Confronting the bind of ruinous social care and assisted dying - David Behrens

It has long been our custom to disparage American healthcare, a system in which the treatment you receive depends on how much you can pay. We have overlooked the equally iniquitous model that has compromised our own national health.

Andy Burnham confronted the matter head-on when he acknowledged that social care in England is as unfair as health provision in the US. We punish people for growing old, he said, by taking away their money, their homes and their dignity so they can afford to be helped.

The PM’s case is that the system needs fixing and that it has to be done before we even think about enshrining in law the right to opt out of it. Otherwise, he implies, we risk replacing a terrible regime with an even worse one, in which patients are offered only two choices: abject poverty or assisted death.

Ethically, that is a sound argument, and if we were building a model from the ground up it is unquestionably how we would proceed. But we aren’t doing that. We are where we are. Families need relief more urgently than a Whitehall review can dispense it and the uncomfortable truth is that the arguments over social care and assisted dying are inseparable, and they are economic as well as ethical.

It is inhumane to view the ending of a life as a purely financial measure and that’s why few politicians mentioned the economic considerations when the matter was last debated. They focused instead on the moral dimension of ‘playing God’ with the lives of vulnerable patients.

But the debate will return to the Commons next month and the reality will have to be faced that most terminally ill patients and their families are less interested in crossing ethical boundaries than in protecting themselves from ruin. The PM has now set that hare running; it’s up to sympathetic MPs to take up the chase.

A glance at the headline figures gives you an idea of the crippling expense of caring for yourself or a relative in old age. These will come as no surprise to many of you.

It currently costs at least £3,000 a month, and often nearly twice that, to give someone basic care in a residential home. The families of dementia patients will pay well over £80,000 a year for specialist care.

A live-in nurse is more expensive still, with complex care costing upwards of £2,200 a week, or £114,000 a year. Not many families, even with insurance and the best of intentions, can sustain that kind of expense.

In the United States, the PM’s point of reference, the typical cost is slightly higher still – but a more interesting comparison is with France, whose parliament has just voted, after years of debate, to allow assisted dying under strict conditions.

The measures approved by French MPs will apply to adults with a serious, incurable and advanced life-threatening illness which has left them in unbearable physical or psychological pain. The choice to end a life will rest with the patient, and though it will be subject to the approval of a doctor, it will not fall to any medic to wield mortal authority.

That does not sound to me morally subversive. It sounds humane and pragmatic, all the more so since it is not a binary choice but one of a range of options open to patients, depending on their condition.

That’s because France, unlike England, already has a national health system that encompasses social care. It saw to that first, in the way Andy Burnham is advocating, but it did it a generation ago.

The French philosophy is that dependency in old age is a ‘social risk’ which should be supported by everyone. The Allocation Personnalisée d’Autonomie is an entitlement for those over 60, irrespective of wealth, who are judged to be no longer capable of caring for themselves.

England has no equivalent. Everyone is strictly means-tested. Patients must use up all their money and assets until there is nothing left; only then does the State step in. Any ambitions you may have held to pass your home or savings to your children count for nought.

That is a hard-hearted approach which we make less compassionate still by offering no alternative, no way out. So it’s doubly cruel and we can no longer throw up our hands and invoke divine providence by way of justification.

Changing the way we pay for social care to make it fairer will be contentious. The money will have to come from somewhere. But the concept of spreading the cost is hardly more Socialist than the health service we already have and which we supposedly cherish. Nevertheless, it will take time to find a consensus.

Assisted dying, however, is a debate we have already begun. Around three-quarters of us support it in some form. It’s up to MPs to balance the choices we enjoy in life with those that are denied us in death.