[00:00:00] Hello, I’m Suhail Mirza and welcome to this episode in season three of Voices of Care. My guest today is Joseph Musgrave, CEO of Home and Community Care Ireland. Joseph, delighted to have you here. Thank you for flying over to meet us.

[00:00:13] Thank you. It’s good to be back in back in London.

[00:00:16] It’s been an extraordinary four years. I think you’re coming up to four years.

[00:00:20] Five and a half.

[00:00:21] Five and a half, incredible. I wondered if we could, I’ve got some really important topics here around social care, transformation globally and in Ireland. But give us a little bit of a background on HCCI’s work. It’s an advocacy group. It’s been around and it’s promoting the idea of a unified approach to social care.

[00:00:38] Yeah, brief history of time. It was founded in 2012 by a bunch of private home care companies. I was appointed its first-ever CEO in 2018, and since then we’ve over doubled our membership. We’re open to any home care company in Ireland. And really what we do is we’re advocating for the sector to be at the leading edge of the health care discussion. Part of that overall discussion about how we care for people as they age and grow infirm. And so, we do everything from the standard things like policy, media representation, reports, and then increasingly, you know, going to conferences and doing stuff like this to talk about the wider debate because it affects us all.

[00:01:16] And when we look at home care, it’s one part of social care. If you can just flesh out for us, is it about 65% of home care provision in Ireland is from the independent and not-for-profit sector?

[00:01:29] Yes. So around 55,000 people. Ireland’s population is around 5.3 million or so. 55,000 people get publicly funded home care services funded by the state, much like, imagine like an NHS but in Ireland. So, the HSE it’s called, is the counterpart and they do fully fund home care centrally. 55,000 people get it. And the split is 65% of it is outsourced and 35% is delivered by their in-house teams. Another, around 7500 people get the disability services and that’s people between 18 and 65. And then a smaller percentage again, take private home care services. So overall you’re looking at around 60 to 65,000 people getting home care across Ireland.

[00:02:15] So it’s quite a significant segment of the economy. I think the numbers, I might be out of date. In recent years, the budget for home care has gone from just under €500 million to above 700 million now, and the hours have grown as well.

[00:02:27] Yeah, I think one of the reasons I’m still in my job is that the funding has gone up 75% since I’ve been in post. We saw a big boost in funding after and during Covid because the government took the view that it was a good policy to keep people in their own home. And we’re still building on that through, you know, reforms to how we operate home care and how we might regulate it. We might return to that topic. But certainly, the funding has increased. And the numbers of people cared for at home is very similar now to the number of people cared for in nursing homes. So, they’re almost at parity. And in fact, home care is beginning to outstretch that, whereas for the previous ten years, nursing home care was by far and away the most common way of getting social care. And that has changed, particularly over the last 5 to 10 years.

[00:03:19] And that’s, I think, a policy imperative and a preference for people to have care delivered in a home setting.

[00:03:25] Yeah, it is. I think it comes from the understanding that across the world, in fact, by 2064, more people will die than are born. And that is a stark way of saying we’re ageing, and we know this. And in Ireland, there has been a concerted effort for probably around ten years to change the policy around residential care and to more fully promote home care. There was a vision for the Irish Health Service called Sláintecare, an Irish word basically meaning care for everybody. And we are approaching sort of year seven of that vision, as a lot of these policy documents don’t translate into full action. But one of the most notable things that’s happening, apart from changes in our hospital system in Ireland, is the promotion of home care and is the promotion of the idea that people are best cared for at home as long as we can care for them at home before then, we look at alternate settings and government has, by and large, backed that up. We’d like to see more, but by and large, they’ve supported that policy.

[00:04:32] Now, you talked about the scale of home care, and the increase in the number of hours has been quite significant, picked up a lot by the independent sector. But if I just scale back a little bit, there is a really big imperative here because let’s talk about demographics in Ireland, for example. I mean, the numbers are quite stark. Over the next decade, we’re seeing, I think, a 75% increase of over 85s. So, paint that picture for us. It’s quite a big challenge socially and politically now in terms of that ageing population for Ireland.

