Select Committee on Health Minutes of Evidence

Memorandum submitted by Social Policy Ageing Information Network (DD 22)


  1.1  The SPAIN group is a consortium of over 30 voluntary organisations of and for older people, which meets on a regular basis to work together on issues to do with social care and older people.

  1.2  The SPAIN groups welcomes the Committee's inquiry into delayed discharges. The consequences of the lack of social care for older people are stark. Social care for older people, like the NHS, has suffered from long term under-funding. Like the NHS, it shows signs of major strain, with rationing on many fronts. But while substantial new investment is promised for the NHS, there has been no comparable review of social care funding. The SPAIN group has documented the impact of delayed discharge and the difficulties that older people and their carers experience in trying to access care.[12]

  1.3  Just over a million older people receive formal social care, nearly half in their own homes, the rest in care homes. The great majority are in their 80s and older, all are frail, many are disabled and a high proportion suffer from dementia or other mental health conditions. They experience huge difficulties in trying to access the care system. In addition, older people make up two-thirds of all hospital patients.

  1.4  The government has taken major steps to modernise the health and care system. Older people and organisations that represent their interests warmly welcome the Government's commitment to improve services through the NHS Plan, the National Service Framework for Older People, the setting of minimum standards, improved joint working and the modernisation of social services. We also welcome the commitment to substantial new investment in the NHS. However, for older people and their carers, health and social care are part of the same system. The underfunding of social care leads to back-ups and bottlenecks in the NHS which jeopardise the realisation of the Government's objectives for the health service.


  2.1  There are waiting lists for older people even in the highest need categories—people may have to wait for weeks or months without help for residential or nursing home care or for support in their own homes. There is limited support for those older people assessed as being in moderate categories of need, as those in the highest categories have first call on resources, resulting in unmet care needs and reduced quality of life and a need for more expensive care later on.

  2.2  With ever tighter eligibility criteria for access to social care, those being looked after by Social Services are frailer and more dependent each year. The intensity of services has therefore increased, with fewer people receiving more hours of home care, as reflected in Department of Health statistics and the attached chart (App 2). Local authorities, perhaps understandably, give priority to older people living alone. However, too little help is available for carers, including older carers living with their sick husband/wife, who may themselves be of a similar age and in a poor state of health; research demonstrates that older co-resident carers receive little help from health or social services.[13]

  2.3  Although provision for respite care is rising nationally, there is not enough to give carers a break and those needing care a change in routine, whether in their own home or in another location. Many carers have been caring for years without a break. Day care lacks focus and clear purpose. It may not be available to those who could benefit and doesn't deliver what people want.

  2.4  Ethnic minority community organisations—the only gateway to health care and support for many ethnic elders—are poorly and insecurely funded and have to restrict access, resulting in isolation for many elders. There is little or no scope for innovation and development of preventative services or for investment in community-based services to support the continued independence of older people, severely impacting on Standard 8 of the NSF. The merging of prevention and partnership grants has exacerbated this situation.


  3.1  Social services authorities customarily place lower cash limits on social care packages for older people than those for younger people, irrespective of the level of need and contrary to Standard 1 on the NSF for Older People. For example units costs of residential and nursing care in 2000-01 were £342 for older people, £512 for those with physical disabilities, £423 for adults with mental health problems, and £669 for adults with learning disabilities.[14] If local authorities are to equalise levels and quality of care between older people and younger adults, a major new injection of resources is going to be needed to bring older people's services up to those routinely expected by other groups.

  3.2  Home care hours are tightly rationed for those who do meet the eligibility criteria; short task-orientated visits are commonplace, and there is little or no scope to promote quality of life. Tasks undertaken by home care workers are strictly limited and tightly defined, resulting in little or no choice for the user and lack of person-centred care. Home care is rarely able to adapt or be responsive to changing needs or personal circumstances. It tends to be fixed in the mould of the original assessment, and unable to adapt without ponderous reassessment procedures.

