of residential and nursing care, and the concerns of older people (and their families) that they would need to sell their homes to pay for institutional care. The Commission made recommendations relating to the full spectrum of long-term care, from home services to residential and nursing care, but it was the latter that occupied most of its attention.

The costs of residential and nursing home care are divided between the state and older people themselves, with the relative amounts each has to pay determined by an assessment of the wealth of the person requiring care. This assessment is commonly known as the 'means test'. In 1997 just over 70 per cent of all residents in care homes were funded by the public sector in some way.(33) Following the recommendations of the Royal Commission, the government changed the way that private individuals pay for long-term care. Prior to April 2001 anyone with capital assets above £16,000 had to pay the full fees for care in a residential or nursing home.(34) In all other cases, in which people had capital assets of less than £16,000, individuals were expected to make a financial contribution towards fees. For those with capital between £10,000 and £16,000, an income of £1 per week for every £250 of capital was assumed, known as the 'tariff income'. Income from retirement pensions or income support was added to this tariff income, as a contribution towards fees. For those with assets below £10,000, only income from retirement pensions and income support was paid as a contribution. After the contribution towards fees, individuals were to be left with at least the amount of their 'personal expenses allowance'—often called 'pocket money'—which in 1999 was worth £14.45 per week. Following the government's changes, the system has been altered so that the nursing element of care is now (supposed to be) free and the value of a resident's home is disregarded during the first three months of care. The upper capital limit for paying full fees has now been raised to £18,500 and the lower capital limit to £11,500.(35)

The government's changes will improve the financial situation for many older people, although they fall short of the Commission's main recommendation that all personal care (including social care tasks, such as help with bathing) should be paid for from general taxation. It is worth noting, however, that in Scotland—which has devolved government—personal care is now free at the point of demand.

Another key change worth noting that emerges from the government's response to the Royal Commission is that the Residential Allowance in Income Support is to be transferred directly to local authorities (to be implemented from 2002, subject to parliamentary approval, for new cases only). The Residential Allowance is a payment to residents on income support in independent (private or voluntary) sector care homes, which means that a resident in their 80s outside of London could (in 1999) be entitled to £147.35 per week (almost twice that of a resident in a council home). Residents themselves do not benefit from this payment—it is counted as income to be contributed towards the payment of fees—with councils simply recouping the payment via the means test. However, it does encourage councils to use the independent sector for purely financial reasons, and can tip the balance between placing people in residential care and providing domiciliary care. By transferring this allowance straight to councils, this incentive for institutional care will be lost, and this may influence the numbers of individuals that local authorities choose to place into Jewish voluntary (and other independent) sector care homes.

Regulation and standards
A defining feature of successive governments over the past twenty years has been to introduce national regulations and standards for the local provision of services. In terms of education, for example, this includes the imposition of a national curriculum for all state schools, a national inspection system carried out by the Office for Standards in Education (OFSTED), and protection for pupils through a national database of individuals with criminal records involving children.(36) New Labour is continuing on this path in its programme for welfare services, including the introduction of the General Social Care Council to regulate the social care workforce, and national minimum standards to regulate care homes and other social services (including domiciliary care).(37)

Until recently, care homes located in the 150 local authorities and 100 health authorities, which were responsible for regulating and inspecting their services, were faced with major differences and inconsistencies in the standards they were expected to meet.(38) In March 2001 the government published the Care Standards Act 2000, which replaces the Registered Homes Act 1984 and is designed to implement national minimum standards (to apply mostly from 1 April 2002). These standards apply in seven key areas: choice of home, health and personal care, daily life and social activities, complaints and protection, environment, staffing, and management and administration. The National Care Standards Commission (NCSC), an independent non-governmental public body that has the power to determine the registration of services, will regulate these standards. Accordingly, care homes will be required to provide:

• an up-to-date statement of purpose for service users;
• each service user with a written contract/statement of terms and conditions;
• a service user plan of care for each resident;
• care and comfort to service users who are dying, handling their death with dignity and propriety, and observing their spiritual needs, rites and functions;
• communal space (apart from private accommodation, corridors and entrance halls) of at least 4.1 square metres for each service user (to apply from 1 April 2007 for homes existing prior to 1 April 2002);
• en-suite facilities (minimum of toilet and hand-basin) to all service users in all new buildings or extensions from 1 April 2002;
• a minimum of 12 square metres usable floor space in single rooms in all new buildings or extensions (excluding en- suite facilities);
• at least 10 square metres usable floor space in single rooms in current homes (from 1 April 2007);
• a minimum ratio of 50 per cent trained members of staff (NVQ level 2 or equivalent), to be achieved by 2005, excluding the registered manager and those care staff who are registered nurses;
• assurance by the registered person that there is a staff training and development programme that meets National Training Organisation (NTO) workforce training targets;
• a registered manager who has at least two years' experience in a senior management capacity and a qualification (by 2005) at NVQ level 4 in management and care or equivalent, or, where nursing care is provided, who is a first level registered nurse and has a relevant management qualification (by 2005); and
• effective quality assurance and quality monitoring systems, based on seeking the views of service users, in order to measure success in meeting the aims, objectives and statement of purpose of the home; the results of service user surveys to be published and made available to current and prospective users, their representatives and other interested parties, including the NCSC.

We urge the Government to recognise the significant under-investment in care and support services, and to commit itself to making good the substantial shortfalls that have occurred year on year. We believe that the order of investment required is likely to be at least the same as that being injected into the NHS, i.e. a growth of approximately half in cash terms, and one- third in real terms in just five years. Without such investment, care and support services will be struggling to stand still. They will be unable to address the major improvements needed in quality or to meet the additional requirements on new national standards.(50)

Conclusions

In recent years there have been enormous changes in the UK system of social care services for older people. These changes are set to continue and are driven by a combination of demographic, financial, political and social factors. Demographically, the number of older people in the United Kingdom is increasing, as indeed is their proportion relative to the (pre-65) working- age population. Estimating population trends is difficult, but the best estimates are that, while the increase in those aged 75– 89 will peak in the middle of this century, the numbers of those aged 90+ will continue to rise for the foreseeable future. Moreover, those aged 90+ are the age group most likely to need formal care services.

Most older people will continue to live in their own homes, but for those who do require formal care, this can take place in a variety of settings, including people's own homes (domiciliary care), day centres, and residential and nursing homes. The annual costs for long-term care were estimated to be £11 billion in 1995, which could rise (at 1995–6 prices) to almost £20 billion in 2021 and to £45.3 billion in 2051. These spiralling costs have been a major impetus for reform, with the current New Labour government introducing an array of (often confusing) legislation, guidance and initiatives. The overall direction of government thinking is, however, to encourage people to remain independent in their own homes, to impose national standards on care services, and to balance the costs of maintaining (or developing) current provision with people's willingness to pay for it.

Notes

1 Note that the age of retirement for women will increase to 65 by 2020 (to be phased in over a 10-year period from 2010).

2 Royal Commission on Long Term Care, 8–22. Note that these figures do not include financial estimates for unpaid, voluntary work, which is a considerable element of the care given to older people. They are also based on assumptions about population growth, healthy life expectancies, care costs and levels of informal care.

3 Melanie Henwood, Future Imperfect? Report of the King's Fund Care and Support Inquiry (London: King's Fund 2001), 8–9.

4 Anthony Warnes, 'The demography of old age: panic versus reality', in Rosemary Bland (ed.), Developing Services for Older People and Their Families (London and Bristol, PA: Jessica Kingsley 1996), 26–42; 2001 figures from United Kingdom Government Actuary's Department (GAD).

5 See Maria Evandrou (ed.), Baby Boomers: Ageing into the 21st Century (London: Age Concern 1997).

6 Based on figures provided by GAD.

7 Based on figures provided by GAD.

8 For interesting critiques of ideas that older people are a 'demographic time bomb', see Phil Mullan, The Imaginary Time Bomb: Why an Ageing Population Is Not a Social Problem (London: I. B. Tauris 2000), and Warnes.

9 Andrew Bebbington and Adelina Comas-Herrera, Healthy Life Expectancy: Trends to 1998, and the Implications for Long Term Care Costs, PSSRU Discussion Paper 1695 (London School of Economics), December 2000.

50 Ibid., 140.