[00:05:00] So Ireland is both one of the youngest populations in Europe, but also one of the fastest ageing. In the last decade, the number of over 65s has increased by 35%.

[00:05:12] Wow.

[00:05:13] And the number of over 65s will double over the next 20 years. One of the things I think about then is how does the social contract play out. And pensions today are funded by workers. It’s not, as you know, a lot of people think that I paid into social insurance therefore I’m going to draw out my pension. That’s not how it works. And right now, there are five workers for every person over aged over 65. So that ratio.

[00:05:44] In Ireland?

[00:05:45] Yeah, in Ireland. So that deal can be supported.

[00:05:47] Yes.

[00:05:48] In 20 years’ time there’s going to be three workers for every one person. And not only will they have to as currently constituted, as currently conceptualised, they’ll not only have to pay for the pensions of over 65s, but they’ll also have to bear the social care costs of those over 65. And I recently gave an interview to an Irish newspaper where I said, I don’t think that’s generationally fair. And this is not just a challenge in Ireland. It’s a challenge in the UK, in America. South Korea is actually on the sharp end of this right now. By 2034, they will have double the number of people over 65 as under 18. So, their ratio is shrinking. And we’ve got to think creatively about how do we solve this challenge to make sure that we don’t have a juddering social debate in 15 years’ time going, hey, wait, wait a second. The workers of today are being shortchanged because they’re having to fund a much older cohort that aren’t willing to fund it themselves.

[00:06:51] And that you touched upon that Ireland, we’ll certainly come back to that. I’ll be really interested to get your views about how that’s going to be solved. But that social contract piece, as you said, it’s playing out globally. It’s not just in the western larger GDP nations, it’s across all countries. You’ve said some you talked about South Korea. I think the stats from the UN showed something like there’s 25% of the population in high income countries will be over 65 in 2050. And that was only I think that’s tripled in the last 50 odd years. So just paint that picture. This is something actually everyone’s having to grapple with.

[00:07:26] Yeah, they are, it is as you say, it’s a global phenomenon. We are having less children and therefore we’re ageing. That’s not, I’m not trying to paint that as a bad thing. You know, I want my parents to be around for a lot longer. Um, but what it presents is a change to the way we think about that social contract. The idea that the younger generation today will be better off than their parents. That’s kind of been the promise of most societies. And also, as I said, that the workers of today fund the pensions of those tomorrow. And I think one of the phenomenon’s we’re going to encounter for the first time are starting to see it now is we’ve never lived this long, ever in the entire history of humanity. And as a result, we haven’t fully confronted what do you do when you have an older generation that are generally financially wealthier? They have more assets, more housing wealth, more pension wealth, and more private assets than the younger generation. The younger generation are finding it harder and harder to own houses and also to accrue the same sorts of wealth than their parents.

[00:08:37] Meanwhile, you’re starting to see for the first time, you know, people listening to this podcast will have parents, particularly in the UK, confronting the social care system. And they’re starting to see the inheritance, the wealth of their parents being eaten up by social care costs and go, hey, wait a second. What’s happening here? I know I’ve heard of stories of people who, you know, their mother or father has got, you know, £1 million between their financial, between their house and their pensions and whatever. But that’s disappearing between nursing home costs and the social care costs. So, we can either continue trundling towards what will be a really difficult debate. When I think in around 20 years’ time, almost everyone’s going to be confronting this problem or we can start to make some changes now about how do we fund this into the future. I mean, The Economist just three weeks ago had an op-ed basically saying the same thing that we couldn’t confront it from a position of relative strength today. Or we can wait 20 years, as you say.

[00:09:39] So this issue around the ageing population globally has a clear implication of funding models. How are nations and how is this nation and every nation going to fund? I think The Economist article you talked about mentioned that rich nations, in a couple of decades, 2050 will be devoting 21% of GDP, looking after the older population, a quarter on pensions, the rest on health and social care. That’s a huge increase from 16% of GDP only a few years ago, 2015. Talk around, I know you’ve done a lot of work around this, and you’ve been around the globe talking around these issues. What are we seeing in terms of policy initiatives? We’ve got co-payment. We’ve got social insurance. It’s a very nuanced and differentiated approach from country to country.

