6 Achieving lasting reform |
227. In this chapter we examine the key issues
of social care reform that remain controversial and the reasons
why they continue to be major obstacles to reform.
228. The most contentious part of social care
reform is the issue of funding, which underpins all other aspects
of reform. Below we examine why consensus on this issue has not
yet been achieved.
229. The Green Paper sets out five possible funding
options for social care, each with the potential to bring in additional
funding, which it explains sit "on a continuum".
At one end of this is a Pay for yourself system, where
everybody would be responsible for paying for their own basic
care and support, whether through insurance or savings. This is
ruled out on the grounds that it would leave many people without
the services they need.
230. At the opposite end of the continuum is
a Tax-funded system, free at the point of use. This too
is ruled out, on the grounds that it:
place "a heavy burden"
on people of working age;
would be unsustainable, due to the projected
worsening of the old age support ratio;
would allow older people to get more
out of the system than they paid in; and
does not allow for the fact that older
people have benefited disproportionately from house-price inflation
(holding £932 billion in housing assets in 2004), while people
of working age are disadvantaged by high property prices.
231. Three further funding systems, sitting between
these two extremes, are put forward by the Green Paper as options
Everyone who qualified for care and support would
receive state funding for a proportion of the cost of their basic
care and support (for example a quarter or a third), or more if
they had a low income. They would have to pay the rest themselves,
effectively as a co-payment or user charge. The Green Paper indicates
that the majority of working-age adults who need care and support
would not have to pay under this system because younger disabled
people tend to have low incomes and few assets. The DH told us
that this option was based on the funding model developed by Sir
Derek Wanless for the King's Fund.
This is the same as the Partnership model, but with
an element of voluntary insurance to cover individuals' contributions
in the event of their needing care. This could be a state insurance
scheme, or one developed with the private insurance market. With
the state guaranteeing to pay part of the cost of care, premiums
for private insurance would be lower than in a purely private
system. The Green Paper estimates that the total insurance premium
would be between £20,000 and £25,000 (compared with
the average lifetime cost of care for a 65-year-old of £30,000);
this could be paid in instalments or in a lump sum, before or
after retirement. This option is not for working-age adults, since
they would not be able to insure against the care needs that they
already have. It appears to be presumed that they would mostly
qualify for free care on the basis of means-testing, as under
the Partnership option.
Everyone over retirement age, apart from the poorest,
would be required to pay into a state insurance fund; the contribution
could be set at a flat rate or varied according to people's ability
to pay. Everyone would then receive free care and support if they
needed it, paid for from the insurance fund. The Green Paper estimates
that the total contribution from each person would need to be
between £17,000 and £20,000. The cost would be less
for people who were already aged over 65 when the scheme was introduced.
It is suggested that couples might make lower contributions, in
recognition of the extent to which people within couples act as
each other's carers. The Government would consider having a free
care and support system for people of working age alongside the
Comprehensive option for older people.
Ms Norrish, of the DH, told us that all the shortlisted
options were based on the principle of progressive universalism,
with all eligible people receiving some state help but less well
off people receiving more help than others.
The National Care Service would thus not be a fully universal
service like the NHS (despite the, presumably intentional, similarity
232. None of the funding options is intended
to cover "hotel costs" for people in residential care,
which would continue to be the responsibility of individuals (with
means-tested help available for the poorest). The Green Paper
states this is "because we would expect people to pay for
their own food and lodging whether or not they were in a care
233. It also states that, in recognition of the
difficulty of meeting these costs, they could in future be met
by means of a "universal deferred payment mechanism",
so that payment could be taken from people's estates after their
death. (Although councils currently have the discretion to offer
this option, around a fifth do not.)
This mechanism could potentially also be used to meet co-payments
under the Partnership and Insurance options, or the one-off insurance
contribution under the Comprehensive option.
RESPONSES TO THE OPTIONS
234. It is widely agreed that the Government
is correct to rule out the Pay for yourself option. In
our evidence we heard that private insurance against care and
support needs has long been characterised by "market failure".
This is due to low take-up (because few people expect they will
need care) and "adverse selection", i.e. the fact that
people who are more likely to need care are more likely to buy
insurance (which skews the "risk pool" of any insurance
fund). These factors drive up premiums and make this form of insurance
at best a niche product for better off people (e.g. immediate
needs care annuities),
or at worst commercially unviable.
235. We also heard there is scepticism in the
insurance industry itself about the Conservative Party's plan
for a privately-run insurance scheme to cover residential care
at a premium of just £8,000. Chris Horlick, of Partnership
Life Assurance Company Ltd (a provider of immediate needs care
annuities), welcomed the idea of exploring funding options involving
the private sector, but on this specific proposal told us:
I think there are some pretty flawed assumptions
in it and the two most fundamental ones are the numbers of people
going into care, so the front end bit of it, if you like, and
at the other end their longevity in care. I have not seen the
model so I do not understand the details of it but it seems to
me to be flawed, I am afraid [
236. There was general agreement that it was
desirable to have a more universal system than the status quo
(in which many people receive no state support at all), but beyond
that opinions differed.
237. A wholly universalist system (i.e. the Tax-funded
option) had considerable support among those who gave evidence
to our inquiry. Its advocates pointed out that the three progressive
universalist options put forward for consideration in the Green
Paper "all continue to involve an element of means-testing
and unfairness", as the National Pensioners Convention told
us. The Tax-funded
option, by contrast, would be a truly fair and equitable way to
pay for care and support. It would enable "risk pooling"
right across society, with people contributing, through the tax
system, on the basis of their ability to pay and receiving care
and support solely on the basis of need. This approach is supported
by all the main political parties, and the great majority of the
public, as the underpinning principle of the NHS and many cannot
see why it should not apply to social care too.
It is notable that the DH's own polling shows that half of people
asked think social care is already provided on the same basis
as the NHS.
238. In attempting to justify funding social
care in a different way to the NHS, the Secretary of State referred
to people accepting personal responsibility for aspects of social
care and to the extent of home ownership nowadays.
Yet variants of these arguments could just as easily be deployed
against the principle of a free NHS. Mr Humphries, of the King's
Fund, thought the Green Paper made a "cogent" case for
believing tax-funded social care would be unsustainable, but could
not see why this did not apply equally to the NHS. He concluded:
"Some of this does boil down to political choices about what
you want to do out of taxation or not, as the case may be".
239. Support for the Partnership form
of progressive universalism put forward in the Green Paper did
not seem strong in the evidence we received and it attracted a
number of criticisms. Linda Pickard, of the PSSRU, told us that
it could lead to heavy reliance on carers, since "many of
those without sufficient financial resources to purchase care
services would seek support from their families". This would
make the social care system vulnerable in the future to declining
availability of informal care.
