Social Care - Health Committee Contents


5  Plans for reform

163.  There are two interrelated strands to the Government's programme for social care reform: the first is concerned with how care and support are funded, and the second with how they are commissioned and provided. In this chapter, we examine critically how these have developed, outline the vision set out in the recent Green Paper Shaping the Future of Care Together and look at the aspects of that vision on which there is consensus.

The road to reform

164.  In this chapter we summarise briefly how the Government has approached social care reform since 1997.

REFORM OF FUNDING, 1997-2008

165.  In September 1997 the then Prime Minister, Rt Hon Tony Blair MP, told the Labour Party conference "I don't want [our children] brought up in a country where the only way pensioners can get long term care is by selling their home".[197] Shortly thereafter, in fulfilment of a manifesto promise, the Government convened a Royal Commission to consider reform of the funding system for the long-term care of older people.

166.  When the Royal Commission reported, in 1999, it recommended (although with dissent from two of its number) that all long-term personal care (including nursing care in nursing homes) should be provided free, funded from general taxation. Soon after the publication of the Royal Commission's report, our predecessor committee issued a brief report on The Long Term Care of the Elderly, in which it endorsed the Royal Commission's position on free, tax-funded personal care and warned "Failure by the Government to act urgently would be a serious dereliction of duty".[198] The Government rejected the Royal Commission's proposal for free personal care in respect of England (in contrast, it was adopted by the devolved Scottish administration, beginning in 2002). The Government did, though, agree that nursing care in nursing homes would be made free (funded by the NHS).[199]

167.  In the years since the Royal Commission's report, the issue of social care funding reform has not gone away. On the contrary, it has become all the more pressing, for all the reasons that we have already identified. Yet, despite mounting evidence of the problems with the current system, for many years funding reform did not appear to feature on the Government's list of priorities.

168.  In the absence of any Government initiative to resolve the funding issue, various bodies sought to stimulate debate. In 2006 the Joseph Rowntree Foundation (JRF) published Paying for long-term care, which concluded that the present system was underfunded, incoherent and unfair. The report welcomed the introduction of free personal care in Scotland and suggested immediate changes that could be made to the system in England pending fundamental reform.

169.  Also in 2006, the King's Fund published a report by Sir Derek Wanless, Securing Good Care for Older People, which set out various funding options and indicated a preference for a "partnership" model. This would involve a guaranteed minimum level of state funding for all, expressed as a percentage of a "benchmark" good-quality package of care. The remainder of the cost would be met by user contributions, with further "match funding" from the state.

170.  In December 2006 that year's Pre-Budget Report noted the "important contributions" of the Wanless and JRF reports. Proposals for funding reform would be considered "as part of the long term vision of the 2007 [Comprehensive Spending Review]", in light of whether "they are affordable [and] whether they are consistent with progressive universalism".[200] The somewhat opaque term "progressive universalism" was defined as the principle of "providing support for all and more for those who need it most".[201] In October 2007 in that year's Pre-Budget Report the Government finally gave a commitment to the reform of social care funding, on the basis set out in 2006, promising a Green Paper on the subject,[202] although this was not immediately forthcoming.

REFORM OF DELIVERY, 1997-2008

171.  The Government proved somewhat bolder in developing a reform programme to change the delivery of care and support by means of personalisation.[203]

172.  As we have noted, Direct Payments, the pioneering form of personalisation, were introduced in 1997. They were initially only available to eligible people aged 18-64, but this was subsequently widened to embrace other groups, including older people and carers. The power to offer Direct Payments was also strengthened and in 2003 local authorities were given a duty to offer them as an option to people who use services. Nevertheless, the take-up of Direct Payments remained very low.

