Social Care - Health Committee Contents

Memorandum by the National Pensioners Convention (SC 22)



    — Social Care has long been the "Cinderella Service" of the welfare state; often finding itself overlooked and under-funded. The publication of the new green paper entitled Shaping the Future of Care Together offers the chance to properly address these issues.


    — The proposal to create a National Care Service which will clearly set out entitlements is welcome, but the green paper's instant dismissal of a tax-funded payment option undermines such a proposal. The fairest and most equitable way of providing a universal, free at the point of need National Care Service is through general taxation (rather than through any of the other models put forward or the use of existing care or disability benefits) and there is wider support for this amongst the public and other stakeholders than the government seems prepared to acknowledge.


    — The personalisation of care must not be seen as the same as individual budgets. Individual budgets raise serious concerns about personal safety, the quality of care and unacceptable burden of responsibility that will be placed on many vulnerable older people.


    — There needs to be greater recognition of the role and value carers provide, including payment of the carer's allowance to older people.


    — There should be an acknowledgement of the changing and weakening nature of the regulation of care services that has taken place. Any new National Care Service should be properly regulated with regard to registration, standards, monitoring and inspection of care providers and those employed in the care sector.


  1.1  For years, social care has been the "Cinderella" service of the welfare state; often lacking sufficient funds or enough political interest to raise its profile. Now, with the publication of the long awaited green paper on care, entitled Shaping the Future of Care Together, it is finally the focus of national debate. The green paper identifies a number of problems with the existing care system, namely its complexity, the unfairness of means-testing, a postcode lottery of funding and standards and its lack of personalised services. Alongside this is the perceived growing pressure of an ageing population. The one issue on which there can be little doubt, is that the existing social care system is failing the most vulnerable members of our society and needs urgent attention.


  1.2  A snapshot of social and long-term care provision in England shows the following:


  Domiciliary Care


    — Around one million older people receive some form of care in their own home


    — The private and voluntary sector care providers receive around £9.3 billion a year in public funding


    — An estimated £5.9 billion is spent by individuals on social care either through private contributions or through charges


    — A huge unmet need and care gap exists between the services older people require and what they actually receive because services are being rationed. As a result, only those with high care needs qualify for assistance. This unmet need places an additional burden and strain on many relatives and friends who provide unpaid care (eg. 1.2 million men and 1.6 million women over 50 are unpaid carers)


    — All care in the home is means-tested, and individuals need an annual income of less than £13,000 to receive services free


    — The charges for those with income above this level, vary widely depending on each local authority area, thus creating an unfair postcode lottery


  Long-term residential care


    — In 2003, out of 500,000 care places: 69% were in the private sector, 17% in the public sector and 14% in the voluntary sector


    — Private care is worth around £6.9 billion a year


    — One in four care workers leave their jobs every year and this high turnover is almost entirely due to poor pay and conditions of employment


    — Within care homes, only one member of staff is required to have an appropriate care qualification (but even they do not have to be situated on-site)


    — Those with assets (including the value of their property) of more than £23,000 must fund their own care. Those between £13,000 and £23,000 are means-tested and pay a proportion whilst those below £13,000 have their charges paid by their local authority. Average charges are around £800 a week


  1.3  This submission will conclude by proposing an alternative vision of social care provision which acknowledges that the real challenge facing today's social care system is a lack of funding and a short-term political approach to the care of older people in their own homes and the wider community.



  2.1  In the year 2006-07, local authorities spent £14.2 billion on social care for all adults, of which 61% went on services for older people. The amount spent on home care was around £2.3 billion, reaching just over 1 million adults, with around £6.3 billion being spent on residential services. From 2001-02 to 2005-06, the percentage of gross expenditure on care services with private and voluntary providers grew from 59% to 72%—amounting to £9.3 billion in total. Further grants were also made by local authorities to over 5000 voluntary organizations providing care services in the community.