240. Professor Caroline Glendinning, of York
University, told us that the Partnership model:
may be very difficult to operationalise with people
who have very significant fluctuations in their conditions, or
deteriorating conditions, where the amount of money that would
be contributed may well change from time to time and, indeed,
on a very frequent basis [
241. Mr Laing, of Laing & Buisson, argued
that this option would constitute a de facto continuation
of the current means-tested system. While better-off people would
receive some state funding, this would be offset by the impact
of reforming Attendance Allowance (which is currently payable
as a non-means tested benefit to self-funding care home residents):
"that is smoke and mirrors; no change at all!"
242. Another weakness in the Partnership model
is that, as under the current system, there is no cap on the amount
that a person could end up paying from their own resources, should
they need care that is very expensive by reason of its type or
is some indication that the relatively low level of state contribution
for some people in the Green Paper's version of the Partnership
model (at least a quarter of each person's costs) would leave
significant numbers facing substantial co-payments at the point
243. Although the DH insisted its version of
the Partnership option was essentially the same as Sir Derek Wanless's,
we heard that there were crucial differences and Sir Derek's proposal
may have more support. Sir Derek's version of the Partnership
option involved state funding of two-thirds of the cost of a benchmark
package of care, with the remainder paid for by co-payments, along
with further pound-for-pound "match-funding" by the
state (meaning that the state could contribute up to 83% of the
cost in each case).
Mr Humphries told us that the King's Fund thought match-funding,
which was intended to give people an incentive to make provision
for themselves, was "an important component of the original
Another difference is that Sir Derek's proposal involved higher
quality benchmark packages of care than does the Green Paper,
which simply assumes that care packages will be worth their current
244. The Insurance option is a variant
of the Partnership option and, as such, is susceptible to the
same criticisms. In addition, it is improbable that the voluntary
insurance element of the Government's Insurance option would actually
attract significant numbers of people, since it would fall foul
of the problems that have always beset private insurance (i.e.
low uptake and adverse selection).
245. The Comprehensive option found some
support among our witnesses because it would effectively "cap"
people's contributions from their own resources, unlike the two
co-payment options (Partnership and Insurance), as well as spreading
risk significantly more widely than those options.
246. The charity Counsel and Care supported the
Comprehensive option, seeing it as close in spirit to the Tax-funded
option (which Counsel and Care also favoured). The charity thought
that the Comprehensive option would operate most fairly by means
of a "care duty" of 2.5% on people's estates (with perhaps
a threshold of £25,000 below which assets were disregarded),
to be hypothecated, i.e. paid into a ringfenced fund for social
There has recently been political controversy about the possibility
that the Government will favour this form of the Comprehensive
option, which has been criticised as a "death tax".
From this point of view, it is regarded as effectively an additional
form of Inheritance Tax, which would hit people hardest in London
and the South East, where property values are highest. However,
a recent Care and Support Conference, involving a range of stakeholders
was favourably disposed to it, while also regretting "that
the option of general taxation had not been explored".
247. Others who were also sympathetic to the
Tax-funded model have been less positive about the Comprehensive
Ms Pickard thought that, of the options in the Green Paper, only
the Comprehensive one "would potentially reduce reliance
on intense informal care" (since there would be no financial
disincentive to accessing care and support), she added:
It is not clear, however, that a "comprehensive"
option should necessarily be funded only by the resources of older
people themselves, as is suggested in the Green Paper. There are
many organisations representing older people who feel that tax-funding
of social care should not be ruled out and that "costs must
be shared fairly across the generations".
Professor Glendinning pointed out to us that in Germany,
where social care is funded through a social insurance scheme,
contributions are paid by the working age population and this
is generally accepted.
248. Age Concern and Help the Aged reported that:
"our research shows that the proposal for a 'care charge'
outlined in the 'comprehensive' option is very unpopular."
The charity calculated that overall (allowing for the reform of
Attendance Allowance and "hotel costs") the option was
likely to prove:
little cheaper than insurance people can already
buy to cap their costs, once they know they will need care [immediate
needs care annuities]. We think few older people will see the
care charge as a "price worth paying".
249. Mr Lloyd explained to us how "soft
compulsion" might be used to avoid the pitfalls involved
in both voluntary and compulsory insurance. This could be done
by automatically enrolling everyone in a state insurance system,
but giving people the choice to then opt out if they wished. Since
most people would not trouble to opt out, this would give the
broad coverage of compulsory insurance but would not be as strongly
250. The DH's view that funding reform did not
need to address "hotel costs" was widely criticised.
It was pointed out to us that these costs can be much higher than
the cost of living at home; and "hotel costs" can end
up being catastrophic just as care costs can.
We heard that in Scotland, despite free personal care, residents
still pay substantial sums from their own resources to cover "hotel
independent consultant Donald Hirsch told us:
Is there not another way of looking at this and that
is to say not an accommodation cost but an accommodation charge?
] It certainly would not look right to have a system which
provides everything to people when previously they would have
been paying for those things, food and accommodation, but if you
could have a charge based on what people can pay, then you would
not have this issue.
People of working age
251. Another issue that caused concern was the
Green Paper's failure to say enough on how the funding options
would affect people of working age. It assumes that people of
working age will mostly qualify for wholly free care under the
Partnership option on the basis of means-testing. The charity
Leonard Cheshire Disability told us:
We are very concerned that a means-test in the partnership
model could have exactly the same effect as now, actively discouraging
saving among disabled people who use care and support services,
preventing many from going out to work and leaving more trapped
252. Regarding the Insurance option, the Green
Paper indicates that this is for people of retirement age only
(it would not be possible for people of working age to insure
against an existing impairment). This appears to mean that, as
under the Partnership option, working-age people would qualify
for free care on the basis of means testing.
253. The Government says it would look at a free
care and support system for people of working age alongside the
Comprehensive option for older people. However, Leonard Cheshire
Disability told us:
this brings its own complexities with regard to a
subsequent point of transition being created between working age
and older people's services, by requiring individuals to start
paying for some or all of their care at the point when they are
no longer earning a monthly income from work.
THE OVERALL "FUNDING ENVELOPE"
254. The Impact Assessment for the Green Paper
suggests that the National Care Service could cost the state annually
between £18.2 billion and £20.7 billion by 2014 (in
real terms at 2006 prices), depending on the funding option chosen.
The Partnership and Insurance options would cost the state marginally
more than the current system in 2014, and the Comprehensive option
significantly more (£3.4 billion, i.e. the same additional
cost as the Tax-funded option).
255. These are "illustrative comparative
costs suggesting the possible cost to the state of the different
with the assumption that the budget for Attendance Allowance is
merged into social care funding (we discuss this proposal further
below). They are, therefore, no indication of what the future
"funding envelope" for social care will actually be.
Thus, as ADASS noted in its evidence to us, the Green Paper:
is silent on the prospects of more state funding
even though the options imply increased state expenditure and
increased contributions from individuals.