173.  In 2003 the "In Control" partnership, involving the Valuing People Support Team,[204] Mencap, local authorities and a number of independent organisations, was created to develop and refine the idea of "self-directed support" and find new ways of organising social care accordingly. In Control began as a social enterprise and subsequently became an independent charity.[205]

174.  The model of "self-directed support" focused on enabling people to control the support they needed to live their life as they chose. An important means of doing this was by making available Personalised Budgets. These entailed giving each person the right to manage for themselves the budget allocated by their council to provide them with care and support (with the option of being helped to do so by others, or handing control of the budget to a third party to manage on their behalf). This budget could be (but did not need to be) taken partly or wholly in the form of a Direct Payment. Over several years, piloting of these arrangements was undertaken in a significant number of local authorities and the model of self-directed support became increasingly influential in shaping Government social care policy.[206]

175.  In the meantime, the uptake of Direct Payments nationally remained very low. In 2004 CSCI attributed this to:

—  lack of information for service users;

—  low staff awareness of direct payments and what they are trying to achieve;

—  patronising attitudes on the part of staff about the ability of people to manage a Direct Payment;

—  inadequate or patchy advocacy or support services for direct payment users; and

—  unnecessary and bureaucratic paperwork.[207]

176.  In March 2005 the Government published a Green Paper, Independence, Well-being and Choice, as the basis for discussion on the future direction of social care. It envisaged social care services that "help maintain the independence of the individual by giving them greater choice and control over the way in which their needs are met",[208] with a focus on achieving a series of specified outcomes for people who use services. Key means of achieving this would be continued use of Direct Payments and the piloting of Individual Budgets, which would build on the model of Personalised Budgets, possibly extended to include streams of funding other than social care budgets.[209] These pilots, which ran from November 2005 to December 2007, were evaluated by the Individual Budgets Evaluation Network (IBSEN).

177.  In addition, there would be more flexible ways of assessing need and allocating funding, using as the starting point self-assessments (In Control pioneered this by means of a "Resource Allocation System" questionnaire). The Green Paper did not envisage any change in the overall scale of social care funding for the next decade or more and explicitly stated that "implementing the vision will need to be managed within the existing funding envelope".[210]

178.  In the January 2006 Green Paper Our health, our care, our say the DH said that it would extend the scope of Direct Payments and affirmed its commitment to piloting Individual Budgets, which would definitely bring together funds from a range of agencies in addition to social care funding. However, the DH explicitly ruled out "extend[ing] the principle of individual budgets and direct payments to the NHS", on the basis that:

we believe this would compromise the founding principle of the NHS that care should be free at the point of need. Social care operates on a different basis and has always included means testing and the principles of self and co-payment for services.[211]

179.  The 2006 Pre-Budget Report promised that "the debate around the future of social care provision" would "be informed by Individual Budgets, Partnerships for Older People Projects [POPPs],[212] direct payments and the In Control programme", as well as proposed changes in funding arrangements. Any changes would be judged on "whether they promote independence, dignity, well-being and control", as well as their affordability and consonance with progressive universalism.[213]

180.  In December 2007 Putting people first, which was described by the Government as a unique "ministerial concordat", was signed by six Secretaries of State as well as leading Chairs and Chief Executives across social care and local government. This set out shared aims and values to "guide the transformation of adult social care" by placing choice, independence and dignity at the heart of service delivery.

181.  At the same time the DH announced that, as part of Putting people first, there would be a roll-out of Personal Budgets, which would take the same approach as Individual Budgets, but would apparently involve social care funding only. Coming as this did at the end of IBSEN evaluation of the Individual Budgets pilots, and before publication of the results, this announcement caused some confusion regarding DH policy.

182.  A DH circular, "Transforming Adult Social Care", published in January 2008, set out a vision for personalisation and gave details of a new ring-fenced grant of £520 million, the Social Care Reform Grant, which was allocated for the next three years to support local "transformation" (i.e. personalisation). The circular stressed the importance of working across boundaries with other services, "such as housing, benefits, leisure and transport and health". This could be facilitated through the new Local Performance Framework, with Local Strategic Partnerships agreeing new Joint Strategic Needs Assessments to "provide the foundation for health and wellbeing outcomes within each new Local Area Agreement".[214]

THE CASE FOR CHANGE (2008)

183.  A discussion paper, The case for change—Why England needs a new care and support system, was published in May 2008. This referred to both the need for funding reform and the programme of "transformation", in an apparent attempt by the DH to converge the two policy streams.

184.  It was followed by a six-month public "engagement process"; and financial modelling was commissioned from the PSSRU. In the meantime, however, the Government continued to pursue some aspects of reform.

