In the United States there has been a huge influx of for-profit companies into what was started as a humane, civilised way of leaving this world in a caring, kindly way.  Profiting from death was the last thing the founders of St. Christopher’s hospice in London thought of when they established the first hospice in the mid-’70s.  But a Washington Post analysis of hundreds of thousands of U.S. hospice records indicates that, as for-profit companies, financed by Wall Street, transformed the movement once dominated by community and religious organizations into a $17 billion industry, patient care suffered along the way.

Between 2000 and 2012, the number of for-profit hospices tripled to 2,196, according to federal figures, compared with about 1,500 nonprofit hospices, including those run by local governments.   In 2012, Medicare spent more than $15 billion on hospice care,

On several key measures, for-profit hospices as a group fall short of those run by nonprofit organizations:

• For-profit hospices had a smaller proportion of registered nurses than non-profits; patients at for-profit hospices received a narrower range of services; and  for-profit hospices were more likely to restrict enrollment of patients with potentially high-cost care.
•  For-profit hospices spend less on nursing per patient –  $30 a day per patient on nursing visits, compared with $36 per day for non-profits.
•  For-profits are less likely to have sent a nurse to a patient’s home in the last days of life.  A typical patient at a for-profit hospice is 22 percent less likely to have been visited by a nurse during this window than a patient at a nonprofit hospice.
•  For-profits are less likely to provide more intense levels of care for patients undergoing a crisis in their symptoms. Nonprofits offered about 10 times as much of this per patient-day as did for-profits.
•  For-profits have a higher percentage of patients who drop out of hospice care before dying. 22 percent of  patients leave a for-profit hospice, while only 14 percent leave  nonprofits. High rates of dropout are often viewed as a sign that patients were pushed out of hospice when their care grew expensive, left dissatisfied or were enrolled for hospice even though they were not close to death.

The quality of individual hospices varies widely. In some cases, for-profit hospices provide service at levels comparable to nonprofits, according to the review. But the data analysis, based on hundreds of thousands of Medicare patient and hospice records from 2013, shows that the gap between the for-profits as a whole and nonprofits is striking and consistent. There is a pressure to cut costs and  sparse government oversight.  Hospices are paid a flat daily fee by  Medicare for each of their patients, and this means that the fewer services they provide, the wider their profit margin.

On the plus side for-profits can more easily raise money for investments in equipment and expansion, achieve a size that offers them economies of scale, and are maybe more efficient.  A large hospice can, in theory, afford to lose money on some patients who may need extraordinary care.

My own observations, necessarily limited, suggest that care homes and hospices are run by poorly paid and barely-trained people, often imported from developing countries, with no experience and sometimes poor English.   Serving in such homes is for the staff, unsurprisingly, a temporary expedient before finding a better-paid job.  The care can be rough and casual, the food pretty dreadful, the patients drugged, and the TV permanently on. This is how we push the elderly out of sight and out of mind.

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Two-thirds of older and disabled people in England who turn to their local councils for help with care are turned away, figures show.  Only 144,000 of the requests for help resulted in them being admitted to care homes or given home help for tasks such as washing and dressing.  Of the remainder about 220,000 got short-term help, such as rehabilitation after discharge from hospital, and another 300,000 got low-level support such as walking aids and telecare. The rest either received nothing or were advised to seek help from charities, the NHS or from housing services.

Social care is not free, so all the above who are accepted into the system pay something towards the cost of their care,  with some covering the entire cost.  Only the poorest get financial help.  An estimated 1.5 million older people with care needs rely on family and friends for help.  One in ten older people faces bills in excess of £100,000 for care when they are old and need it.

There has been a steady year by year fall in the number of elderly people who are helped by social services.  The Local Government Association predicts if extra money is not put in there will be a shortfall of more than £4bn in care services by 2020 – and that is before the implications of the national living wage are taken into account.

An elderly relative, who my wife and I looked after,  was born with cerebral palsy. She was unable to look after herself at all.  For years Social Services visited her daily at home.  One day she received a letter from the local Council telling her that “Halleluyah!  The era of choice had dawned and she could choose what level of care she wanted!”  This was a lady who needed maximum care and visits three times a day, but, because she was in her own home, it cost less than in a nursing home.  She was, of course, quite unable to decide how to reply to the letter, whose subtext was that they offering reduced services, and which of these reduced services would she like?   While my wife and I were trying to find out what the implications were and telling the Council that the patient was totally helpless, she died.  It was a blessing, because the outlook was horribly grim.  This situation is and was re-played many times  all over the country, as local Councils, starved of funds, have to reduce services.  Meanwhile, the government talks about updating the Trident nuclear submarine fleet and bickers over Brexit, the self-inflicted wound.

Epicurus would suggest that the priority is the well-being of the the population and, among other humane objectives, ensuring that the elderly are treated decently and with rsepect.

To The Daily Telegraph
With Brexit, the problem for my structural engineering consultancy business is not the collapse of the construction industry. Far from it, our order book is overflowing. The problem is getting staff. Last year we advertised for civil engineering graduates and attracted 80 applications, only two resident in Britain. The same has been the case this year, with the most interest from very able and yet terminally unemployed fellow Europeans from Italy, Spain and Greece. They are enterprising and eager to work, and, frankly, Brexit without them would make life very difficult for us.
By contrast, the UK crop of youth is much less inspiring and seemingly sleepwalking into non-vocational higher education in the belief that employers will want them. We won’t. For us, the aftermath of Brexit raises serious questions about our education system and how it is failing to get the next British generation working. (M.H. Fisher, managing director, Pure Structures Ltd, Little Hadham, Hertfordshire, UK)

In both the UK and the US the problems are similar – the educational system is so poor that it’s hard to find well- trained local people. I believe that, in the British context, the problem dates back to the idiotic decision to encourage technical colleges and polytechnics to become universities. They then began to teach drama, history and the other arts subjects and watered down their technical offerings. What we should be doing is to have people take a basic BA and then go on to do high quality training at a “polytechnic” (most Germans don’t start serious jobs until their late twenties or beyond). Thus, in theory at least, they would have thinking and reasoning skills, be able to problem solve, but would also have valuable technical skills that companies need. The conversion to “universities” was a chapter in the stupid class war. It was perceived by the class warriors that technical schools were “inferior” to universities such as Bristol or Exeter, so they were “levelled up”. This was a lot of utter nonsense and has set Britain back behind other Western countries. Both types of further education have their place.