Yet, as we have noted, one of the greatest problems
with the current system is the extent to which it is underfunded.
Age Concern and Help the Aged stated in their evidence that:
The Green Paper proposals are broadly "revenue
neutral" (except for the "comprehensive" option).
But the care and support system needs more resourceseven
to respond to the needs of people who meet today's means-testin
order to achieve better quality and earlier availability of services
] Before we can make any meaningful comment on the funding
options proposed in the paper we need more detail on the costing
assumptions: the level at which eligibility criteria will be set;
how much resource will be available per person; and the nature
of the means-test [
In giving oral evidence the charity's representative,
Mr Harrop, elaborated on this:
The critical issue that is missing from this Green
Paper is the analysis of the problems of the current system, all
those issues [
] about it not being available to enough people,
the amount spent per service user being insufficient, all that
is rolled forward into the Green Paper's proposals. The Green
Paper is mainly about extending the current offer to higher income
groups, rather than deciding: are there enough services available,
is the amount of resource in that total envelope sufficient? We
say it is not.
Mr Chidgey, of the Alzheimer's Society, also explained:
the big worry for people is there is nothing in the
proposals that they think very clearly describes: what are you
going to get? Are you going to be able to get some respite care
except in an emergency, which is often the case at the moment,
some planned respite? Are you going to be able to get a little
bit of help to get someone out of bed, and to involve them in
some meaningful activity?
256. However, when we pressed the Secretary of
State on the future social care "funding envelope",
he could only tell us:
Obviously, those are decisions for the Treasury and
the Chancellor. Spending on social care through local government
is obviously a decision for the Chancellor when the final spending
review is completed [
] Obviously, we cannot prejudge spending
reviews in future.
257. While there is universal recognition of
the need for fundamental reform, we heard in our evidence that
there are several more limited reforms that could quite easily,
and relatively cheaply, alleviate some of the worst aspects of
the status quo.
Revising capital limits
258. When we asked Mr Burke, of Counsel and Care,
about options for short-term reform, he told us:
what we have embarked upon is system wide reform
and long-term reform, inevitably that will not happen for three
or four years yet, so there are probably things that you could
do in the short-term, so certainly increasing the [upper] capital
limits [above which a person receives no state help; in 2009-10
set at £23,000], probably [to] £50,000 [
was the figure recommended by a recent commission on care from
Hampshire County Council [
259. We also heard from Mr Hirsch that the JRF
had looked at "suggestions of things you could do while you
were fixing the present system in the long term". The Foundation
had concluded that one such measure would be to double the upper
capital limit "so that at least people would feel they had
something to preserve in a worst case scenario".
A case might also be made for concomitantly raising the lower
capital threshold, below which a person may keep all their capital
(in 2009-10 set at £14,000).
Capping individual liability
260. The charity Mind mentioned to us in its
evidence the idea of a "limited liability" arrangement,
whereby if someone is required to pay for care from their own
resources before they qualify for public support, "the individual
contributes only for a certain length of time".
In this way, liability is effectively "capped" and there
is no chance of incurring unlimited catastrophic costs in the
event of needing care that lasts for a long time.
261. Sir Derek Wanless's report considered "limited
liability" as a possible funding model, with a cap taking
effect either after a specified period of time or after a specified
sum of money had been spent. (It was rejected on the grounds that
it would only protect the assets of those who have more than the
limited liability threshold.)
It was also recommended for consideration by one of the two signatories
to the Royal Commission minority report.
Universal access to deferred payment arrangements
262. As we have noted, local authorities currently
have the discretion to offer a Deferred Payment Agreement (allowing
people to avoid having to sell their home during their lifetime
to fund residential care, should they fail the means test) but
many do not. The Green Paper, as we have also noted, proposes
that this should be made universally available to help people
pay "hotel costs" (and possibly also co-payments or
insurance contributions) under a new funding system. There is
support for this proposal
and there would seem to be no reason it could not be implemented
ahead of fundamental reform of the funding system.
Reducing the tariff income
263. The presumed "tariff income" on
capital between the two thresholds (£14,000 and £23,000)
in 2009-10 is set at a rate equivalent to an annual net interest
rate of 20.8%, which is considerably higher than the current (March
2010) Bank Rate of 0.5%. Although the tariff income is not intended
to represent actually available rates of interest, the very large
discrepancy between it and currently available interest rates
is forcing people to "spend down" their capital much
more quickly than would otherwise be the case. Citizen's Advice
told us in their evidence that "The tariff income rate is
much too high and should be reduced."
Raising the Personal Expenses Allowance
264. The low level of the PEA for local-authority
sponsored care home residents (£21.90 in 2009-10) is a source
of particular resentment under the current system. We heard that
this amount is far too low for people to be able to maintain their
quality of life, for instance by purchasing equipment such as
a specialist chair or services, such as foot care.
Mr Hirsch told us that the JRF had "thought roughly £20
a week was just not compatible with dignity and it would not cost
a lot to double that in the overall order of things".
265. The Government has, however, resisted demands
to increase the PEA on the grounds that this would consume scarce
resources but would not "increase the availability choice
or quality of care services or support the transformation of adult
social care provision".
266. The Government's presentation
of the funding options in the Green Paper is significantly flawed.
The option of free care wholly funded from general taxation is
ruled out by the Government on the grounds that it would place
"a heavy burden" on taxpayers of working age. However,
many of those who gave evidence to us supported this option and
most of the arguments against it can be said to apply just as
much to the idea of a free NHS. We recommend the Tax-funded option
should be debated in order to gauge whether people are prepared
to pay higher taxes for social care or wish to see tax revenue
diverted to it from other areas of spending.
267. The DH told us that the
Partnership option presented in the Green Paper derived 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 the idea of the
state matching individuals' contributions pound-for-pound, on
top of a basic state contribution, to provide an incentive for
people to make provision for themselves. We believe that Sir Derek's
original Partnership option should have been included in the debate.
268. We are dissatisfied with
the Green Paper's approach to the issue of "hotel costs",
which it excludes 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". It can plausibly be argued
that such costs are significantly higher in residential care than
they would be in a person's own home. Funding reform that fails
to address the risk of incurring uncapped catastrophic costs of
this kind risks being quickly discredited and losing public support.
The Government must look at options for dealing with this issue,
such as an accommodation charge that takes account of people's
ability to pay.
