The Big Care Debate
by Paul and Jennifer Roberts
This article is published in the latest edition of the Journal of Care Services Management. For details on how to subscribe to the the Journal, contact the publishers on www.henrystewart.com
A bold vision for the future of care in England – or a document long on options and short on costs? The blueprint for a National Care Service – or an unrealistic and unattainable goal? A green paper that offers the way forward for radical reform – or one that will founder in the face of a General Election and cutbacks in a continuing recession?
The ‘Big Care Debate’ on the Government’s green paper, Shaping the Future of Care Together,1 provides the first meaningful step towards answering these key questions. Praise, fears and fierce criticism have been voiced in equal measure over the 136-page document, launched by Health Secretary Andy Burnham on July 14, 2009.
With public consultation on the green paper ending on November 13 this year, this is a good opportunity to reflect on the proposals put forward, the initial reaction to them and the hurdles that need to be overcome to make them reality.
The creation of a National Care Service2 – heralded by the Government in terms similar to the National Health Service – is the key goal in Shaping the Future of Care Together. A refreshingly ambitious plan to make the care system fairer, simpler, more affordable and tailored to meet individual needs, it has, not surprisingly, won widespread acclaim.
At the heart of the National Care Service would be:3
· Better prevention services to enable people to stay independent
· The right to have care and support needs assessed in the same way
· Better ‘joined up’ care and health services
· Improved information and advice services
· Personalised care and support
· A fair funding system
Many of us would welcome this as a way forward. But is it achievable? Is it affordable? How long would it take to create a National Care Service? Would the funding system be fair to most, if not all people? Would the plan ever come to fruition with a change of Government a real possibility in 2010 and the Conservatives and other political parties yet to announce their proposals for social care reform?
The Government has given clues to some of the questions. For instance, there are strong indications that it will take five years to start ‘phasing in’ the National Care Service. The green paper sets out complex and controversial options for funding the new system. As the financial implications are put under the microscope, it is clear that the road to radical change will be a long and rocky one.
The Government is suggesting three ways in which the National Care Service could be funded in the future:4
· A partnership arrangement in which the state would guarantee a certain level of care (potentially up to a third), leaving the individual to pick up the bill for the rest. For many, this could total £20,000, but this figure would be much higher for people needing long term care
· An insurance model, again guaranteeing a certain level of care, in which the Government would help to set up private or state insurance schemes to help people cover the extra costs – and protect their savings
· A compulsory state insurance scheme in which people reaching retirement would pay between £17,000 and £20,000 – through a lump sum, instalments, or from their estate after death – to fund their social care package
The Government, which believes that a partnership arrangement would provide the best foundation for the new system, argues that, with the average cost of social care for a person aged 65 being £30,000 over the remainder of their lifetime, many people would be financially better off under any of these three schemes.
The Government indicates in the green paper that it would attempt to tackle one of the most talked about issues of today – the ‘injustice’ of people having to sell their homes to pay for residential care. It says it would be prepared to ‘look at’ allowing people to defer the costs of going into care until their death, when the amount would be taken from their estate.5
How our future care needs are funded will be the focal point of the ‘Big Care Debate’. In looking at the merits and pitfalls of the three options tabled, we first have to decide whether it is right that we should have to pay for care in our old age. Should the state meet a smaller or larger proportion of the costs that many of us are likely to incur? Who will suffer the most under the changes proposed?
If we genuinely want a National Care Service with all the benefits described, then the vast majority of people will have no option but to make a substantial contribution towards their future care. With 1.7 million more people likely to need care and support in England by 2026,6 public funds will be stretched to the limit – and beyond – to meet even a small proportion of our care costs.
We have to start looking at paying for care in the same way as taking out life assurance or car and house insurance. We should also consider it in terms of a weekly or monthly ‘maintenance’ arrangement. Many of us pay out regular amounts for gardening and hairdressing, for our TVs, domestic boilers and computer equipment. Should we begin to treat payment for care in the same way?
If we want the right care at the right time and high quality and better ‘joined up’ services, the investment required will be huge. Much of that money will have to come from our own pockets. A partnership arrangement, guaranteeing payment for up to a third of care costs, backed up by affordable and easy-to-take-out insurance, could well be the best way forward for many people in England.
Most of us would prefer joining a voluntary insurance scheme. But would that be effective? How many people would take out this kind of insurance? Twenty five per cent? Fifty per cent? Fewer than one in five of us? Maybe, deep down, we know that compulsory payments – where everyone who could afford to do so would pay in, whether or not they actually needed care and support themselves – would be the only solution.
Either way, the Government will face a monumental task in persuading us that insurance payments through private or state-backed schemes will be reasonable and available to the vast majority of people. The thresholds for qualification, the methods of payment and the likely premiums – information not yet at hand – will be crucial to the public reaction to insurance proposals.
The ‘Big Care Debate’ gives us the first real opportunity to consider our future care needs and how serious our support will be for meaningful change. As we examine the options in this consultation period, we need to establish the ‘devil’ in the detail and the likely ‘losers’ in the funding shake-up to ensure that the poorest and most vulnerable will not become victims of the new system.
For instance, many people facing long term care, including those with dementia, could still face crippling costs running into hundreds of thousands of pounds under a National Care Service. Will they be able to secure affordable insurance to pay for their care? Will they really be spared the loss of their home to pay for accommodation costs if they face 10-20 years of care?