[00:10:22] Yeah, it is. We’ll park the workforce because we’ll come back to that. I think that’s a key component of this. But older people tend to be the most politically engaged. And as a result, some of the baby steps we’ve seen towards reform have come out against huge resistance. And I think that’s kind of made the debate seize up. You know, when Macron went to raise pensions in France, protests across the country, when Theresa May proposed quite a radical way of funding social care, where she said in 2017 that you could keep 100,000 of your assets, but in theory, anything above that would use be used to fund your social care costs. And I think she lost an election on that basis. The Dilnot Commission in the UK said differently to Theresa May, there’s a cap on how much you could spend in Ireland. We’ve ducked the question for now. And so, my view currently is that, generally speaking, social insurance systems paying into a dedicated pot provides transparency to voters. They understand what their money is being used for, and there’s direct link then to who’s paying it. In the Irish context, I have said that people over 45 should probably pay extra social insurance to fund social care costs. Those below 45 are still struggling to get on the housing ladder, so struggling to send kids to university and to school and childcare costs are also huge. So, we have to have a mature debate about a mixture of things. Number one, how is it going to be funded? I think we have to look at one of two things.

[00:12:12] Either older people, people 45, 50 have to pay into social insurance or they’re going to have to accept that some of the wealth they have built up over their lives isn’t then just transferred to their children, which embeds generational inequality, but instead is used to fund their care because society has helped them accrue all of this wealth. Should they just be able to keep it and pass it on? I think that’s a germane question. And also, retirement ages are going to have to rise. So, I think these are the mix of things, and most countries are pulling at one lever at a time, and they aren’t really painting the picture because most countries, as I say, haven’t yet dealt with a generation of older people who’ve effectively gone bankrupt because they couldn’t pay for social care. And I fear if we don’t make these changes now, in ten years, that’s the debate we’ll be having. We will be looking at, you know, Korea, South Korea has the most number of older people in poverty, that is coming to every other country if they don’t get this right. So, you know, I think that it’s probably a mixture of both, quite frankly, a mixture of higher social insurance contributions for at a certain age to help fund that social care and accepting the hard bargain that, yes, some of my wealth is probably going to have to use to fund my care.

[00:13:30] Controversial, of course, but as you say. Without hyperbole, the very fundamentals of the social contract depend on this, actually, because if we don’t get it right, there’s going to be a hell of a lot of tension.

[00:13:44] You know, one of my first kind of acts as an adult was to help to legalise gay marriage. And one of the reasons I wanted to is because not only as a gay person did, I want that, but I felt there’s this institution marriage, that promotes relationships. It’s the bedrock of many societies, and I wanted gay people to be part of that institution and not lock them out. So, in the same way, your question really, we look at the system we have right now, which for all its faults, we have, generally speaking, as a world, never been richer, never lived longer, never been healthier. We’ve got a lot of problems still to solve, like climate change and others. But broadly the system has delivered really good outcomes. So, we either sort of blow up the system. That generally leads to a lot of war, or we reform the system to maintain it. And I do fear that if we don’t reform it, this old, this ageing demographic will just collapse that generational contract, that younger people will be able to get on the housing ladder, younger people will be able to raise families. And that this new phenomenon of people living until they’re almost 100. And how do they get cared for? I think we’ve got to be imaginative. Otherwise, our system will stop working.

[00:15:07] Absolutely. Now, the other side of that coin, of course, is having the people to deliver the care around the world and in Ireland, in the UK. And I want to touch on workforce and what you’ve picked up in your global engagement here, because it seems to me when we look at work from the Global Ageing Network, etc., and findings that the perennial issues of social care workers and social care professionals, we should call them because of the complexity of the work that they do. It seems to be echoed around the world. It’s underappreciated work. Lots of pressure. What are your thoughts? Because we’re going to need to solve that problem as well.