  2.2  The green paper states that: "Two in every three women and one in two men can expect to have high care needs (difficulty getting dressed, bathing etc) during their retirement." It goes on to argue that the average lifetime care cost for a 65-year-old in England is currently £30,000—claiming that at least 50% of pensioners have costs of £25,000 to £100,000 and over. For example, just four years of care and accommodation in a care home could cost over £100,000.


  2.3  An estimated £5.9 billion is already spent by individuals on social care either through private contributions or through charges. In a recent NPC social care survey[85] (see Fig 1), almost half of all users were paying up to £50 a week for home care; with up to 20% paying between £100 and £200.



  2.4  In the Comprehensive Spending Review 2007, the government announced a 1% real terms increase to the revenue support grant for local government—with Department of Health funding for adult social care of £190 million by 2010-11. However, these amounts are insufficient to provide care for all those in need and the fact that the government's introduction of individual budgets is actually anticipated to save 3% continues to show how little financial and political priority this issue is given.



  3.1  In 2003, the Fair Access to Care Services (FACS) guidelines were introduced as a response to the outcry against the "postcode lottery" which allowed local authorities to use different criteria for assessing the need for care. The guidelines state that every local authority in England must use four standard criteria: critical, substantial, moderate and low to assess and deliver social care. These are described as being:


    — Critical—where life is in danger; or serious abuse or neglect has or might occur


    — Substantial—where abuse or neglect has occurred or might occur; or the individual is unable to carry out the majority of personal care or domestic routines and there is no-one available to assist


    — Moderate—where the individual is unable to carry out several personal care or domestic routines; or several of their family and social roles


    — Low—where the individual is unable to carry out one or two personal care or domestic tasks; or one or two of their family and social roles


  3.2  However, the Commission for Social Care Inspection (CSCI)[86] in one of its last reports before it became part of the Care Quality Commission, stated that "most councils now only help people with substantial or critical needs, leaving many needing help to fend for themselves or rely on friends and family for support." Furthermore, the CSCI found that:


    — 75% of local authorities do not provide the moderate and low criteria


    — 160,000 households are denied help


    — 1.2 million men and 1.6 million women over 50 are unpaid carers, saving the country £87 billion


  3.3  The recent National Coalition on Charging report[87] also revealed that rising charges for people receiving care in their own homes, were causing disabled and older people in England to reduce or even stop their support services. The report found that:


    — 80% of people surveyed who no longer use care services say charges contributed to their decision to stop their support


    — 29% of respondents did not feel their essential expenditure (related to impairment/health condition) was taken into account in financial assessments to pay charges, meaning they have to choose between essential support and equally essential food, heating or utility bills


    — nearly three quarters (72%) of people surveyed believe the government should think about the charges people pay for support at home in any plans to reform adult social care


    — a fifth (22%) of people surveyed who currently use support suggested they would stop if charges increased further


  3.4  By contrast, those with low and moderate needs are forced to either rely on voluntary organisations or family members to help, or go without. Naturally, this situation can lead to a worsening of their condition and their needs may eventually reach a substantial or critical level. The cost of providing this extreme level of care is therefore more expensive in the long term than would have been the case with earlier intervention; when needs are at a lower level.


  3.5  This point was clearly evidenced by the Prime Minister's recent announcement at his party's conference, when he stated that in the interim from next October those with the highest needs would receive free personal care in their own homes. However, the estimated annual spending of £670 million would work out at just £38 of care a week for each of the 350,000 people affected—far short of the estimated £165 cost of the average 11-hour package of domiciliary care provided in 2007. Furthermore, the failure to also help those with less severe needs will ultimately lead to a worsening of their condition and a subsequent greater demand on higher levels of care and support.


  3.6  In addition to providing care to all in need, there should also be the active promotion of prevention, low level care, advice and advocacy to enable older people to retain their ability to live independent lives as long as possible and to obtain the services they need. Advice and advocacy should be available both for people who need publicly funded care and for those who under the existing system fund their own care.



