Last reviewed 24 July 2012
Jef Smith reacts to the publication of the White Paper Caring for Our Future: Reforming Care and Support, and offers a suggested solution for the future funding of care.
Journalists fairly routinely describe government publications as “long-awaited”, but in the case of the White Paper on social care that description is more than justified. The Dilnot Commission’s report to which it is the official response was published more than a year ago, and when that came out the Department of Health promised to react “in the autumn”. Nothing having materialised by Christmas, that phrase was smoothly replaced by “in the spring” and officials, as if admitting the possibility of further slippage in the timetable, studiously declined to be more precise. The document was eventually published on 11 July.
There is more than point-scoring to this chronology since the repeated delays demonstrate the difficulty the Government has had — and, to be fair, a government of any other political persuasion would equally have experienced — in reaching decisions on the highly controversial and complicated questions involved in social care funding. Labour when in power not only ignored the recommendations of the Royal Commission it had itself set up, but also failed to take any effective action for the remainder of its 13 years in office. There are genuine political differences over social care, as the bitterness and ultimate breakdown of inter-party talks in both this and the last parliament demonstrates. Nevertheless, the failure of politicians to summon up the courage to take action in an area everyone recognises as crucial is surely by this stage quite deplorable.
All might have been forgiven if what emerged after all this delay was in any sense a solution. In fact the White Paper has been met with almost universal condemnation. Mike Padgham of the United Kingdom Home Care Association (UKHCA), for example, deplored the buck-passing between central and local government and appealed for cross-party talks to be resumed as soon as possible.
The Secretary of State’s description of its appearance as a “watershed moment” was surely tongue in cheek, most commentators preferring epithets like damp squibs, sticking plasters and long grass. A mountain of consultation and consideration has, it seems, brought forth no more than a mouse of action, and much of what is proposed is to be deferred pending further thought about how it is all to be financed. But wasn’t this pretty much where we came in?
The fact is that funding, ostensibly the White Paper’s central issue and certainly the key element in Dilnot’s terms of reference, has again been sidestepped. Unlike the NHS, social care is paid for by individuals, the exception being the very poor who have to undergo a means test to receive local authority funding. So high can the costs be, especially if care needs continue for some years, that many people have to sell a property to pay the fees. The arrangement is widely unpopular, not least among the children of service users who would otherwise stand to inherit, and for people wanting to stay with help in their own homes — easily the majority preference — the option of selling up is of course not available.
The Commission’s first recommendation addressed this problem with a cap on individual contributions to care costs at £35,000, a figure which, Dilnot recognised, could be varied by political decision. The second proposal was that the asset threshold for those who would be eligible for free care be increased from £23,250 to £100,000, but people born with a care need or developing a need early in life should be eligible for free care without a means test.
This was a reminder that the question of how care and support are paid for is not one faced only by older people. The so-called “young disabled” may be just as needy as those who develop dependency in old age, but financially their situation is often quite different as they have not had the chance to plan for expenditure by responsible saving.
The Government’s self-styled “progress report on social care funding” goes no further than agreeing “the principles of the Dilnot model”, but immediately adds the killing condition “if a way to pay for it can be found ... given the structural deficit and the economic situation the country faces”.
A decision has therefore been put off till the next Comprehensive Spending Review, which will probably take place only in 2014. Professor Dilnot has been touring the country over the last year telling audiences that the cost of implementing his reforms — initially less than £2 billion, rising to £3.6 billion by 2025 — would be a drop in the ocean of the public expenditure budget as a whole, but such calculations have clearly not carried much weight at the Treasury.
Dilnot’s attempt to shrug off the financial implications of care reform has never chimed with the Secretary of State’s repeated caution. In his first reaction to the report’s publication, Mr Lansley warned that “we have to consider carefully the additional costs … against other funding priorities”, and having bluffed the Government into a costly reorganisation of the NHS, he clearly has little illusion that he could work that trick twice.
With or without Dilnot, the financial implications of the predicted growth in the elderly population is already worrying politicians. In August 2011, the Office for Budget Responsibility (OBR) predicted long-term and deepening public sector debt, arising largely from simply maintaining existing levels of services for older people. Coincidentally, OBR repeated its dire warning only a couple of days after the White Paper’s appearance. Growth in the numbers of vulnerable people living at home is in principle good news for the domiciliary care industry, but only if the rise in demand is accompanied by realistic resourcing.