REFORM OF ELIGIBILITY CRITERIA

185.  As we have noted, in October 2008 CSCI published a report, Cutting the Cake Fairly, which was highly critical of the operation of FACS. CSCI proposed adopting three new eligibility criteria bands, based on "priorities for intervention" to replace the current four bands based on risks to independence.[215]

186.  However, the DH concluded that it would be more cost-effective and cause less upheaval to retain the current eligibility criteria and focus instead on fairer and more transparent implementation, although there might be an argument for discontinuing the use of the fourth eligibility criteria band (Low). Draft revised criteria along these lines were put out to consultation during July-October 2009 and the outcome of this is still awaited.[216]

FURTHER DEVELOPMENT OF PERSONALISATION

187.  In June 2008 the NHS Next Stage Review Final Report, High Quality Care for All, announced that the DH would pilot models for new "integrated care organisations", across primary, community and secondary healthcare and social care.[217] The Department would also pilot "personal health budgets" in the NHS, primarily in respect of people with long-term conditions, reversing its previous policy on this.[218]

188.  In October 2008 the results of the IBSEN study of the Individual Budgets pilots were published. The key findings were as follows:

—  There was little difference in the average costs of IBs and conventional social care support. However, implementing IBs nationwide would require substantial investment, including in staff training.

—  People using IBs were more likely to feel in control of their lives than people receiving conventional social care support.

—  Satisfaction varied between client groups and was highest among mental health service users and physically disabled people, and lowest among older people.

—  A substantial proportion of older people felt that taking control of their support was a "burden".

—  Staff encountered significant barriers to integrating funding streams.[219]

189.  In October 2008 Jeff Jerome was appointed to the new role of "National Director for Social Care Transformation". This post is funded by the DH (through a "top slice" of the Social Care Reform Grant) and accountable to a "consortium" that includes the Department, the LGA, the Improvement and Development Agency and ADASS. The post is designed to support councils by offering leadership and guidance in implementing Putting People First.[220] At the same time the DH published a leaflet, Putting People First - the whole story, which enumerated the four key aspects of "transformation":

—  Universal services;

—  Early intervention and prevention;

—  Choice and control; and

—  Building "Social Capital".

Shaping the Future of Care Together (2009)

190.  The long anticipated Green Paper, Shaping the Future of Care Together, was published in July 2009; it was followed by a consultation (branded as the "Big Care Debate" by the Government), which ran until November 2009. The Government received 28,000 consultation responses and held 37 stakeholder events around the country.[221] A White Paper, setting out plans for legislation to reform social care, is expected imminently.

191.  In the Green Paper the Government proposed a "National Care Service", which would have six aspects as follows:

1. Prevention services: You will receive the right support to help you stay independent and well for as long as possible and to stop your care and support needs getting worse.

2. National assessment: Wherever you are in England, you will have the right to have your care and support needs assessed in the same way. And you will have a right to have the same proportion of your care and support costs paid for wherever you live.

3. A joined-up service: All the services that you need will work together smoothly, particularly when your needs are assessed.

4. Information and advice: You can understand and find your way through the care and support system easily.

5. Personalised care and support: The services you use will be based on your personal circumstances and need.

6. Fair funding: Your money will be spent wisely and everyone who qualifies for care and support from the state will get some help meeting the cost of care and support needs.[222]

192.  This will constitute a "universal offer",[223] meaning that social care becomes truly a service for everyone rather than the residual or "safety net" service that it has hitherto been. The Government states in the Green Paper that:

We believe that the care and support system should give everyone some help with meeting their needs. Everyone should get support to stay independent and well. Everyone should be able to have access to information and advice about care and support. If their needs qualify for further assistance, everyone should get financial help in meeting the cost of care and support.[224]

We believe that the new National Care Service must be a system for everyone. It must help everybody to find and obtain the good-quality care and support they need so that they can live their lives the way they want to.[225]

193.  The Secretary of State has told the House that it is:

no exaggeration to say that the Government's Green Paper "Shaping the Future of Care Together" is a Beveridge moment for social care. It is a chance to rebuild the social care system from first principles[.][226]

As he reiterated in evidence to us, he wants to build on the basis of the Green Paper "unstoppable momentum" for legislation in the next Parliament.[227]

The National Care Service consensus

194.  On the key aspects of the National Care Service set out in the Green Paper a widespread consensus is apparent. Below we look at each of these aspects and the points around which there is consensus.