[00:15:44] Yeah, we are so. My youngest brother was a carer. He left because he saw no room for advancement and the work carers do is phenomenal and complex emotionally, physically and from a skills point of view. Back to that kind of system we talked about. I have challenged conferences and I have said, if your son or daughter came to you and said, Mum, Dad, I want to be a carer, tell me truthfully. Would you not be disappointed? And why would you be disappointed? Not necessarily because of the thing they want to go do, but you know, it would lock them out of the ability to own a car or own a house, build a capital in order to do something. We have a system based on accruing capital. So, in Ireland, we have done some things like raise the hourly wage rate. But I still think there’s a tension between what we learned during Covid, all of these vital things. Care being one of the foremost among them, does not command the same hourly wage rate as an AI engineer and never will. And let’s be realistic about that. So, I then think, well, how else could we promote both the recognition of caring as a profession, but also its contribution to society? And I think we need to look at something like Universal Basic Capital. We’re familiar with Universal Basic Income.

[00:17:13] Universal Basic Capital is the idea that at a certain age, everyone should be given a capital grant. There’s a professor at the LSE, Julian Le Grand, who used to lecture me where this kind of comes from. Piketty has done this. In my view, we’ve got to take some essential things like care. And I think we could say to care workers, not only are you going to get a slightly better wage than the minimum wage in Ireland, they get the living wage as a basic rate. Not only do we need to look at the pathways to develop that career, but I think we should be saying to care workers, hey, listen, if you do this work for five, ten years or whatever, we’re going to give you 15,000, 20,000 in capital, something meaningful that allows them to get a car, send a kid to university, maybe help put money down on a house. Because what I hear from carers is I can’t get a car loan, I can’t get a mortgage. My work is not frequent enough, I don’t have rational hours, or I can’t save that much. So, I think we’ve got to let them into the system. Either you lock low wage workers, which frankly, care workers are low wage workers right now. You either lock them out of the system or you let them into the system.

[00:18:34] And if we lock them out, we’re going to be drawing from the current cohort and have little hope of meeting the projections of increased demand, because we need to make the sector hugely attractive to graduates and people leaving school.

[00:18:47] Exactly right. We can either create an underclass of people that provide this care, you know, sorry to sound slightly populist about it. Elon Musk does not need $1 trillion. He can’t spend all that money. And I think we have to take a view of society being it is literally it’s not individuals, it’s a society. And I think we have to say to those, particularly things like care, you know, some people are going to have to help pay into a pot to give these people access to this system of accruing capital. If they don’t get access to it, they’re not going to want work. As you say, we’re going to run out of people to provide the care and the work, and we could do all the reforms then we want to social insurance contributions and pension ages and everything else. But no one wants to go into it because there’s nothing for them. We’re just asking them to essentially volunteer to be carers. Again, I think there are things we can do in the meantime around the wage. They get paid around the career path, and we’re doing some of that work at HCCI. I do think we need to go a step deeper than that. Otherwise, it will not be attractive enough for people to do this work. And it also fails to recognise the trade-off they’re putting in if we don’t give them capital, whereas we’re not recognising, in my view, the fundamental contribution they’re giving to providing care.

[00:20:10] No, it’s an interesting point because I think studies have been shown here in England, there’s 5 million unpaid carers, for example. I think their economic value of the work there is over 160 billion. So, it’s an interesting topic. I want to come back to the situation here in the UK, new government election and then finish off with Ireland. But one quick interjection, if I may, from your global perspective, some of the things that you’ve seen that perhaps you’ve been impressed by right now where societies are tackling, I think there’s been some efforts at more unified approach with health and social care and the use of technology.

[00:20:42] Yes. So, I mean, technology excites me. We see stuff out of Japan with diabetes interventions and we see some of the technology now being deployed in some parts of the States and some parts of Germany. This is all to say that I think there’s a category of care work that doesn’t require a physical human to go in. There’s a category which is around monitoring and medication prompting and essentially aiding somebody without physical intervention. And a lot of systems currently, the IRIS one is chief among these. It doesn’t fund the technology interventions; it only funds an hour or a half hour of care. And it doesn’t yet recognise that a piece of technology, you know, say overnight monitoring that alert to care to come and, you know, help out. We’re starting to see some of those in nursing homes. But yeah, some of the technology we’re seeing getting embedded in the Japanese care system in particular, where it is quite closely embedded, and we’re starting to see some things in New York State in particular. They passed a law in 2015 to promote working between different healthcare groups. We’re starting to see technology being embedded into those systems. That is quite exciting to me, and it’s something that I think commissioners of care have to get more intelligent at is commissioning for a technology as well as a physical hour of care.

