Despite a big overhaul in the way care for the elderly will be funded, there are still fears that it isn’t enough and we’re surely “heading towards disaster”.
The government is keen to emphasise the importance of its Care and Support Bill, especially after a somewhat policy-light Queen’s Speech. The highlight of this bill is a £72,000 cap on care costs from 2016 and is part of the government’s response to how we fund long-term care for the elderly without them having to sell all of their assets.
Many see this measure as a half-hearted response that will disproportionately benefit the better-off. Andrew Dilnot, who was commissioned to report on the issue, recommended a cap of £35,000.
Now the King’s Fund, a health thinktank, points out in its new report that the real problem in adult social care is not so much about protecting people from the high costs of care but their eligibility for local authority help. The criteria is set so high that it will be difficult for many people to qualify.
Around 231,000 fewer elderly people in England received help with their care from local authorities than four years ago, despite an increasing number of people reaching old age. And it’s not because people are getting richer.
The ratcheting up of council eligibility criteria for accessing support has been going on for some years and the problem was fully exposed in Lost to the System, a report I co-wrote for the now defunct Commission for Social Care Inspection, back in 2007. The situation is now far worse, with vastly reduced funding in the face of rapidly rising demand.
As the King’s Fund report notes this has a knock-on effect across the whole system, and in particular there is now less focus on preventive care, more demands on family carers and increased demand for expensive NHS care.
The way forward is divided
Few dispute this diagnosis. Where opinions differ is on how best to respond. For the King’s Fund it’s “a single strategic budget for the NHS and social care”. This would help to better shape care on a person’s individual needs. It would also put the new Health and Wellbeing Boards, where leaders from health and social care now have to come together, in the driving seat.
The idea of one pot of money is intuitively attractive. It would also pave the way for the Department of Health’s proposal for up to ten “integration pioneers” to run large-scale experiments on integration of health and social care across England.
However, as is often the case with the debate about integrating health and social care, it is not so much the vision that is the problem but the detail.
The first dilemma is the fact that adult social care is means-tested while NHS care isn’t. The past 30 years have seen more and more former NHS activities surreptitiously shunted over to local councils - and Andy Burnham, the shadow Labour health minister has proposed more council control.
But establishing a single budget around individual needs doesn’t solve the old problem – what is paid for and what is free?
Who pays and who has control?
The neatest answer is to put adult social care on the same footing as NHS care – free at the point of use and funded via general taxation.
Pushing the Health and Wellbeing Boards into a key role is another difficulty. These boards are barely out of the starting blocks and there is no evidence to suggest they are able to take on the major job of planning and commissioning care yet.
The only alternative is to vest control in either the NHS or local government.
The Labour Party seems to favour doing this, as Burnham’s idea shows. But the government has only just established clinical commissioning groups in the NHS to put GPs in the driving seat when it comes to buying in services. Do we really want another “redisorganisation”?
Whether the NHS or local government takes a lead, there are question marks over who has the best skill and capacity to commission health and social care services. Does anyone imagine that one budget in the hands of a single or joint organisation or agency will solve everything?
The Health and Social Care Act is taking us in a different direction with competition and outsourcing to private companies. It’s not a distraction being faced by people in Scotland or Wales who aren’t covered by this legislation.
What is certain is that this is a system-wide issue that requires everyone – commissioners, social care providers and the public - to sit around the table and plan this strategically.
Ultimately the real issue is about priorities. Do we, as a society, want to find the resources to invest in securing better care and support for people who are sick and frail? If so then resources can be found. But until this happens we will continue to have a fire-fight over people with the highest need while allowing others to fester behind closed doors.