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| Social care in the 21st century one of the great issues of our time |
| Email your comments In May, the government launched a large-scale and long awaited nationwide consultation on how social care should be funded in the future, with the discussion document: “The case for change - Why England needs a new care and support system” (HM Government 2008). It was unveiled at an event hosted by the think-tank organisation the King’s Fund and was attended by the Prime Minister, Gordon Brown and care services minister, Ivan Lewis MP. The six-month consultation process will culminate in a governmental Green Paper due for publication next year (a Green Paper being a consultation document issued by the government which contains policy proposals for debate and discussion before a final decision is taken on the best policy option. A Green Paper may contain several alternative policy options. Following such a consultation the government will normally publish firmer recommendations in a White Paper). As part of this process the government will be asking the public and stakeholders at a series of regional events, for their views about care and support, to create a new system that:
The scale of the problem The rapidly ageing population means that in 20 years’ time a quarter of the entire population will be over 65 and the number of people over 85 will have doubled. Furthermore, in 20 years time the cost of disability benefits could be increased by almost 50% and the government expects a £6 million ‘funding gap’ for social care. If current levels of service provision and patterns of care continued, public expenditure on Personal Social Services for adults is projected to rise from £12.7 billion in 2007, to almost double and reach £24.1 billion in 2026 and a colossal £40.9 billion in 2041 (at 2005 prices and therefore certainly a significant underestimate). The Prime Minister – radical fundamental reform needed The PM opined there were three central issues to reform: The PM noted that without “radical reform the provision of care and support throughout later life and through periods of serious illness and disability...” will predictably “…make even greater demands on both informal carers such as family and friends and on the care system”. The Health Secretary, Alan Johnson, concurred with this view in acknowledging the current system was unsustainable and at times unfair. Personalising care services – this challenge was outlined as the current system needing to be “more personal to people’s needs and their aspirations as individuals and to deliver…high standards of service people have a right to expect” i.e. emphasis on person-centred care. Future care services need to be more responsive to the rising demand for personal care and for independence – the thrust being on making it easier to maintain people to be cared for in their own homes. Alan Johnson also commented, “Funding is a vital part of this debate, but it is not just about money. It is also a question of individual choice, enabling people to live as independently as possible for as long as possible”. A fair system that won’t punish savers – the PM acknowledged entitlement differences between different areas of the country as being anxiogenic for people, particularly when they are most vulnerable e.g. many people fearing the prospect of selling their homes and having to use assets which they would have ordinarily passed onto family members. There was “no easy solution” but “it is essential that in future there is fairness to those who work hard and save for retirement”. He advocates the greater use of (the already introduced but possibly underused) personal budget concept which, he suggests, is essential to empower people when choosing their own care. He then goes on to introduce an interesting new political direction when he stated, “…we can and must look to give people the opportunity and the support to save for their old age in a way that insures them and protects their houses and their inheritance” i.e. a new form of social care insurance (as opposed to general taxation to fund long-term care – but there was “no country in the world where such a system was fully formed”). Ivan Lewis MP added that the current means-tested system sometimes penalized those who “scrimped, saved and played by the rules”. The PM advocated the need to consider “both how health and social care might work better together” i.e. closer collaboration, and underpinned this with the fact that more than half the NHS budget and over two-thirds of that of social care is now spent on over-65s. He concluded in ascertaining how we can “create a new social care and support system fit for the 21st century” he aimed to make “great progress” in addressing matters of social care, “one of the great issues of our time”. (A video of extracts of the PMs speech at this event can be found at www.kingsfund.org.uk/events/past_events/breakfast_ discussion.html) Telecare and Telehealth There are three Whole System Demonstrators sites (in Newham, Kent and Cornwall – announced in May 2007), which collectively serve people from a variety of demographic and geographical contexts (albeit somewhat southernly biased!). The demonstrators will run for a minimum of two years with the aim of providing services to 2,000 people per site (hence 6,000 in total). The sites will design and develop new services based on telecare and telehealth technology. Telecare is the continuous, automatic and remote monitoring of real-time emergencies and lifestyle changes over time in order to manage the risks associated with independent living. Telehealth is the delivery of healthcare at a distance using electronic means of communication – usually from service user to clinician e.g. a service user measuring their vital signs at home and transmitting this data via a telehealth monitor to a clinician. The focus will be on three patient/user groups:
I suspect these groups will not be able to be so neatly defined, will evolve differently in each site and there may be other conditions, not currently included that impact upon the scenarios/eligibility criteria. It seems the thrust of this programme is similar to that of the introduction of community matrons in recent years in an attempt to reduce the ‘revolving’ door of acute hospital patient admissions with chronic illnesses and social problems. Caring Choices – The future of care funding Caring Choices is a coalition of 15 organisations from across the long-term care system (led by the King’s Fund, Joseph Rowntree Foundation, Help the Aged and Age Concern). It sought to gather the views of older people, carers and others with direct experience of the system on how care should best be funded in the future. This was borne out of widespread concern that the current long-term care funding system is not fit for purpose. Throughout 2007, it has engaged with more than 700 individuals at events across England and Scotland and through an interactive website. The report ‘provides insights into potential areas of consensus as well as some of the difficult choices and trade-offs that will need to be made in order to create a funding system that is fair, effective and sustainable’. There was almost no support for the current funding system. Ninety per cent of participants rejected the use of a means test to determine whether or not an individual receives state-funded care i.e. they supported a stronger ‘universal’ element, determined by (person-centred) care need rather than by people’s income or wealth. The vast majority of participants also wanted a simpler system, in which entitlements are clearer and people are able to plan ahead with greater understanding of what will be on offer. Almost all participants (99 per cent) believed that more money needs to be spent on long-term care – regardless of what kind of funding system we have in place or where that money comes from Interestingly nearly three-quarters of participants believed that the costs of long-term care should be shared between the government and the individual (although there was a range of views on how that could be organised and what the balance should be). Most participants were in favour of the idea that the state should support schemes such as equity release, that help to unlock private resources or to encourage private contributions towards the cost of care. But there were mixed views on specific schemes and a clear sense that participants felt a variety of options should be encouraged rather than a single ‘solution’ i.e. clear support for a ‘co-payment’ principle in the funding of personal care, in preference to a system of free personal care. In the report, three areas in particular, were mentioned repeatedly as areas where extra funding could make a substantial difference. The most important of these was respite care services. Carers often feel they are left ‘high and dry’ by a lack of consistently available, high-quality services of this type. They emphasised the need for services whose availability is dictated by the needs of the carer and the older person, not by the convenience of the service (a problem I commonly see, especially where ‘urgent’ respite is needed, which could at times avert hospital – acute, rehab and psychiatric – admissions). Secondly, a more generous, widely available and less tightly means-tested carers’ allowance would make a big difference. The present version was thought to be insulting in its level and inadequately promoted. The third area of assistance repeatedly mentioned as crucial, 24-hour help and advice in an emergency. The ‘Wanless’ report - Securing Good Care for Older People The author, Sir Wanless, commenting on this report a year after its publication (Caring Choices, 2007), remarked on the slow progress by the government – ‘Little has changed one year on from the publication last year of my review…except perhaps a greater awareness of the depth of the crisis. The challenges it posed have not been taken up with the necessary urgency, and social care has missed out as attention and money have been directed elsewhere’. He re-emphasised the chronic under-funding of the current system where budget increases were not keeping pace with demographic change which have ‘squeezed care services’. He observed the current system only survives because of the huge contribution of informal care by family and friends, and that the postcode lottery ‘is alive and well’ in social care, with large inequitable differences in local authority charging. He noted the perverse incentives encouraging excessive use of care homes rather than care at home. Poor people with assets less than £21,000 are left with £19.60 a week personal allowance after care costs. Somewhat scathingly, he noted this was ‘the exact opposite of the rhetoric about independence and dignity’. More recently (The Guardian, 2008) the Liberal Democrat leader, Nick Clegg MP, commented on the slow progress and poor funding, accusing the government of “11 years of delay and dither” in its management of social care. He said it had “…presided over a collapse in elderly services” and that “Ministers have responded to the chronic warnings of a looming crisis with only criminal under-funding”. He felt his party was the only one to offer an immediate solution to this crisis with proposals for a ‘personal care payment’ that would ensure a fair deal for all older people and put “an end to the injustice of poor access to social care”. Wanless reiterated the obvious need to address the chronic problem urgently and felt we had ‘reached a tipping point’ where government and opposition parties all acknowledged the major shortcomings in the current system, and to work towards ending the ‘current shameful treatment of older people and transform the rhetoric into reality of dignified lives’. Febrile political atmosphere The government ‘speak’ surrounding this subject is rich in person-centred rhetoric but again there is huge need to move from speeches to reality quickly and efficiently. An interesting and encouraging observation of such government ‘speak’ however, is that it is finally incorporating a human rights-based approach in its language with terms such as fairness, respect, equality, dignity and autonomy (i.e. FREDA – the government has been roundly criticised for the lack of implementation of the Human Rights Act 1998 across all areas. For a review of a human rights-based approach see Department of Health, 2007). The political atmosphere surrounding the government at this time is somewhat febrile with problems on several fronts, which I hope does not engulf or overshadow the launch of the overdue consultation on the future of adult social care. As discussed above there are already recent reports on this area which should serve as a springboard to, and provide the foundations for the consultation. Martin Curtice References Caring Choices (2007) Wanless one year on. www.caringchoices.org.uk/?p=35 Department of Health (2007) Human Rights in Healthcare – A Framework for Local Action. London: Department of Heath. Department of Health (2008) http://nds.coi.gov.uk/environment/fullDetail.asp?ReleaseID=367176&NewsAreaID=2 HM Government (2008) The case for change – Why England needs a new care and support system. London: COI & Department of Health. King’s Fund (2006) Wanless Social Care Review. Securing Good Care For Older People – Taking a long-term view. London: King’s Fund. King’s Fund (2008) Caring Choices: Who will pay for long-term care. The future of care funding – time for a change. London: King’s Fund. The Guardian (2008) Johnson signals support for social care insurance, May 12th. View at www.guardian.co.uk/politics/2008/may/12/health.localgovernment BGS Newsletter, Aug 2008 |