FOCUS ON PREVENTION

195.  We heard from Jeff Jerome, the National Director for Social Care Transformation, that local authorities had hitherto approached the issue of prevention in a very broad and general way, in relation to the general provision of collective services such as "employment, education, transport, suitable housing, and information and advice as well as good health improvement programmes".[228] Now a more targeted and individualised approach was being promoted:

We would look at individual need and assist people to identify whether there was any potential for them to improve well-being and independence and there would be targeted programmes.[229]

196.  Mr Bolton, from the DH, indicated that the evidence base in this area was still being developed, but some piloting was taking place:

The POPPs pilots […] of which we are about to see the final results, has been a major study into the impact on people of those kinds of schemes. I think the evidence is going to show us they have a particularly positive impact in reducing people's need for healthcare.[230]

197.  As we have noted, our evidence indicated that a significant weakness in the current social care system is the lack of a major and coherent focus on prevention. We were told about the benefits that could accrue from certain interventions, such as Telecare[231] and falls prevention,[232] and the particular importance for prevention of appropriate housing provision, integrated with social care.[233] Mr Harrop, of Age Concern and Help the Aged, also underlined the importance of involving agencies beyond social care and suggested some of the cost should be borne by them, particularly the NHS "because they get an awful lot of the benefits from both primary and secondary prevention".[234]

"PORTABLE" ASSESSMENT

198.  Mr Behan told us that one reason the National Care Service would be fairer than the current social care system was that it would include:

a national assessment system which is portable so that, if a person moves from Durham to Devon, or vice versa, they can take that assessment with them.[235]

Alexandra Norrish, Head of Social Care Strategy at the DH, explained that this meant:

wherever you have your assessment carried out in the country, you know that you have a right to receive services that meet your needs wherever you move to […] you will then have a right to have your needs met and be sure that you do have that flexibility. You have the ability to move around the country for employment, or for whatever reason, in the way that most of us would take for granted.[236]

199.  The principle of a nationally portable assessment was universally welcomed in all the evidence we received. However, the question of entitlement to care and support on the basis of such an assessment was more controversial, as we discuss in the next chapter.

JOINED-UP SERVICES

200.  In its memorandum of evidence, the DH told us it was pursuing:

More joined-up working between health, housing and social care services and between social care and the disability benefits system […] This would not necessarily involve structural change but improved joint ways of working to help to transform the experience of people who need care. The recently established Ministerial Group on Integration of Health and Social Care Services[237] will help identify what has worked well in places round the country, as well [as] current evidence to help push forward joined-up working.[238]

201.  Mr Behan cited several local examples of social care services working well with the NHS and other partner agencies. On the prospects for future joint working, he told us:

The vision that we have in the new system is that the [health and social care] systems will be drawn together and we need to build on the work that is already there. There are many tools that are currently available that draw services together but there is a strong signal in the Green Paper that we need to do more of this and this needs to progress more quickly.[239]

202.  However, Mr Jerome added that the relationship between the NHS and social care remained "really very, very complicated" and was "particularly difficult around long-term conditions and long-term care funding". He thought that "On the ground that is sometimes difficult for people to address".[240]

203.  The idea of more joined-up care was welcomed in the evidence we received and some successful forms of integration were mentioned, such as multi-service "one-stop shops" and the co-locating of different types of service.[241] However, as the King's Fund pointed out to us:

The promise that people will enjoy "joined-up services" is laudable but the means whereby this will become a consistent reality have yet to be specified.[242]

Citizen's Advice likewise told us:

[what the Green Paper says on joined-up care] looks highly desirable, but the difficult question is how this is to be achieved. The green paper has little to say about this beyond saying that people should be assessed for all forms of support at a single assessment, which only addresses one aspect of the issue. It appears that we must wait to see what the new Ministerial Group on Integration of health and Social Care Services comes up with.[243]

INFORMATION AND ADVICE

204.  In the implementation of Putting People First, information and advice are included as part of "universal services", one of the four areas on which councils have been told to focus. Ms Norrish, of the DH, explained to us the importance of information and advice as part of the "universal offer" of the National Care Service:

We have spoken to many, many people who have said they have tried to approach their local authority for information or for help and in some cases they have had no response at all, in some cases they have been signposted on to Age Concern or one of the organisations in the voluntary sector. I think what to move to a universal system does is it breaks down that barrier; it moves away from a system which only some people, the poorest essentially, are sure that they are going to get any help from the state into a service where everyone in the country who has a care need is entitled to at least advice support from the state.[244]

205.  As we have noted, our evidence underlined how far many councils must progress in ensuring everyone can access appropriate information and advice about the options available to meet their care and support needs.

206.  Although there is widespread support for the principle of universal access to information, the means of achieving this are not necessarily obvious. While the idea of "one-stop shops" appears popular,[245] we received evidence from the Princess Royal Trust for Carers warning that this must not be seen as the only solution (since "if you miss the door, then you've missed the chance"). The Trust told us "There needs to be a variety of information gateways, national and more locally targeted".[246]

PERSONALISED CARE AND SUPPORT

207.  The DH explained to us as follows the relationship between the Green Paper and Putting People First:

some of the problems in the current system will extend beyond the timescale of Putting People First. They will need a longer-term, national approach to providing care and support. The Green Paper builds on the approach that Putting People First developed and goes further to ensure in future everyone will be eligible for help with finding and paying for the care they need. In addition, an individual's care and support plan, will give much greater choice over how and where they receive support, and the possibility of controlling their own budget wherever appropriate. This means that people will know what resources they have available and that they will be able to make decisions about how it is used. This system will be the same regardless of where people live.[247]

208.  During the course of the Green Paper consultation the DH pushed on with this aspect of reform. In September 2009 it agreed with ADASS and the LGA the key priorities for the first phase of transformation (by April 2011), with "milestone" dates (see Appendix 1).[248] In January 2010 the Department published Putting People First: Personal budgets for older people—making it happen, a guide to assist councils and partner organisations in developing choice and control for older people who use social care services.

209.  The continued emphasis on personalisation was universally welcomed in the evidence that we received. Mencap, whose views were quite typical, told us that it:

fully supports personalisation as it reinforces the idea that the individual is best placed to know what they need and how those needs can be best met. Personalisation is about giving people greater choice and control over their lives and replaces traditional and institutional care services.[249]

However, many aspects of the actual implementation of personalisation were contentious, as we discuss in the next chapter.

A MORE UNIVERSAL FUNDING SYSTEM

210.  Part of the "universal offer" of the National Care Service is that everyone who is eligible for care and support will be entitled to some element of state funding. This would be in contrast to the current system, under which means-testing excludes many people, including those with relatively modest means, from receiving any state funding at all. It would also go some way to addressing the perceived unfairness of local variations in funding, since, as the Green Paper states, "you will have a right to have the same proportion of your care and support costs paid for wherever you live".[250]

211.  In the evidence that we received we found no hostility to the idea of moving to a more universal system of "fair funding". This is not surprising given that the current system is very widely seen as confusing, unfair and a disincentive to saving for older age. However, as we explain in the next chapter, the specific options set out in the Green Paper proved extremely contentious.

MORE SUPPORT FOR CARERS

212.  Mr Behan acknowledged that the high level of unmet need under the current social care system meant that "the informal care system will often have to do a lot of the heavy lifting of care, providing that day-to-day care". The Government did have a Carers Strategy,[251] which "was designed to help to continue to support carers, to enable informal carers, unpaid carers to continue to provide that care". However, "the balance between the formal care system and the informal care system has changed over recent years" and this needed to be addressed.[252]

213.  The Green Paper indicates how the National Care Service could "in many ways" help to redress that balance. Carers' loved ones would be able to access care and support more easily; better care and support would be ensured; and fair funding would particularly help carers whose loved ones currently receive no state funding.[253]

214.  The Secretary of State admitted to us that the Green Paper had not put the needs of carers sufficiently to the forefront and emphasised that:

the state needs to do more to make life tolerable for them so they can care and raise their own children or go to work and I believe that today we are not doing enough in that regard.