269. We are also concerned that
the Green Paper pays insufficient attention to how the various
funding options might affect people of working age who use social
care services. The means-testing element of the "Partnership"
and "Insurance" options would risk replicating the existing
poverty trap in which many disabled people of working age find
themselves. The proposed free system for people of working age
alongside the "Comprehensive" option for older people
would avoid the poverty trap. However, we are concerned that the
transition from one system to the other at the age of 65 could
mean that people become worse off merely by reason of growing
270. A major deficiency in the
Green Paper is that it is silent on the question of the overall
"funding envelope" for social care, i.e. how much money,
from all sources, will be spent on people with care and support
needs in future. This leaves the Green Paper unable to indicate
the scope of the new system. The state of public finances as a
result of the credit crunch, the bank bailouts and the recession
clearly makes the question of future spending levels particularly
problematic. However, the issue cannot be ducked. We need to know
in hard cash terms what future overall social care funding will
271. Ahead of fundamental reform,
there is scope to mitigate significantly the worst aspects of
the existing funding system quickly and relatively cheaply. This
is not to argue for minor change as an alternative to major reform,
but rather to make the case for addressing some of the deficiencies
as a matter of urgency. We recommend that the following measures
be taken immediately:
capital thresholds in the means test must be substantially raised
in order to ease the burden on people of relatively modest means.
be given to some form of "cap" to limit people's liability
to pay from their own resources before they qualify for public
Universal access to
the deferred payment mechanism (which allows people to avoid having
to sell their home during their lifetime to fund residential care)
must be introduced.
The presumed "tariff
income" on capital between the two thresholds is punitive
must be substantially reduced.
The Personal Expenses Allowance
for people in residential care is far too low and fails to ensure
dignity or opportunities for people to maintain their social and
family relationships. It must, as a minimum, be doubled.
Free Personal Care at Home Bill
272. Since the publication of the Green Paper,
social care reform has been made more complicated by the Free
Personal Care at Home Bill. Below we outline the Government's
proposals and examine reactions to them.
273. At the Labour Party conference in September
2009, the Prime Minister, Rt Hon Gordon Brown MP, unexpectedly
announced that the Government would be introducing free personal
care for those people with the highest levels of need being cared
for in their own homes, beginning in October 2010.
274. The Personal Care at Home Bill was introduced
into Parliament on 25 November 2009 and is currently making its
way through the House of Lords.
The Government has meanwhile consulted on proposed regulations
to be made under the Bill, should it become law. It is proposed
that free personal care at home should be given to people whose
needs are classified as "Critical" under FACS and who
need significant help with four or more personal care-related
Activities of Daily Living.
There are also proposals regarding how resources will be allocated
to individual people;
and the formula for distributing to councils central-Government
funding earmarked for this purpose.
In addition, the draft regulations would permit councils to make
free personal care conditional on a person undergoing a period
of intensive support or re-ablement for up to six weeks before
having their care and support needs formally assessed. A consultation
on these proposals took place between 25 November 2009 and 23
275. The Government estimates that more than
400,000 people will benefit from this policy, with 130,000 people
receiving re-ablement services and 280,000 actually receiving
free personal care. Of those who will receive free personal care,
166,000 already receive free care after means-testing and 100,000
currently pay charges, receive informal care, receive residential
care, self-fund or have unmet need.
276. The cost is estimated at £670 million
per annum, of which £420m will be supplied by the DH (from
efficiency savings). In a recent interview, the Secretary of State
said £60 million would be "reprioritised" by the
DH from "lower-priority" health research and development,
and £50 million saved from public health campaigns as part
of funding free personal care at home.
277. He explained to us that these figures related
to the first six months of implementation (the second half of
2010-11), during which the DH would have to find £210 million
to fund the policy. He said that the Department planned to "release
savings from the administration of the research budget",
but strongly denied that "front line research into cancer
or other high-profile conditions" would be cut, as had been
reported. However, he could not yet give "a precise list
of the implications" of the planned savings. As regards public
health campaigns, he suggested that cuts could be made in "how
we procure advertising and communication space from the media"
and by "taking a very tough approach to the use of management
278. Local government will be expected to find
the remaining £250 million, also from efficiency savings.
The Secretary of State referred us to the DH's document Use
of Resources in Adult Social Care (October 2009), which he
said "identified £250 million efficiency savings that
we believe are there to be made", a figure that had been
confirmed in the Pre-Budget Report in December 2009.
The latter states that local authorities could, by 2012-13, save:
£250 million from reducing variations in spend
on residential care, including greater use of preventative approaches
to care for older people allowing people to stay longer in their
279. The Government argues that the Bill does
not in any way cut across the Green Paper but is rather, as the
Secretary of State put it to us, "a stepping stone or bridge"
to the National Care Service.
He argued that it did so firstly by ending the current "lottery"
of care for the most vulnerable and replacing it with a national
entitlement to free care; and secondly by linking domiciliary
care with re-ablement and a preventive approach.
280. Following the announcement of this policy,
the DH commissioned revised financial modelling from the PSSRU.
We twice wrote to the Secretary of State asking him to show us
the interim financial model that the DH had received from the
Unit in November 2009, but he declined to do so.
He denied this was because he was embarrassed to admit that the
change in policy had badly damaged the DH's original calculations.
REACTIONS TO THE POLICY
281. The Government's free personal care at home
policy has proved to be extremely controversial. Lord Lipsey,
who was a dissenting member of the Royal Commission on Long-Term
Care, memorably accused the Prime Minister of being like "an
admiral firing an Exocet into his own flagship" when the
policy was included in the Queen's Speech.
In our evidence we heard a number of reactions to the policy,
both positive and negative (although largely the latter), and
these are summarised below.
Relationship to the Green Paper
282. The Secretary of State insisted that free
personal care at home had grown out of the Green Paper and not
been "unilaterally chucked in";
and DH officials insisted to us that the new policy had not been
considerable surprise has been expressed at the announcement of
the policy in the middle of the Green Paper consultation (the
Big Care Debate). Ms Scott, of the National Care Association,
I thought we were in the middle of a public consultation
about the whole issue, and so it was quite a shock, in the first
instance, to have the announcement made [
] This is a large
amount of money that has been dedicated, and we truly believed
that we were having this major public consultation which would
make these sorts of decisions. So this large amount money that
is being allocated to one part of the service makes us think that
other parts of the service may not be so fortunate.
Mr Burke, of Counsel and Care, was sympathetic to
the policy but thought:
the question is where are we heading generally, because
we are obviously halfway through a Green Paper consultation on
the future of care which is talking about system-wide reform,
and that is what we need, we need to reform across the whole system.
So a piecemeal change is not necessarily the best way to approach
283. A key point here is the perceived contradiction
between free personal care at home and the categorical ruling
out of the Tax-funded option by the Green Paper, as we heard from
Professor Peter Beresford, of Brunel University:
if we have ruled out as an option considering general
taxation in a Green Paper to which there have been 24,500 responses,
a significant number of which have supported the idea of general
taxation at least to be included, then it feels like it is policy
being made on the hoof to introduce a new idea which contradicts
Scope of the policy
284. The narrow scope of the policy, as outlined
in the proposed regulations, has caused concern. Mr Harrop, of
Age Concern and Help the Aged, thought the policy was "a
really welcome move forward" but noted that the proposed
eligibility threshold meant that:
you really will need to be very, very disabled and
in need to get this free offer [
] the people who are going
to be supported by this actually could be relatively few in number.
