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Many people need care and support. Since this cannot always be provided on a voluntary basis by family members and others, there have long been other sources of help. The post-war welfare state promised "cradle-to-grave" care for all according to need and in 1948 the NHS was created to provide healthcare on that basis. However, a deep division was opened up between health and social care.
Unlike healthcare, social care was to be administered by councils, with significant local discretion, and substantially funded from local taxation. There was to be means-testing and charging for care; and it was to be a "safety net" service, predicated on the assumption that care would substantially be provided by voluntary carers. Much has since changed in the adult social care system, which today helps nearly two million people and costs £16 billion a year, but it retains those fundamental characteristics. The system is widely seen as failing and it has long been clear that fundamental and lasting reform is necessary.
Reform is made all the more urgent as an ageing population will mean rising demand for care and support. Projected changes in demographics, availability of support from carers, unit costs of care and other factors indicate that social care in its current form will struggle to meet people's needs. However, anticipating these factors is a far from exact science. Projections are made from observed trends, based on a series of plausible assumptions, but within a considerable "funnel of doubt". To minimise doubt, the best possible evidence is needed. However, the Government has been too slow in seeking better evidence regarding healthy life expectancy.
On all reasonable assumptions, the social care system will face considerable increased pressures, but it is important to avoid demographic despair and alarmism. The DH must be careful in presenting data and avoid overstating the case. The demographic challenge is partly a "cohort effect", caused by the ageing of people born in the post-war "baby boom". Since the first "baby boomers" will not enter their mid-80s until the early 2030s, there is still a 20-year "window of opportunity" in which to prepare.
Longer life need not mean more time spent in ill health. Improving public health and developing interventions for long-term conditions could pay major dividends. The old-age "support ratio" (the relative numbers of working-age and older people) is not the most important factor in the likely future affordability of social care. Our society must not underestimate its ability to become more productive and wealthier, nor the contribution that older people will make to that.
The shortcomings of the existing social care system provide powerful arguments for reform. Too often people do not receive even information and advice on what help is available. The system is often poorly co-ordinated with other help (not least the NHS and voluntary care). People encounter various forms of rationing, including by eligibility criteria, means-testing and charging, with much local variation. Care can be insufficiently focused on helping people to remain independent and avoid developing greater needs, as well as limited in scope and not always of good quality. In these respects too, there is marked variation between areas. All these factors mean there is a great deal of unmet need.
These shortcomings are all indicative of a system that: provides a "safety net" service, rather than a universal one; is chronically underfunded; and is insufficiently focused on the needs and aspirations of individual people. Pervading the whole system is a persistent ageism; we welcome the fact that the Government and the Equality and Human Rights Commission have finally recognised this and begun to address it but we are appalled it has taken so long.
Social care reform has two interrelated strands: the first is concerned with how care and support are funded and the second with how they are commissioned and provided. When the Government took office in 1997, it stated that the first of these was one of its major priorities. Yet it took until 2009 for the Government to set out a range of options for fundamental reform, in the Green Paper Shaping the Future of Care Together. On reforming how care and support are commissioned and provided, the Government has initiated a radical programme of "transformation". We strongly welcome the focus on personalisation, although there is still a long way to go in realising it.
Shaping the Future of Care Together sets out the Government's vision for a National Care Service, embodying both strands of reform. We strongly endorse the major elements of this vision which have attracted practically universal consensus:
— a focus on prevention;
— a "portable" national assessment;
— a more joined up service;
— easy access to information and advice;
— personalised care and support;
— a more universal funding system;
— more support for carers;
— building a sound evidence base on different forms of care and support.
However, on other key issues there is still no agreement. Worthwhile and lasting reform will only be achieved if consensus can be reached on these issues too, so that the necessary tough decisions can be taken with broad popular support.
Free care funded from taxation is ruled out by the Government as it would place "a heavy burden" on working-age taxpayers. However, this option has many supporters and most of the arguments against it apply just as much to the idea of a free NHS. The Tax-funded option should be debated to gauge whether people are prepared to pay higher taxes or wish to see tax revenue diverted from other spending.