He promised that this would be fully addressed in the White Paper.[254]

215.  The Secretary of State also told us that he did not accept the view, put forward by some commentators, that if the state provides more care and support, many people will shirk their personal responsibility to act as carers.[255] Greater public provision was not about impinging on the "proper preserve of families, relatives, communities and neighbours", he said, but about helping carers both to care and to live their own lives.[256]

216.  Our evidence indicated that there is a very strong consensus in support of this approach, as summed up for us by Ms Redmond, of Carers UK:

You do not need to encourage [carers] to love their families more; you just need to make sure they get proper breaks and that they get proper assistance, proper help. That is all you need. It is an enabling role that the state should be in […] We just need to be on the side of families. I do not see them shirking their responsibilities.[257]

Mr Wittenberg's evidence indicates that there is a good evidence base to back this up:

supposing formal care increases, do the informal family carers drop out? The literature of which I am aware suggests no, they do not drop out. They may reduce the hours a bit but not hugely and they may change exactly what they do […] Professor David Bell commented in his report that the expansion of home care linked to the free personal care in Scotland appears not to have caused family carers in Scotland to drop out of providing care.[258]

A SOUND EVIDENCE BASE

217.  The Green Paper states that:

Although the evidence base is improving, there is still not enough information as yet on how to spend money most effectively in care and support. This is vital to ensure that people can get high-quality services that they can trust to meet their needs. It is also crucial if services are going to work well first time and give good value for money—whether they are paid for by taxpayers or people who need care and support.[259]

218.  Accordingly, it advocates the creation of an independent body to provide advice on the effectiveness and cost effectiveness of services, fulfilling a similar role to that of the National Institute for Health and Clinical Excellence in the NHS. The Green Paper leaves open the question of whether this should be a new body or whether the remit could be filled by an existing body, such as the Social Care Institute for Excellence (SCIE).[260] To the extent that this proposal was mentioned in the evidence that we received, by SCIE and the CQC, it was welcomed.[261]

Law reform

219.  Since the passing of the National Assistance Act 1948, which remains in force, the law underpinning the social care system has evolved into a complex and unwieldy structure, as the Law Commission noted in 2008:

The legislative framework for adult residential care, community care and support for carers is inadequate, often incomprehensible and outdated. It remains a confusing patchwork of conflicting statu[t]es enacted over a period of 60 years. There is no single, modern statute to which service providers and service users can look to understand whether services can or should be provided, and what kinds of services […] In addition to a number of different statutes, there is also a great deal of "soft law" in the form of guidance and departmental [i.e. DH] circulars.[262]

Much of the existing law embodies outdated attitudes towards people with care and support needs that are at odds with current policy and modern thinking about equality, human rights, dignity, personalisation and autonomy (the 1948 Act, for instance, refers to "dumb and crippled persons").

220.  The Law Commission is committed to the reform of social care law and is currently consulting about options for reform, with a view to publishing a final report in 2011.[263]

Conclusions

221.  Social care reform has two interrelated strands: the first 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. This came so late in the present Parliament that the White Paper containing the Government's plans for change will be published just weeks before a general election, with no prospect of legislation until the next Parliament. The problems, and the options for solving funding reform, have long been known; and prime opportunities to initiate reform (a Royal Commission in 1999 and major reform proposals resulting from independent reviews) have been squandered. The failure to grasp this nettle is sadly indicative of the low priority given to social care by successive administrations and this must not continue.

222.  On the second strand of reform, how care and support are commissioned and provided, the Government has made better use of its time in office, initiating a programme of "transformation" with potentially far-reaching consequences. We strongly welcome the focus on personalisation as the way forward, although we recognise that there is still a long way to go before all councils are offering genuinely self-directed support.

223.  The Green Paper Shaping the Future of Care Together sets out the Government's vision for a National Care Service, embodying both strands of reform. The following major elements of this vision have attracted practically universal consensus and we too strongly endorse them:

—  A focus on prevention, rehabilitation and re-ablement;

—  A "portable" national assessment, backed up by national uniformity in the proportion of care and support costs being paid for from public funds;

—  A more joined up service, with social care, the NHS, housing support services and the social security benefits system all better integrated;

—  Easy access to information and advice for everyone, regardless of their circumstances;

—  Personalised care and support, so that the needs and aspirations of each individual person are met;

—  A more universal funding system, ending the situation where many people get no support at all from public funds;

—  More support for carers, recognising their vital role, supporting them and ensuring that they are not obliged to take on too much responsibility for care;

—  Building a sound evidence base on the effectiveness and cost effectiveness of different forms of care and support.