There is a particular concern that people with fluctuating
needs could be disadvantaged by the tightness of the eligibility
285. The piecemeal nature of this reform raises
concerns that it could have unintended consequences in interacting
with the rest of the social care system. Mr Chidgey, of the Alzheimer's
Society, was worried that it could:
create perverse incentives to either admit people
to long-term care too early, because perhaps there is a local
authority incentive, or [
] incentivise people to keep the
person with dementia at home far longer when actually it is not
good for that person's quality of life or for the family's quality
286. Admitting people to residential care prematurely
would, of course, run directly counter to the policy's stated
intention (and long-term DH policy) of making it possible for
people to be cared for at home for as long as possible. Ms Owen,
of ADASS, accepted that councils had a duty not to place people
inappropriately in residential care; but they also had a duty
to get value for money. If "the same sort of good quality
care, can be provided at better value in residential care, you
have a real dilemma".
287. Mr Bolton, from the DH, told us that this
would be limited by lack of care home capacity, could be detected
using councils' spending returns and would be policed by the regulator
(i.e. CQC). He
thought there was "nothing particularly" that could
prevent the operation of the opposite perverse incentives, for
families to keep people out of residential care for too long.
The Secretary of State also told us that the operation of the
policy would be reviewed after 18 months to check for unintended
Definition of personal care
288. The policy's focus on the provision of personal
care alone is also seen as problematic. Ms Owen referred to disputes
in Scotland about demarcating the boundary between free personal
care and other (means-tested) services:
the four activities of daily living I think could
wrap us up forever in arguments about what does it mean. This
is the experience of Scotland. Let us just take one example: Help
with eating. What does it mean? Does it mean cutting up the food?
Does it mean help with putting the food in your mouth? Does it
mean microwaving it? Does it mean cooking it? For lawyers [
this is going to be an absolute minefield.
She was also concerned at how the focus on personal
care alone would fit with personalisation:
we have been spending the last two years working
on personalising services, getting away from: "If you need
this activity of daily living, then you need this" but having
much more flexibility around the response. We must not throw out
the personalisation of our services as we have to start looking
Paying for the policy
289. The most controversial aspect of free personal
care at home is the question of paying for it. Sir Jeremy Beecham
told us about the "new burdens doctrine", whereby any
new statutory duties imposed by central government on local government
are fully funded, either by providing new money or lifting other
obligations. In this case, he thought the Government had violated
290. The Secretary of State insisted to the contrary:
The Department of Communities and Local Government
does not consider this to be a new burden; it is part-funding
and brings a lot of new money to the table for local government
to build those services and help them achieve those savings. We
see this as a partnership, not the dumping of a new burden.
He cited the Isle of Wight Council as an example
of an authority that was already providing free personal care
for all people aged over 80 who were being looked after at home,
funded by efficiency savings, including reduced use of residential
care. He thought that the Bill "very much nationalises the
example of the Isle of Wight".
291. Sir Jeremy and Ms Owen both indicated that
they doubted whether the Government's estimates of the cost of
implementing free personal care at home were "robust",
in respect of both the level of demand and unit costs. They suggested
that the modelling work done for the policy could have understated:
cost of re-ablement relative to its benefits;
possible increased demand from people
who have hitherto been buying their own care;
possible increased demand from people
currently being looked after by carers;
Sir Jeremy found the Government's figures "suspiciously
and thought it might have been better to pilot the policy before
going ahead with full implementation, to evaluate its cost properly.
292. According to the results of an ADASS survey,
published in January 2010, the true cost of the policy could be
at least £1 billion per annum, with the cost to local authorities
reaching more than twice the £250 million stated by the Government.
ADASS questions the Government's assumption that personal care
needs can be met through an average package of 6.54 hours of care
per week at £15.75 per hour (amounting to £103 per week).
It states that local authorities estimate a much more expensive
average care package for a person with high needs, at an average
cost of about £200 per week. In addition, the Association
points out that the number of existing self-funders in any given
area is often unknown, as well as the number eligible under the
293. We acknowledge that the
Government is itself bringing forward significant interim reform
of social care through the Free Personal Care at Home Bill. However,
we have strong misgivings about this. The proposal for free personal
care should be substantially increased, consistent with the introduction
of a National Care Service.
294. For the Government suddenly
to announce this new policy just weeks after publishing the Green
Paper, and in the middle of the consultation period, smacks of
policy-making on the hoof. The haste with which the proposals
have been assembled is all too apparent in their shortcomings.
295. Since only part of the
social care system is to be changed, there is a risk of creating
perverse incentives and introducing unanticipated consequences.
Witnesses told us that families will have an incentive to try
and keep people out of residential care longer than is appropriate,
in order to continue receipt of free care. Councils, meanwhile,
will have opposite incentives to place people in residential care
prematurely, or to manipulate their eligibility criteria so that
people being cared for at home are not classified as having higher
levels of need.
296. Furthermore, estimates
of the likely levels of demand and cost appear low, and there
is a risk that the reform could be substantially underfunded.
Local authorities have warned that they will not be able to fund
their share of the costs from efficiency savings, as the Government
intends. This could result in rationing or cuts in other services,
including aspects of social care. Meanwhile, the DH has yet to
make clear how exactly it will find its share of the funding.
It has indicated that some will come from public health and research
budgets, which could be detrimental to the long-term interests
of NHS patients.
297. As we have stated, the
option of a free social care system is one that needs to be debated
and considered. However, it is not helpful for the Government
to rush in a poorly thought-out and very circumscribed form of
free care, as it is doing, rather than it being an integral part
of a National Care Service.
"Fully national" or
"part local/part national" system?
298. The Green Paper poses a choice between two
models for the National Care Service, regardless of which funding
option is ultimately chosen: a "part-national, part-local"
system; and a "fully national" system.
299. Under the "part-national, part-local"
option, people would be entitled to have their needs met, and
a given proportion of their care and support package paid for
by the state, wherever they lived. However, local authorities
would decide how much to spend on each individual person's package
of care and support, giving councils flexibility to take into
account local circumstances and costs, as well as the requirements
of individual people.