  4.1  A shortfall in care can occur when people either do not access services (eg. due to cost or ineligibility) or when the services they do receive fall short of their requirements. This is particularly a problem amongst those with moderate or low care needs. Over a three year period up to 2006, the number of older people using services dropped from 867,000 to 840,000—at a time when the population aged 75 and over increased by nearly 3%. Since 1997, the number of households receiving supported home care has fallen from 479,000 to 358,000 in 2006.[88] It is also further estimated that the number of older people who get no care or informal care, despite being in need, is 381,000.


  4.2  Even more concerning, is the poverty of expectation expressed by many older people. The CSCI found that individuals had low expectations and modest desires about what help they might get when entering the social care system. Many said they were receiving less support than they felt they needed—or were trying to muddle through the system without any help or guidance.


  4.3  The exclusion of lower bands of eligibility means that people have particular difficulty in getting support with practical—yet vitally important tasks—such as housework, gardening and shopping. The NPC social care survey found the care gap included a lack of help with cooking, gardening, housework, visiting day centres, going out, shopping, DIY/maintenance, adaptations to property (ramps, showers etc) and bathing.


  4.4  Recent changes to the Supporting People Fund allocated to local authorities have also led to cuts in care services and support for older and disabled people. The decision not to ring-fence budgets has, amongst other things, hastened the unpopular removal of many on-site wardens from many sheltered housing complexes.


  4.5  Ultimately, the burden of the care gap is felt by the individual's family and carers. Despite a commitment to "valuing" carers through a Carers' Strategy which will come into reality by 2018, there is no suggestion of changing the current rules on the carer's allowance which prevents someone in receipt of a state pension from claiming. Many support services are also unavailable to existing carers. This can lead to passive neglect of their loved ones, because they are unable to cope.



  5.1  Despite the introduction of the FACS, a postcode lottery within the provision and cost of social care still exists. The NPC social care survey found there were clear variations in the amounts charged for an hour's worth of care (see Fig 2).




  5.2  For example, whilst in one London borough the charge for home care was £17.50 an hour, in another it was £25. What is also clear from the survey is that the lack of a nationally agreed set of care charges (including a maximum charge) damages the legitimacy and credibility of the whole social care system.



  6.1  The green paper outlines five possible funding options, two of which; individuals paying for everything and tax-funded care are instantly ruled out of the debate. The three remaining options, Partnership, Insurance and Comprehensive all continue to involve an element of means-testing and unfairness. By contrast, the Caring Choices Report[89] in 2008 found widespread demand for change. In particular 90% rejected the present means-tested system, preferring a stronger universal element determined by care need rather than income or wealth.


  6.2  It is our view that the state should provide a high quality, comprehensive system of social care that meets national standards and is available to everyone, based on their care needs. Despite the green paper's claim, the tax-funded option should therefore be reintroduced into the debate.



  7.1  The new care green paper makes it clear that the personalisation of care is at the heart of the government's proposals for reform. Under the Conditional Resource Enhancement (CRE) scheme, an assessment is made of the user's needs in terms of hours, which is converted into the £s required to deliver that care, and this is provided in the form of an individual budget which is given to the user to spend as they choose. Local authorities are therefore gradually handing over responsibility to individuals to enter into the commissioning process.


  7.2  However, the introduction of individual budgets raises serious concerns. Many people will be met with a bewildering choice of care providers, consisting of local authority services, private companies and the voluntary sector. The individual budget holder therefore has to be directed to the "experts" offering advice and services and is inevitably drawn into the growing "market" where private companies, the voluntary sector and charities compete for contracts to supply such services.


  7.3  Ultimately, this will transfer risk and responsibility either to the individual who needs social care or to their relative(s). They must now take on management tasks or deal directly with the private companies which will provide their advice or care for profit. However, there is no clear guidance for the individual when becoming an employer.


  7.4  Fundamentally, expecting some of our most vulnerable older people to take on the responsibility of employers—recruiting, dealing with payroll matters, contracts, employment rights and discipline—is simply unrealistic. In effect, rather than giving choice, individual budgets open up opportunities for abuse by those who manage the individual's affairs and those organisations who see it as a chance to win contracts and make profits.