The DH's Partnership option supposedly derives from the model developed by Sir Derek Wanless. However, a key part of Sir Derek's model which is missing from the DH's is "match-funding". Sir Derek's original Partnership option should have been included in the debate.
The DH excludes "hotel costs" from the funding options "because we would expect people to pay for their own food and lodging whether or not they were in a care home". Yet such costs can be significantly higher in residential care than in a person's own home. Without addressing the risk of uncapped catastrophic costs of this kind, funding reform risks being discredited and losing support. The Government must look at options for dealing with this.
The Green Paper also pays insufficient attention to how the various funding options might affect people of working age with care and support needs.
A major deficiency in the Green Paper is that it is silent on the question of the overall "funding envelope", i.e. how much money overall will be spent on social care in future. This leaves the Green Paper unable to indicate the scope of the new system.
Ahead of fundamental reform, there is scope to mitigate significantly the worst aspects of the existing funding system by means such as raising the capital thresholds in the means test.
We have strong misgivings about the Free Personal Care at Home Bill, which smacks of policy-making on the hoof. This piecemeal reform risks creating perverse incentives and introducing unanticipated consequences. Estimates of demand and cost appear low, and the reform risks being substantially underfunded. The DH has yet to clarify how it will find its share of the funding, except to say some money will come from public health and research budgets, which could be detrimental to the long-term interests of NHS patients.
"Transformation" promises to take social care into uncharted waters and the profound ramifications, and risks, of this need to be fully considered and worked through. There has been confusion about whether the Government is pressing ahead with Individual Budgets (combining various funding streams in addition to social care moneys) or instead adopting Personal Budgets (involving social care funding only). The policy, and the associated terminology, must be made absolutely clear, as well as the basis for whatever decisions are taken.
The apparent goal of bringing together all disability-related expenditure, while giving individual disabled people control of all the sums available to them, has a logic; but it will raise some contentious and difficult issues.
Reforming disability benefits for older people (Attendance Allowance and Disability Living Allowance) by merging them into social care funding is particularly controversial. People with significant needs and modest means could be left worse off. The Government has given assurances that there would be "no cash losers" among existing benefit recipients, but people who develop a care need in future could be worse off than they would have been under the current system.
Personalisation must not be seen as a cost-saving exercise. People who use services must not be turned into rationers of their own care and support.
Not every person who uses social care services will want to take on an entrepreneurial and managerial role as commissioner of their own care and support. The potential of "co-production" (i.e. full partnership between providers and people who use services) to allow personalisation of mainstream services should be fully explored. In some cases it may be appropriate to "ringfence" services such as day centres for people who wish to continue using them, although outmoded and poor quality services should not be protected.
Information, advice, advocacy and brokerage must be available and must not be funded from people's own resource allocations.
There are concerns about whether councils will have the capacity or the capability to act as effective market managers.
Policies to protect vulnerable adults must be tailored to situations where people are directing their own care and support. Carers must also be protected from unreasonable demands as a result of personalisation.
There are fears about the possible emergence of an unskilled, casualised, unregulated, and potentially exploited, workforce of Personal Assistants (PAs) operating in a semi-informal "grey" market. Local authority "banks" of PAs may be one way of addressing this. There are differing views on whether PAs should be subject to mandatory regulation and vetting. Without a "level playing field" in this respect between PAs and social care staff employed by councils and others, unsuitable staff could migrate from regulated sectors into unregulated PA roles. Nonetheless, many people who employ PAs will insist that they should be able to choose who they wish to work for them. There should be a regulated option for those who wish to use this route, but people who prefer not to use it, and give informed consent to accept the risks that may arise, should be free to do so.
The social care workforce is increasingly in a state of flux. The future role of social workers in particular is still unclear; and plans to extend regulation to the rest of the social care workforce now seem to be in disarray. We are concerned at the apparent lack of an overarching strategic vision for the future social care workforce, and this must be addressed.
We would have liked to see all the political parties come together to map out sustainable reform, instead of indulging in pre-election point-scoring. There is still an opportunity, though, in advance of the demographic challenges to come, to reform social care, achieving consensus and creating a lasting solution.
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