300. There is certainly a case for a "localist"
approach to social care. Geographical variations that are regarded
as indicative of a "postcode lottery", may in fact reflect
different local circumstances, e.g. variations in cost or need
for particular services or priorities. Where services are more
limited in some areas than in others, it can be argued that this
is balanced out by other things (for instance, lower Council Tax
or more generous services of another kind). Sir Jeremy Beecham
of the LGA told the Committee:
Sometimes I have been tempted to form a society for
the preservation of the postcode lottery because I do think you
have to respect local differences, not only in demand but how
you meet that demand, and so you need a system which is flexible
enough to allow you to engage with other partners, the third sector
perhaps, in particular, to commission appropriately and to offer
301. Under the National Care Service's "universal
offer", there would be a "portable" assessment,
as we have noted. However, as Ms Norrish, of the DH, told us:
It does not necessarily mean that you get exactly
the same services wherever you are, because if you are living
in rural Devon you may actually need different services to those
that you would need if you were living in the city of Durham [
The prospect of there being no greater consistency
between areas in respect of rationing and resource allocations
does cause anxiety that the unfairness of the "postcode lottery"
will simply be perpetuated under the new system. Sue Ryder Care
if the Local Authorities retain control of the social
care budgets and a National Assessment is introduced, both eligibility
for services and the level at which they are delivered need to
302. From this point of view, "localism"
looks significantly less attractive than the "fully national"
option. Under the latter, central government would set "the
level of funding that people with a particular level of need and
who need a particular outcome would receive".
The amount of funding allocated could be consistent across the
country, or it could vary depending on location, to take account
of the different costs of care across the country. Under this
system, it is likely that all funding for care would be raised
through national taxation, with councils not needing to raise
funds locally through Council Tax.
303. In his evidence, the Secretary of State
seemed to lean towards this option:
one can have national assessment and entitlement.
Obviously, the question is: entitlement to what? That takes one
into the question of how big one makes the offer. I agree with
you. In recent times there has been a lot of fashionable talk
about localism and giving people the ability to run things at
local level. I believe that often the public do not want a postcode
lottery certainly for healthcare but also social care; they want
clarity about what they can expect and they want it to be fair
across all areas. I believe that the case for national entitlement
and assessment is very strong.
304. Another issue is the question of integration
of health and social care, for which our predecessor committee
argued strongly in 2005.
It can be argued that a "fully national" social care
service might be more easily integrated with the "fully national"
305. Whether the National Care
Service should be a national system locally provided ("fully
national") or a local system with national standards ("part
local/part national") is a key area of controversy. The argument
in favour of local accountability, along with flexibility to meet
local needs and priorities, is very persuasive. On the other hand,
the "fully national" option would clearly be the best
way to ensure more clarity and consistency in provision; it would
also seem to be an effective means of bringing about full integration
of health and social care. The lack of detail in the descriptions
of the two options given in the Green Paper makes it difficult
to arrive at a definitive view one way or the other. In particular,
the Government must make clear whether the fully national option
will involve a funding allocation mechanism that takes account
of differing local costs.
306. Despite the universal consensus in favour
of greater personalisation of care and support, the details of
implementation are contentious in relation to issues such as fairness,
equity and protecting vulnerable adults, as we consider below.
INDIVIDUAL BUDGETS OR PERSONAL BUDGETS?
307. Professor Glendinning, who led the IBSEN
review, told us the Government was implementing Personal Budgets
(involving social care funding only), rather than the more ambitious
model of Individual Budgets (involving funding from a range of
The personal budgets that are now being implemented
under Putting People First are social care resources only, and
I do want to emphasise that this was probably the most disappointing
element of the [IBSEN] pilots.
I do not know the reason for the decision. The decision
to roll out personal budgets across English adult social care
was, of course, made before the findings of the IBSEN evaluation
were available [
] My own personal view is that it was a
political decision. I am not aware of any clear evidence underpinning
308. There appears to be a widespread view that
such a policy decision has been made.
However, this was denied by the Secretary of State and Hazel Hobbs,
of the DWP:
Q942 Dr Taylor:
Why have you given up on individual budgets which combined local
authority social care money and other funding streams?
Andy Burnham: We certainly have not. Ms Hobbs may
be able to say more about the right to control work that is going
on for which DWP has legislated.
Q943 Dr Taylor: So, you
have not given up on the idea?
Ms Hobbs: Certainly not. The principles running through
and across government in this sense are about giving people the
right to control, bringing together different funding streams,
for which parliament legislated in the Welfare Reform Bill last
Ms Hobbs agreed there was some confusion of terminology.
309. The Secretary of State emphasised that this
approach was part of a fundamental shift that would occur across
public services over the long term:
This is a very interesting side of public service
reform that will play out not necessarily immediately but over
the next 20 years. When you look at the effect of our health personal
budgets pilot the intention is to merge it with direct payments
in social care, employment and elsewhere, but here you cannot
run before you can walk. The implications of all of this are pretty
REFORM OF DISABILITY BENEFITS
310. One area where the DH appears keen to run
ahead with combining budgets for care and support is the reform
of disability benefits for older people by merging them into social
care funding (an idea that was suggested by both Sir Derek Wanless
and the JRF in 2006). However, this proposal has proved very controversial,
illustrating some of the potential pitfalls of trying to combine
different sources of funding in practice (something which was
also a feature of the Individual Budgets pilots).
311. The two benefits concerned are Attendance
Allowance (AA) and Disability Living Allowance (DLA), both of
which are paid by the DWP. AA is a flat-rate, tax-free, non-means
tested, non-contributory cash benefit for people aged 65 or over
who need help with personal care. A person can receive AA regardless
of whether they are receiving care and support. AA is intended
to address "extra", i.e. non-care, costs resulting from
frailty or disability (such costs are many and variedincluding
special diets, incontinence pads, additional laundry, special
clothes, extra heating, special bedding, extra lighting). However,
it is entirely up to the recipient what they choose to spend the
312. Council-sponsored care home residents are
not eligible for AA after four weeks but the benefit is payable
to self-funding residents. Many people living in their own homes
who are entitled to AA do not receive local authority funded social
care services, as they have Low or Moderate needs, which do not
qualify for support under the eligibility criteria operated in
their area. In
such circumstances, AA is often used to help purchase services
privately. For those people who meet local social care eligibility
criteria, the benefit is used to help pay local authority social
313. There are two rates of AA;
for 2009-10 they are £47.10 per week and £70.35 per
week. At August 2009, 1.3 million people in England were in receipt
of AA. DWP data
show that in 2008-09, £3.9 billion was paid out in AA in
314. DLA provides a weekly fixed sum for the
purpose of assisting a claimant with the extra costs associated
with disability. As with AA, it is non-means-tested, non-contributory
and tax-free. DLA is made up of a mobility component and a care
component. The mobility component (for help with walking difficulties)
is paid at two different levels. The care component (for help
with personal care needs) is paid at three levels. A person can
receive a care component along with a mobility component. Although
DLA can be paid indefinitely, there is an upper age limit for
making the first claim. Claims must be made before a person's
65th birthday. Otherwise, AA may be claimed instead. AA has no
mobility component, but the disability tests are the same as for
the middle and higher rate care components of DLA (this means
that someone who qualifies for the lower rate of DLA will not
qualify for receipt of AA).