In a letter to The Times newspaper, Leon Smith, chief executive of the care home business, Nightingale, expresses disappointment that the green paper ‘does not challenge a significant flaw in the current system – the means of the children. Instead some children – who may be in a position to help – will be able to continue to wash their hands of any financial responsibility for their parents, who are then funded by the state,’ he says.7
A plan to convert the Attendance Allowance8 – a disability benefit paid to older people – into a discretionary grant for those most in need is being met with growing concern. The allowance, which is not means tested, is currently paid to more than 1.5 million people aged over 65. A similar benefit for the younger disabled is unlikely to be affected in any payments reorganisation.
The Attendance Allowance, usually fixed at between £47 and £70 a week, is very popular among the elderly. Although existing claimants would have their money protected under a revised system, stopping the payment of the allowance could provoke a powerful ‘anti-lobby’ that could dominate the debate on care needs. Stephen Burke, Chief Executive of Counsel and Care, says there could be a ‘massive rearguard action’ to defend the benefit.9
Charities, meanwhile, have rightly criticised the lack of focus on younger disabled adults in the green paper. Mencap chief executive Mark Goldring says it doesn’t address the need for additional learning disability funding. ‘The Learning Disability Coalition, of which Mencap is a member, recently submitted evidence to the Treasury that learning disability services are under-funded by £200 million per year. Over 200 MPs have signed an Early Day Motion (EDM) to plug this funding gap,’ he says.10
‘It is highly disappointing that the government has failed to provide clearer guidance on how it will provide better services for a growing population of people with a learning disability. Many people with a learning disability are not getting the support they need and better assessment and portability are not enough without the money to respond to people’s needs.’
One area that has hardly raised a whisper in the reaction to the green paper is the proposal to award personal budgets to all people in England once their care needs have been assessed.11 This landmark move comes in the wake of successful – and some not so successful – pilot projects launched after the publication of the Government’s Putting People First12 or personalisation agenda.
The expectation is that ‘every eligible person who wants a personal budget will get one. This means that people will know how much resource they have available and that they will be able to make decisions about how it is used,’ says the green paper. ‘Everyone will be able to have as much control as they want over what their care and support money is spent on. Every local authority is working towards the goal of making personal budgets the norm in providing care and support, and the Government has invested £520 million in the Social Care Reform Grant to help them do this.’13
Investment in ‘re-ablement’, a six-week scheme designed to help people regain skills to enable them to continue living in their own homes, is seen as a priority in the green paper. Already in wide use in many areas of then country, the Government suggests that people leaving hospital and needing care and support for the first time, should have the ‘right’ to help through re-ablement.14
That is a very positive step. But disappointingly, telecare – bringing technology-based care and support into a person’s home – does not get the same attention and recognition. The government says it will continue to ‘promote’ telecare and ensure information about prevention and early intervention technology is widely available, but there is no indication that it will be given priority status.15
The consultation period for the green paper ends on November 13, 2009. It is due to be followed by a white paper in 2010. That will be a General Election year. The white paper itself could be delayed because of this and the implementation of plans for reforming our social care system could be put on hold for some time after that.
It could be 2014 before we see the introduction of a National Care Service.16 Who will be in power then?
A change of government could mean a change of priorities. The Conservatives, for instance, are yet to unveil their plans for reforming our care system. If they form the new Government after a General Election, their enthusiasm for proposals put forward by a Labour Government could be less than lukewarm.
The danger is that nothing will happen unless:
· There is an overwhelming call for reform from the public during this consultation period on the green paper
· The Conservatives and other leading political parties outline their clear vision for the future and identify the changes they favour
· A white paper capturing the public mood and expectations for the future is published early in 2010
It’s a big ask. But this is a time for decisiveness, boldness, strong words and action. Anything less could lead to a ‘do nothing’ outcome that could delay reform for a decade or more.
References
1. HM Government, Shaping the Future of Care Together, Published by The Stationery Office, 14th July, 2009 (Crown copyright).
2. Vision outlined by the Prime Minister and senior ministers in green paper (Pages 2-6).
3. Vision for the future (Pages 47-49).
4. Funding options (Pages 96-127).
5. Accommodation costs (Page 120).
6. Future pressures (Page 10)
7. The Times, Letters to the Editor, Old-age care and offspring’s duty, 17th July, 2009.
8. Disability benefits (Page 102).
9. Counsel and Care, Green Paper ambition to create a national care service ‘on a par with the NHS’ praised by Counsel and Care, Counsel and Care press release, 14th July, 2009.
10. Mencap, Government plans to create National Care Service, Mencap press release, 14th July 2009.
11. Personal budgets (Page 60).
12. Ministers, local government, NHS, social care, professional and regulatory organisations, Putting people first: a shared vision and commitment to the transformation of adult social care, The Stationery Office, 10th December 2007.
13. Personal budgets (Page 60).
14. Re-ablement (Pages 51-52).
15. Telecare (Pages 51-52).
16. Plans for phasing in of National Care Service, starting from 2014, outlined by the Government at press conference to launch green paper, London, 14th July, 2009.
Jennifer and Paul Roberts
Joint Editors
November 30th, 2009 at 4:21 am
Health reform will not cover very much long term care, at least nothing close to what long term care insurance covers.
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