  7.5  In addition, individual budgets raise serious concerns about the safety and protection of vulnerable individuals who will be responsible for employing their own care workers, who at present are exempt from registration, regulation and inspection. This dangerous and alarming situation must therefore be addressed as a matter of urgency, particularly when considering that such a major shift in policy has never been approved by Parliament.



  8.1  In recent years there has been a systematic weakening of the rules and regulations surrounding the provision of care. The CQC would seem to have uprated many care homes in an attempt to reduce the number of site inspections required, whilst at the same time downgrading the standards for regulating and inspecting domiciliary care in an individual's own home.


  8.2  It is estimated that 60-70% of home care in future will be provided by individuals (either directly employed by the user or self-employed) because they will be able to get more money than if they worked for an agency or contractor. However, they will not be regulated by the CQC and there will be no requirement for a CRB check, training or qualifications.


  8.3  A return to proper regulation and standards is therefore essential to any proposals for reform. New requirements for registration of care providers should be re-introduced (drawing on previous CSCI guidelines) for 50% of staff in care homes and all new staff working in domiciliary care to be suitably qualified. In addition, care staff who are employed either by an individual, local authority, agency or care home company should have an appropriate qualification as a minimum standard as an essential requirement for registration and the General Social Care Council should be required to register, inspect and regulate all paid care workers.



  9.1  It is a matter for celebration that people live longer and that this demands that society should provide for their needs, even if it means reordering the priorities for public spending. We see no evidence that today's workers are not willing to pay sufficient taxes to fund the kind of system that they wish for their own parents and for themselves in due course. Reordering public spending priorities and addressing the need for increased taxation, diverting money from private health care and introducing a windfall tax on their profits would provide sufficient resources for a 21st century social care system worthy of the name. Such an alternative National Care Service is summarised below:

1.   Prevention services
Care, support and advocacy will be available to enable individuals and their carers to stay independent, well and socially included for as long as possible in their own homes, including sheltered housing.
Those living in their own homes, or prior to returning home from hospital or residential care, will receive the necessary preventative and care services and support appropriate to their needs. This should include home adaptations and equipment, as well as domiciliary care, support and leisure services that would help individuals and their family carers to manage in their own homes.

2.   National assessment
There will be nationally determined assessment criteria which will be used throughout England to assess care needs.
Individuals will have the right to have their needs (critical, substantial, moderate and low) assessed and receive the appropriate care from a universal menu of services. At the same time family carers' needs will also be assessed. The postcode lottery in the quality, availability and cost of services will cease under the tax-funded National Care Service.

3.   A joined-up service
Individuals and their family carers will be entitled to receive a variety of care services from a range of regulated providers, which will be of the highest standard.
There will no longer be a divide between health and social care
provision and the process of accessing care will be transparent and easily understood. All services will operate to nationally agreed standards which will be properly regulated and enforced. These shall include issues of staffing, pay and training requirements.

4.   Information and advice
Individuals and their carers will be able to easily access
straightforward information and advice about their entitlements to services at every stage of their care, and advocacy when required.
Whether in the community, care home or hospital, individuals and their family carers will be entitled to receive information which clearly explains their entitlements to care, how to access the services available and their rights as a service user. Recognition will also be given to those who need assistance from a third party/advocate/friend to help them exercise their entitlements.

5.   Personalised care and
There will be a range of care and support services made available that can be tailored to individual personal circumstances and needs.
Care and support will be designed and delivered around an individual's needs through a regulated provider, whilst the responsibility for managing budgets will lie with the local authority or NHS. Additional financial and practical support will also be available to family carers.

6.   Fair funding
Society will share the cost of
providing care for those in need.
A tax-funded universal National Care Service will entitle individuals to free non-means-tested care, support and accommodation appropriate to their needs.

October 2009



85   NPC Survey of Social Care Users and Providers 2007 Back

86   The State of Social Care 2006-07, Commission for Social Care Inspection. Back

87   Charging into Poverty, National Centre for Independent Living, 2008. Back

88   The State of Social Care 2006-07, Commission for Social Care Inspection. Back

89   The Future of Care Funding: time for a change, Caring Choices Consortium, 2008. Back

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