224.  The current social care system is complex and opaque. This is substantially down to the fact that it has been the subject of countless piecemeal reforms since its creation in 1948. It is underpinned by an outdated structure of numerous Acts of Parliament, case law, regulations, directions, guidance and circulars, much of which are anachronistic and inconsistent with current policy and modern thinking about equality, human rights, dignity, personalisation and autonomy.

225.  We welcome the Law Commission's commitment to thorough reform of social care law to ensure it becomes consistent, coherent and up-to-date. We recommend that the National Care Service be built on fresh legislative foundations, rather than created through further modifying and patching the existing framework, which is clearly no longer fit for purpose.

226.  The Government needs to build on the existing consensus about reform to ensure that the National Care Service becomes a reality. However, as we discuss in the next chapter, before it can do so it must resolve a number of other, fundamental, issues on which there is as yet far from being consensus.


197   Speech by Rt Hon Tony Blair MP to the Labour Party Annual Conference, 30 September 1997 Back

198   Health Committee, Fourth Report of Session 1998-99, The Long Term Care of the Elderly, HC 318, para 16 Back

199   The lack of NHS-funded nursing care in nursing homes was anomalous given that the NHS had always funded nursing care (provided by District Nurses) for people receiving care and support in their own home or in a residential care home. Since 1 October 2001 the NHS has paid for nursing care for people who fund all their care in nursing homes. Since 1 April 2003 the NHS has also paid for nursing care for residents of nursing homes who receive financial support from local authorities. Back

200   HM Treasury, Pre-Budget Report, Investing in Britain's potential: Building our long-term future, Cm 6984, December 2006, para 6.11 Back

201   Ibid, para 5.55 Back

202   HM Treasury, Meeting the Aspirations of the British People: Pre-Budget Report and Comprehensive Spending Review, Cm 7227, October 2007, para 6.9 Back

203   For background information on personalisation, see Annex 2. Back

204   Department of Health, Valuing People: A New Strategy for Learning Disability for the 21st Century, Cm 5086, March 2001, sought to put services for people with a learning disability in the context of modern values and legislation conferring clear rights on all citizens, including disabled people. The Valuing People Support Team offers support and advice to people working to change services. It also promotes communication and the sharing of ideas, listens to feedback and liaises closely with the Government. Back

205   Qq 733, 772-775, 781 Back

206   www.in-control.org.uk Back

207   Commission for Social Care Inspection, Direct Payments: What are the Barriers?, August 2004 Back

208   Department of Health, Independence, Well-being and Choice: Our vision for the future of social care for adults in England, Cm 6499, March 2005, p 9 Back

209   Ibid., p 11. In 2005, the Prime Minister's Strategy Unit had advocated "individual budgets for disabled people, drawing together the services to which they are entitled and giving them greater choice over the mix of support they receive in the form of cash and/or direct provision of services" (Prime Minister's Strategy Unit, Improving the life chances of disabled people: Final Report, January 2005, p 7). Back

210   Department of Health, Independence, Well-being and Choice, Cm 6499, 2005, p 40 Back

211   Department of Health, Our health, our care, our say, Cm 6737, 2006, para 4.39 Back

212   POPPs were launched in 2005 to develop and evaluate services and approaches for older people aimed at promoting health, well-being and independence and preventing or delaying the need for higher intensity or institutional care. An evaluation by the PSSRU has found that "a wide range of projects resulted in improved quality of life for participants and considerable savings, as well as better local working relationships" (Personal Social Services Research Unit, The National Evaluation of Partnerships for Older People Projects: Executive Summary, January 2010, p 1). Back