315. In 2009-10, the three weekly DLA care component
rates are £18.65, £47.10 and £70.35; the mobility
component rates are £18.65 and £49.10. At August 2009,
634,000 people in England aged 65 or over were in receipt of DLA.
The amount paid in DLA to people aged 65 or over in England in
2008-09 was £2.6 billion.
316. Following the publication of the Green Paper,
it appeared that the Government was planning to reform DLA paid
to people under 65, but, in the face of much concern over the
potential loss of this benefit, it was eventually clarified that
this was not the case.
317. We heard that the Government's case for
reform rests on its view that AA and DLA, as non-means tested
benefits, are ill-targeted and the sums involved could be better
used. Ms Norrish, of the DH, told us that "the vast majority
of people who get AA need it, they are on low incomes and they
have high levels of need". However, the Government believes
that significant amounts of money are being paid to wealthy older
people with little disability, as Ms Norrish told us:
I have had people coming up to me telling me stories
about people they know who get their AA and put it in the bank
and are keeping it "to pass on to their grandchildren".
There was one person I heard about who every year goes on a four-week
Saga cruise and uses her AA to extend it to a six-week cruise.
This is where we have to take a view on whether the best use is
being made of public funding. The judgment that we took around
that was that you could transfer that funding from the people
who are on higher levels of incomes to people who are on lower
incomes and who potentially have higher levels of need and so
that is the proposal in the Green Paper.
318. However, in our evidence we also heard strong
opposition to the reform of disability benefits; and even those
who support the idea in principle (seeing the benefits of combining
disparate streams of funding) have concerns about implementation.
319. Ms Norrish's assertion that AA was being
spent on Saga cruises prompted Mr Harrop, of Age Concern and Help
the Aged, to warn: "I think we are in danger of policy-making
This is confirmed by research which has been done by Professor
Ruth Hancock, of the University of East Anglia, and her colleagues.
This found that disability benefits are more likely to be claimed
by "People with higher levels of age and disability, and
lower levels of income", with the benefits "display[ing]
a degree of income targeting", because less well off people
are more likely to have a disability and to claim. The group also
found "no evidence" of significant numbers of people
receiving the benefits "without any accompanying health problem".
320. The key objection to the reform of disability
benefits is that many people with genuine care and support needs,
and only modest means, will be left worse off. The Green Paper
people receiving any of the relevant benefits at
the time of reform would continue to receive an equivalent level
of support and protection under a new and better care and support
321. Ms Norrish and the Secretary of State emphasised
that there would be transitional arrangements to ensure that there
were "no cash losers"
among current recipients of disability benefits in the event of
reform. However, there remain concerns that people who develop
a care and support need in future could be worse off than they
would have been under the current system. While the Secretary
of State refused to be drawn on this, saying he did not wish "to
second-guess the White Paper",
Ms Norrish was more forthcoming and admitted that "yes, some
people would be nominal losers".
322. Critics of reform told us that:
means-testing disability benefits would mean "People on the
threshold of means tested care and support funding will lose out
to the greatest degree",
due to the "cliff edge" effect that is inherent in current
social care means-testing;
disability benefits support prevention
by helping people, especially those with low-level needs, to remain
independent for as long as possible,
in contrast to social care, which currently does very little for
people with low-level needs;
carers could be adversely affected, since
disability benefits are "carer blind", whereas social
care very often is not;
people who use disability benefits to
pay for "extra costs" (their intended purpose) will
lose out, as social care services will not pay for these, which
could particularly affect people with mental health problems,
people with MS and cancer patients, among others;
disability benefits act as "passports"
to other benefits, including Carer's Allowance, so being unable
to access cash support as a consequence of reform could have knock-on
there is an apparent contradiction between
the Government's support for personalisation and potentially excluding
some people from receiving benefits that are described as "the
perfect direct payment"
and "the original personal budget";
applying for disability benefits involves
a simple paper-based, self-assessment process and replacing this
with something akin to the "administratively bureaucratic"
social care assessment could dissuade people from applying;
reforming disability benefits only for
older people will lead to age discrimination, since someone could
become significantly worse off simply by virtue of turning 65
as a result of the type of reform proposed.
323. All of these points, ultimately, stem from
uncertainty about key aspects of the National Care Service: the
nature of the funding system; what kind of means-testing will
operate; how working-age adults will be affected; how people will
be assessed; to what degree rationing will operate; and the extent
and value of the care packages that will be available. Mr Hirsch
pointed out to us:
the illustrative costings that are being used in
the Green Paper are really based on what is being spent now within
the care system. They say it would cost £30,000 roughly over
somebody's life to fund their likely care from age 65. I think
it is likely to be more than that if you bring in these extra
needs [currently being met through disability benefits].
324. Age Concern and Help the Aged told us they
would not object to reform of disability benefits if all the advantages
of AA and DLA could be preserved in the National Care Service,
but the Green Paper says nothing to guarantee that will be the
case. As we have noted, uncertainty about winners and losers under
the National Care Service leaves scope for some to suggest that
"progressive universalism" for many people will be just
"smoke and mirrors", since they will lose at least as
much as they will gain.
325. We heard in our evidence that it is particularly
important for the success of personalisation that the value of
the care packages available under the National Care Service should
be adequate to meet people's needs and not perpetuate existing
shortcomings, such as age discrimination.
326. These existing problems could also be compounded
under personalisation. Mencap told us about its concern:
that some local authorities will use individual budgets
] to save money. It is widely thought that individual budgets
are cheaper than the traditional service provision and could be
used to reduce local authority spending.
UNISON said it:
would like to see a guarantee that Direct Payments
and Individual Budgets will be uprated each year to reflect rising
costs so they maintain their real value. Currently some local
authorities do not have any agreed indexing of rates, leaving
it to individuals to seek to negotiate uplifts.
327. We also heard that Resource Allocation Systems
need to be flexible in order to capture appropriately individual
people's needs and ensure adequate funding is made available to
meet them. Sense, the deafblind charity, told us this was a "crucial
point for deafblind people who often have specialist and therefore
more expensive to meet needs".
CHOOSING TO KEEP MAINSTREAM SERVICES
328. UNISON told us that some people were actually
experiencing less choice as a result of councils "claiming
that the introduction of Direct Payments is forcing them to close
day care centres",
since Direct Payments cannot under current law be spent on council-provided
services. The union's witness, Mr Low, further told us: "we
are getting daily reports of local authorities seeking to close
day care centres, and they are saying it is because of the growth
of personal budgets".