[00:22:09] I’m bringing the discussion back here to these shores in the UK and in Ireland and the election, the new government, anything that you’ve seen, or you would call for because obviously the UK should be a beacon in many ways to support innovative thinking. You’ve talked about the New York example. We have a supposed uniform system, unified system here in England with integrated care systems. But just wanted to get your view on the election and the prospect of social care, which did begin to get some sort of headline.

[00:22:39] Number one, I’ve got to give a lot of credit to Sir Ed Davey and the Liberal Democrats for putting care at the forefront of their message. You know, I think I follow the debate here closely. I was born in Scotland. I lived in London for several years. And you can see the horse race taking over. Sunak. Is he up, is he down, is he going to leave? The D-Day thing? I get all of that right. I get the soap opera around that. But Ed Davey and the Liberal Democrats are talking about something quite fundamental and calling for a new deal on care. And I think some of their proposals are interesting around a Royal College of Carers. I think some of the proposals around a differentiated minimum wage for carers, higher than the minimum wage for other people. We’ve done something similar actually in Ireland already. I think those are good, solid proposals. But because of the soap opera around who’s up, who’s down? The two big parties, Labour, and Conservatives, are getting off lightly with talking about this topic, and they’re flirting with the idea of Dilnot’s cap of maybe 86,000 is the max you can do. But the Conservatives have been promising that since 2019. And we’re yet to see what Labour come out with. But as I say I doubt any will be kind of fundamental far-reaching reforms like I’ve talked about that would actually put it on a sustainable footing. So, credit to the Lib Dems. I think the other two are ducking it because they’re getting away with it. They’re not getting the policy scrutiny.

[00:24:07] Well, let’s finish off where we began, which is to look at Ireland and hopefully not duck. You’ve not been afraid of these questions in recent public pronouncements, we talked about the budget for home care, jumping from just a shy of €500 million a few years back to 700 million plus 2024. I think the projections I’ve seen; it’s going to get close to 2 billion in 2035. If the numbers are right, what would be your prescription? Having looked around the globe, looked at this social contract imperative. There’s been an effort to introduce a statutory scheme. Tell us a little bit about that and what would be in a nutshell to finish off your prescription for home care in Ireland.

[00:24:51] So I think one big thing is that we had a care referendum earlier this year in Ireland, and it’s the largest margin of defeat in the history of the Irish state. And one of the reasons why is because it was hollow. It was changing the wording in the Constitution. It wasn’t a fundamental rethink of the deal on care. And for my mind, there’s three things that Ireland needs to do and can do. One is regulate the sector. And they’ve brought forward regulations which were working with the government on, good thing. Second thing is a legal right to care. And I don’t say that as just some airy-fairy statement about rights, but one of the things a legal right to care then demands of a government is to get these policies in place. Because you can’t provide the right if you don’t have your workforce plan, etc. So, I think a legal right to care is really important. And then. Lastly, how do you fund it? And the government started in 2016 with these three things, and they’ve dropped the funding and the legal right question. So I think as we head into an election season in Ireland, which is either October but latest by next March, these are the things I’ll be putting front and centre of our agenda and trying to get the political parties to promise a legal right how they’re going to fund it, and let’s regulate it properly.

[00:26:10] On that note, Joseph Musgrave, we are delighted to have had you to share your vision with us and hopefully you’ll come back once the election is over and tell us how that’s all gone, but for today, thank you so much.

[00:26:20] Thank you.

[00:26:21] If you’ve enjoyed this episode of Voices of Care, please like, follow, or subscribe wherever you receive your podcasts. And if you want to find out more about how we are transforming the discussion on health and social care, please visit newcrosshealthcare.com/voicesofcare. In the meantime, I’m Suhail Mirza, thank you very much.