213   HM Treasury, Pre-Budget Report, Cm 6984, 2006, para 6.11 Back

214   Department of Health, "Transforming Adult Social Care", LAC (DH) (2008) 1, January 2008 Back

215   The three eligibility criteria bands proposed by CSCI were:

216   Department of Health, Prioritising need in the context of Putting People First: A whole system approach to eligibility for social care: Guidance on Eligibility Criteria for Adult Social Care, England 2009 (consultation stage), July 2009 Back

217   Department of Health, High Quality Care For All: NHS Next Stage Review Final Report , Cm 7432, June 2008, p 65; cf. Department of Health, NHS Next Stage Review: Our vision for primary and community care, July 2008, para 7.14. Sixteen Integrated Care Pilots were announced in April 2009 and began operating in July 2009. The programme was expanded in February 2010. Back

218   Department of Health, High Quality Care For All, Cm 7432, 2008, p 42. Cf. Department of Health, NHS Next Stage Review, 2008, para 4.30. The pilot programme began in 2009 and will run until 2012. Back

219   Qq 778-781. Caroline Glendinning et al., Evaluation of the Individual Budgets Pilot Programme: Final Report (York, 2009) Back

220   Qq 88-89, 117, 843 Back

221   Q 889 Back

222   Department of Health, Shaping the Future of Care Together, Cm 7673, 2009, p 47 Back

223   Q 16 Back

224   Department of Health, Shaping the Future of Care Together, Cm 7673, 2009, pp 47-48 Back

225   Ibid., p 65 Back

226   HC Deb, 29 October 2009, col 484 Back

227   Q 892; cf. HC Deb, 29 October 2009, col 484 Back

228   Q 124 Back

229   Ibid. Back

230   Ibid.; cf. Q 135, 136 Back

231   Ev 27; Q 675. Telecare is a form of telecommunications technology, involving devices that can be triggered deliberately or automatically in the event of an incident such as a fall, summoning help. It allows someone with a social care need to continue living in relative independence despite having become more vulnerable. Back

232   Ev 24, 100, 142 Back

233   Ev 24; Q 675 Back

234   Q 674 Back

235   Q 14 Back

236   Q 15 Back

237   This Group was created in 10 March 2009 and had met four times by December 2009 (HC Deb, 9 November 2009, col 121W and 16 December 2009, col 1321W). Back

238   Ev 3 Back

239   Q 143 Back

240   Ibid. Back

241   Ev 96-97 and 101 Back

242   Ev 78 Back

243   Ev 136 Back

244   Q 63 Back

245   Ev 128, 137 Back

246   Ev 121 Back

247   Ev 2 Back

248   Qq 90-93, 843 Back

249   Ev 7 Back

250   Department of Health, Shaping the Future of Care Together, Cm 7673, 2009, p 47 Back

251   The Government's interdepartmental Carers Strategy was relaunched in 2008. The Strategy sets out the Government's short-term agenda and long-term vision for the future care and support of carers, underpinned by £255 million, to fund some immediate measures (Department of Health, Carers at the heart of 21st-century families and communities: "A caring system on your side. A life of your own", June 2008). Back

252   Q 6 Back

253   Department of Health, Shaping the Future of Care Together, Cm 7673, 2009, p 20 Back

254   Q 875 Back

255   See, for instance, Melanie Phillips, "An uncivilised attitude towards the old", Daily Mail, 18 November 2009; cf. "Unreal Politics" (editorial), The Times, 19 November 2009. Back

256   Q 876 Back

257   Q 758 Back

258   Q 204. The Wanless report came to a similar conclusion: "Many decide to care with little regard for 'substitution potential' of formal care and are motivated by many factors other than the provision of formal care or lack of it" (Derek Wanless, Securing Good Care for Older People: Taking a long-term view, 2006, p 151). Back

259   Department of Health, Shaping the Future of Care Together, Cm 7673, 2009, p 44 Back

260   Ibid., p 79. SCIE was established by the government in 2001 to improve social care services for adults and children in the UK. SCIE does this by identifying and spreading knowledge about good practice; it is an independent charity, funded by the DH and the devolved administrations in Wales and Northern Ireland. Back

261   Ev 85, 147 Back

262   Law Commission, Adult Social Care: A Scoping Report - Summary, November 2008, para 1.3 Back

263   www.lawcom.gov.uk/public.htm Back


 
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