  3.3  Older people are denied the choice of staying in their own home when the cost ceiling for home care is reached. Local authorities have a financial incentive to require people to move into residential or nursing homes when their needs are high, since they can insist that someone's home is sold to pay for care once someone is no longer living there. Moreoever, the quality of life and quality of care in residential and nursing homes is restricted due to lack of staff time, skills and resources.


  4.1  Charging for personal care impacts most on the oldest and frailest pensioners—it is discriminatory in its effect, increases pensioner poverty, promotes social exclusion and adds to the likelihood of needing long term care. Charging regimes are discretionary with regard to home care, day care and respite care, resulting in widely variable charges in different areas, inequity and a postcode lottery.[15]

  4.2  The public does not recognise the distinction between personal and nursing care, resulting in widespread confusion and a sense of injustice amongst older people and their families when they are required to pay for care. The additional assessment process for people in nursing homes using the Registered Nursing Assessment Tool requires yet another process which distracts from person centred care and creates confusion and delay.

  4.3  There is little help and support available for self-payers in most areas at a point where they are having to make critical life-changing decisions. Some local authorities refuse assessments to those with savings over the capital limit, leaving them to find their own way through the care system (the Fair Access to Care Initiative should deal with this when it comes into force).

  4.4  The single assessment process is complicated by the need to undertake a financial assessment as well, and financial assessments are difficult to carry out when people are very ill, very frail or in a hospital bed—the very times when they are most likely to need care.


  5.1  £900 million funding was allocated in the NHS Plan for Intermediate care, and the development of active recovery and rehabilitation services and rapid response teams to prevent admission to hospital. An additional £300 million over two years has recently been announced. The adequacy of this level of funding in relation to the level of need is unknown. There are, however, concerns about the distribution of the money between health and social services; evidence from the Social Services Inspectorate indicates that there has been "a diversion of intermediate care resources into acute services."[16]

  5.2  The new money is geared to tackle only the most visible tip of the iceberg—older people occupying a hospital bed who need alternative care. Others are waiting out of sight in their own homes and many of those who are helped to leave hospital will need long term support.

  5.3  Social care is an essential element in intermediate care, not an added extra. A substantial proportion of intermediate care resources will need to be transferred to social services if older people are to receive the balance of care they need. Both the adequacy and the distribution of intermediate care resources will need to be closely monitored.

  5.4  Intermediate care is only intended to meet the short-term needs of older people discharged more quickly from hospital or avoiding admission. The guidance indicates that six weeks is the maximum period envisaged during which such care will be provided and the norm is expected to be as little as one to two weeks. Many of those who are helped to return home or to stay at home will need much longer term support from social care services in order to live independently, in many cases life-long. It is far from clear where these extra funds are going to come from.

  5.5  Despite Government guidance that all Intermediate care should be free to the user, some local authorities appear to be charging for personal care aspects. Intermediate care cannot be effective without adequate social care to back it up once the intermediate care period is over. Without long term support, Intermediate care will result only in a short delay before intensive services are again called upon. There is therefore a clear need for substantial additional resources for longer-term social are to prevent a "revolving door" cycle of hospital admission or emergency care.


  The following case studies illustrate powerfully the plight of those seeking help with their daily lives and of their families, and the impact delayed discharge has on older people and their carers. These very recent case studies are drawn from the Helplines of several members of the SPAIN group of voluntary organisations including Counsel and Care, Help the Aged, the Association of Charity Officers and the Alzheimer's Society.

    —  Mrs K has been in hospital for 25 weeks, awaiting discharge to her home. She has been assessed as needing two care workers four times a day but due to understaffing she has been placed on a waiting list. The Social Services department will not consider other options, such as paying private carers or offering direct payments. She is extremely depressed in hospital. August 2001.

    —  Mrs B's mother-in-law was assessed as needing residential care while in hospital in November 2000. The financial assessment has yet to be carried out. She has remained in hospital the whole time. The caller has been told that funding can only be arranged when a currently funded resident "no longer requires help" or extra resources are allocated by the government July 2001.

