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".
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
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).
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
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".
The somewhat opaque term "progressive universalism"
was defined as the principle of "providing support for all
and more for those who need it most".
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,
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.
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,
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.
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.
175. In the meantime, the uptake of Direct Payments
nationally remained very low. In 2004 CSCI attributed this to:
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.
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",
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
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".
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.
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],
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.
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".
THE CASE FOR CHANGE (2008)
183. A discussion paper, The case for changeWhy
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.
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.
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. 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.
188. In October 2008 the results of the IBSEN
study of the Individual Budgets pilots were published. The key
findings were as follows:
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.
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
the same time the DH published a leaflet, Putting People First
- the whole story, which enumerated the four key aspects of
Early intervention and prevention;
Choice and control; and
Building "Social Capital".
Shaping the Future of Care Together
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.
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
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
5. Personalised care and support:
The services you use will be based on your personal circumstances
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.
192. This will constitute a "universal offer",
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
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.
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.
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[.]
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.
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
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.
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.
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
and falls prevention,
and the particular importance for prevention of appropriate housing
provision, integrated with social care.
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".
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.
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.
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
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
will help identify what has worked well in places round the country,
as well [as] current evidence to help push forward joined-up working.
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.
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
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.
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.
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
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.
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,
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".
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
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).
In January 2010 the Department published Putting People First:
Personal budgets for older peoplemaking 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.
However, many aspects of the actual implementation
of personalisation were contentious, as we discuss in the next
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".
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,
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.
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.
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
He promised that this would be fully addressed in
the White Paper.
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.
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
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.
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 [
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
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 moneywhether they
are paid for by taxpayers or people who need care and support.
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). To the
extent that this proposal was mentioned in the evidence that we
received, by SCIE and the CQC, it was welcomed.
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.
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.
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
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:
focus on prevention, rehabilitation and re-ablement;
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
Health Committee, Fourth Report of Session 1998-99, The Long
Term Care of the Elderly, HC 318, para 16 Back
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
HM Treasury, Pre-Budget Report, Investing in Britain's potential:
Building our long-term future, Cm 6984, December 2006, para
Ibid, para 5.55 Back
HM Treasury, Meeting the Aspirations of the British People:
Pre-Budget Report and Comprehensive Spending Review, Cm 7227,
October 2007, para 6.9 Back
For background information on personalisation, see Annex 2. Back
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
Qq 733, 772-775, 781 Back
Commission for Social Care Inspection, Direct Payments: What
are the Barriers?, August 2004 Back
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
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
Department of Health, Independence, Well-being and Choice,
Cm 6499, 2005, p 40 Back
Department of Health, Our health, our care, our say, Cm
6737, 2006, para 4.39 Back
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
HM Treasury, Pre-Budget Report, Cm 6984, 2006, para 6.11 Back
Department of Health, "Transforming Adult Social Care",
LAC (DH) (2008) 1, January 2008 Back
The three eligibility criteria bands proposed by CSCI were:
- Immediate - without immediate support
a person's well-being would be immediately threatened;
- Early intervention - well-being
may be threatened within six months without support; and
- Longer-term intervention - well-being
may be threatened within a year without support. Back
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
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
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
Qq 778-781. Caroline Glendinning et al., Evaluation
of the Individual Budgets Pilot Programme: Final Report (York,
Qq 88-89, 117, 843 Back
Q 889 Back
Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, p 47 Back
Q 16 Back
Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, pp 47-48 Back
Ibid., p 65 Back
HC Deb, 29 October 2009, col 484 Back
Q 892; cf. HC Deb, 29 October 2009, col 484 Back
Q 124 Back
Ibid.; cf. Q 135, 136 Back
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
Ev 24, 100, 142 Back
Ev 24; Q 675 Back
Q 674 Back
Q 14 Back
Q 15 Back
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
Ev 3 Back
Q 143 Back
Ev 96-97 and 101 Back
Ev 78 Back
Ev 136 Back
Q 63 Back
Ev 128, 137 Back
Ev 121 Back
Ev 2 Back
Qq 90-93, 843 Back
Ev 7 Back
Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, p 47 Back
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
Q 6 Back
Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, p 20 Back
Q 875 Back
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
Q 876 Back
Q 758 Back
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
Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, p 44 Back
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
Ev 85, 147 Back
Law Commission, Adult Social Care: A Scoping Report - Summary,
November 2008, para 1.3 Back