Funding schemes in the White Paper
What the White Paper is able to offer on the resource front, therefore, is pretty insignificant. The £300 million made available over the next three years from the NHS to “promote better integrated care” represents a relatively small addition to the well-established programme of transfers within the DH budget, but like other proposals is cost-effectively neutral.
The deferred payments scheme, under which anyone going into residential care can delay the sale of their own home, is to be made universal rather than dependent on the policy of each local authority, but the care fees debts thus created will still have to be paid after the resident’s death: a policy the Conservatives derided as a death tax when it was proposed by Labour.
For the rest, the White Paper offers not much more than a regurgitation of existing plans and aspirations. The welcome implementation of the Law Commission report which recommended the consolidation of social care legislation into a single statute had already been announced, though the related consultation about social workers’ right of entry to private premises where they believe abuse might be occurring will be a considerable reassurance to home care workers. These matters, however, are not directly linked to funding and the impression remains that they have been thrown in to distract from that central deficiency.
Elsewhere, well-rehearsed phrases like “helping people stay active”, “enhancing dignity and respect” and “supporting carers” represent little more than reiterated background in a document which was supposed to be presenting firm new proposals.
National minimum eligibility threshold
One proposal momentarily rises above the generally banal level: the introduction from April 215 of “a national minimum eligibility threshold”. At present eligibility for officially provided support is determined by a system known as Fair Access to Care Services (FACS), a system which politicians have often criticised but which was actually devised by the Department of Health. It sets out four categories of need: low, moderate, substantial and critical, each with a full definition, providing in effect a framework for rationing.
As the resources, priorities and policies of local authorities vary, the level of need a potential user has to demonstrate varies in different parts of the country, creating a so-called postcode lottery. Viewed from the centre this is clearly unfair, but such variations are an inevitable result of a system where services are run and decisions taken by elected local politicians, just as the anomaly of free care in Scotland and means tests in England flows from devolution.
It is all very well to set a minimum threshold, but little will be gained if the bar is so high that most people in need remain excluded. The problem over recent years has been less one of differences between areas than of a general upward shift in the level of vulnerability people have to present before getting help, so that almost all local councils now require the need to be at least significant. This can leave vulnerable people in their own homes existing without help for long periods, their dignity and independence apparently counting for very little. Again, this reflects not local perversity but the absolute shortage of resources, a problem for which the White Paper offers no solution and pretty little hope.
A suggested solution
As the debate about the future funding of care has been so disastrously derailed, let me close with a positive contribution that frankly recognises the reality of the national economic crisis rather than trying, as Dilnot unsuccessfully did, to deny it.
Britain’s economy needs growth and an increasing number of economists are urging that this will be achieved not by channelled newly printed money through the increasingly distrusted banking system but by helping consumers to start buying goods and services at an increased rate. So here’s my suggestion.
Local authority adult social services departments should be given an immediate and substantial cash injection to be spent on commissioning additional social care services for vulnerable people. Eligibility for free care would be widened to include many excluded by current levels of means testing and the qualifying level of need significantly lowered.
It would be a condition of the scheme that the money could only be used to purchase from providers who undertook in return for higher fees to make systematic improvements to their services, with improved standards to be rigorously monitored by the CQC.
Enhanced staff training, accompanied by substantial salary increments for those gaining qualifications, would be one obvious area of expenditure; others, in the domiciliary care field, could be extending the length of currently brief visits, better support for front-line staff, and more breaks for family members providing care. (Even implementing Dilnot in full would achieve none of these.)
The effect of this initiative, which I put forward in all seriousness, would be to improve the lives of service users, to relieve pressure on families and carers, and to enhance the status of care work as a career. As far as the nation’s finances are concerned it would provide a swift injection of purchasing power aimed at groups, notably elderly and disabled people, hard-pressed carers, and the social care workforce, who being relatively poor are likely to spend it quickly, indeed in some cases will be obliged to do so.
This is exactly what the economy needs. Taking all those benefits into account, an appropriate name for the scheme would be “qualitative easing”.