    —  Mr M's mother is 93 and has been in hospital since February. She has been assessed as needing residential care, has no property to sell and has savings of below £11,500. Mr M has been told by the Social Services Department that there is a six month wait for residential care funding and it has suggested the "benefits loop-hole" as an interim way to pay the fees. July 2001.

    —  Mrs Z is in hospital and has been assessed as needing a further night call once she returns home. The Social Services department has said that there are insufficient resources to provide this extra call and advised her of her right to use the formal complaints procedure. September 2001.

    —  Mr T's mother has been in hospital for six months awaiting Social Services funding for a care home. The Social Services Department has informed the caller that funds are not available for this at present. He has made a formal complaint, contacted the MP and press and sent letters from a solicitor but to no avail. June 2001.

    —  Mrs R has dementia and needs a hoist. Her husband was told by Social Services that it would have taken a minimum of nine months to get a hoist. This would have resulted in his wife remaining in hospital for that length of time. Mr R approached us for help with purchasing the hoist. June 2001.

    —  Mr C was in hospital and assessed as needing a nursing home. The consultant said that only a few homes were capable of providing the level of care needed. The family were told the Social Services limit, £346, which was substantially lower than the cost of suitable homes. The family were looking at a top up of over £100 per week in order to get Mr C into a suitable home. All other homes had turned him down. The family complained. The Complaints Officer told them that they couldn't use the complaints procedure to complain about funding levels. The family have now made a stage two complaint.

    —  Mrs P is in hospital awaiting an assessment. The Social Services Department has advised her daughter that if her mother returns home, it can no longer afford to provide her with her previous domiciliary care package or any additional care she now needs. They have also said that they "will not be able to afford to pay any residential care fees", although Mrs P has less than £11,500 in savings. July 2001

    —  Mr A is in hospital following a stroke. The Social Services Department has assessed him as needing grab rails to help him with bathing when he returns home, but has said they no longer provide such items. June 2001

    —  Mrs H had been in hospital for over six months and had been assessed as needing a nursing home. The family identified a suitable, local home but the council said that it was above their funding level.


  7.1  Social care is not a luxury or an added extra. People seek help from the Social Services only when they can no longer manage their daily lives or when they are at serious risk of harm. Social care involves helping people to get in and out of bed, get dressed, keep clean, eat a reasonably balanced diet, have their nails cut, use the toilet, have clean laundry and live in a decent environment. Increasingly it involves additional help which would once have been seen as nursing care: changing catheters and dressings, preventing or treating pressure sores, managing medication and so on. Ideally social care also involves enhancing the quality of life of older people, enabling them to keep in touch with friends and family, to get out from time to time, to pursue interests and remain part of society—but with social care in such short supply, these aspects are very often neglected. The SPAIN group has made the following recommendations:

    —  The Government should undertake a comprehensive review of social care funding for older people in parallel with, and in support of, its new investment in the NHS.

    —  There is an urgent need for a "whole systems" review of funding levels for social care for older people.

    —  The Royal Commission on Long Term Care [17] recommended the establishment of a National Care Commission, which would "monitor longitudinal trends, including demography and spending, ensure transparency and accountability in the system, represent the interests of consumers, and set national benchmarks, now and in the future" (recommendation 2). We suggest that such a commission would be of great value to the Government, to those charged with managing services and to the public, and is long overdue.

January 2002

12   Social Policy Ageing Information Network, 2001, The underfunding of social care and its consequences for older people, London. Available from the Policy Unit at Help the Aged on 020 7239 1881. Back

13   Milne et al, 2001, Caring in Later Life: reviewing the role of older carers. Help the Aged/University of Kent. Back

14   Department of Health/Office for National Statistics 2001, Social Services Performance Assessment framework 2000-01 October p 14. Back

15   Audit Commission, 2000, Charging with care, London. Back

16   ibid. Back

17   Royal Commission on Long Term Care, 1999, with Respect to Old Age, The Stationery Office, London. Back

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