329. Professor Beresford explained why the right
to choose such collective services should not be withdrawn in
the name of personalisation:
mental health service users are seriously concerned
about the disinvestment / closure of day services. There have
been day services, day centres for mental health service users
and people with learning difficulties that have not been good
] but what they can be (and some are) is places where people
can feel safe, have relationships, get support and have a springboard
to other things [
] people say, "It is not often safe
outside. If I behave in a way or am seen to be different or weird,
people may not be nice to me. I like to be somewhere where it
is not like that [
] I would like to go somewhere where
I can feel reassured."
UNISON suggested that:
certain local authority services need to be ring
fenced to protect and guarantee local well run services as a sustainable
choice for people wanting a Personal Budget and not a Direct Payment.
Direct Payment holders should be free to purchase local authority
services if they wish.
John Waters, of In Control, thought that maintaining
collective services for some people had to be balanced against
people's right to "vote with their feet" and choose
Professor Beresford emphasised the importance of "User-controlled
services, user-controlled organisations" and was concerned
that, for all the talk of "plurality of supply", this
approach was still insufficiently supported.
INFORMATION, ADVICE, ADVOCACY AND
330. We heard from Professor Beresford that for
Direct Payments to be truly empowering much more was needed than
simply the ability to make cash transactions:
We know that the group of people who do that routinelyself-fundersis
the group most vulnerable, often unnecessarily, to institutionalisation,
to moving into residential services. It was intended as a shift
in power, and I think a lot needs to be in place [
idea of a system of infrastructural support, advice, guidance,
of local organisations of service users, neither of which is truly
in place, both of which have financial implications.
He cautioned that purchasing care and support "is
not the same as buying a fridge or going on holiday".
331. The lack of funding to allow people to access
information, advice, advocacy and brokerage in forms appropriate
to their needs is seen as a significant obstacle to self-directed
support. We heard that it is vital for such services to be available
in appropriate forms and to be adequately funded, so that people
are not obliged to fund them from the budget allocated for their
care and support; and support must be available on a continuing
basis. This could be a role for local authority social workers,
although there is an argument for such services to be commissioned
from independent providers such as the voluntary sector. While
some caution against "over-professionalising" the brokerage
role (suggesting that it could be fulfilled through "peer
support", for instance), others argue that it does entail
a definite set of skills and requires some form of qualification.
332. Witnesses informed us that personalisation
could have a major effect on the social care provider market,
with a shift away from local authority block contracts and towards
commissioning on an individual basis. Mr Jerome, the National
Director for Social Care Transformation, told us:
A decision needs to be made about what councils need
to collectively commission [
] and what they might be passing
over to individuals for them to access the market. The council
role therefore is to make sure in discussion with suppliersand
there is a big issue for suppliers herethat those services
that people want are there.
333. Independent providers could find their services
affected by these changes just as much as council services. According
to Nestor Healthcare Plc-Social Care Division:
In areas such as Extra Care Housing where service
users choose to move into housing where care is provided on site
24 hours per day, the impact of Local Authorities introducing
direct payments for individuals within a scheme could serve to
destabilise a service.
The UK Homecare Association feared major destabilisation
of the homecare sector, with homecare workers being "poached"
and employed as PAs, and low resource allocations driving prices
down even further. There is even, the Association feared, the
possibility of "large-scale destruction of the sector",
leading to an overall reduction in capacity.
334. These predictions may be somewhat exaggerated,
but it seems likely that local authorities could face significant
challenges in their new role as strategic market managers. There
will also be particular local issues that could be difficult to
address. For instance, Professor Anthea Tinker, of King's College
London, informed us that researched indicated "local care
markets may be historically under-developed in more remote rural
PROTECTION AND RISK
Protecting vulnerable adults
335. The nature of care and support (providing
intimate help to vulnerable people, often on a one-to-one basis
in their own home) mean that there can be a risk of abuse or exploitation.
In 2000, the DH and the Home Office published No secrets,
requiring local councils with social services responsibilities,
NHS bodies and other partners to develop local multi-agency codes
of practice to help prevent and tackle abuse of children and vulnerable
adults. In a consultation document in 2008, Safeguarding Adults:
A Consultation on the Review of the 'No Secrets' Guidance,
the Government recognised potential tensions between protecting
vulnerable adults and the personalisation of social care.
336. In 2004 the DH launched the Protection of
Vulnerable Adults (POVA) scheme, whereby prospective care workers
could be checked, as part of Criminal Records Bureau (CRB) Disclosure,
against a list of care workers who had harmed vulnerable adults
in their care. This was mandatory in respect of adult placement
schemes, domiciliary care agencies and care homes. People employing
PAs using Direct Payments were not required to obtain CRB Disclosure,
but had the option to request it. In October 2009 the POVA list
became the Adults Barred List and the scheme was replaced by Adult
First Check, both operated by the Independent Safeguarding Authority
(ISA), a new non-departmental public body.
337. From July 2010 a completely new system will
be implemented. All individuals in England, Wales and Northern
Ireland working or volunteering with vulnerable adults or children
in the education, care and health sectors will be required to
register with ISA under the new Vetting and Barring Scheme (VBS).
Individuals will be required to pay £64 to be registered
with ISA in England. The VBS will apply to homecare workers, but
not to PAs.
338. In 2008 Skills for Care found that "48%
of people receiving direct payments failed to make CRB checks
on their PAs whilst 46% failed to seek references".
339. A survey of social workers in adult social
care published in October 2008 found that nine out of ten respondents
favoured mandatory CRB Disclosure for PAs and others hired using
340. Independent sector providers were unhappy
with the different standards applied to their staff as compared
to PAs in this respect. According to Nestor Healthcare Plc-Social
With the advent of the vetting and barring, system
for domiciliary organisations there is potential for careworkers
wishing to avoid the ISA processes to migrate into personal assistant
roles. In rural areas where the recruitment of personal assistants
may be more difficult and the role of PAs is undertaken by family
members unregulated support again poses the risk of abuse with
research indicating in cases of elder abuse two thirds of incidents
are perpetrated by relatives, most often the individual[']s adult
child or spouse.
341. However, others who raised this issue argued
that it would not be in keeping with the spirit of self-directed
support to require people employing PAs to subject them to formal
vetting. UNISON and CQC both echoed the view of CSCI that local
authorities could discharge their duty of care by ensuring that
all people employing PAs were informed of their right to seek
a CRB (or, in future, ISA) check if they wished to.
342. We also heard that personalisation can raise
issues about the welfare of carers. The Princess Royal Trust for
Carers said that, in the case of Individual Budgets:
There is [
] evidence that the responsibility
for managing and co-ordinating the budget holder's support arrangements
falls to the carer at the risk of experiencing increased stress.
343. In 1997 the Labour Party manifesto promised
that a Labour government would ensure that the entire social care
workforce (around 1.4 million people) would, over time, be subject
to regulation. The General Social Care Council (GSCC) was set
up in 2001 under the Care Standards Act 2000. The GSCC was initially
given the task of registering and regulating social workers (who
number some 80,000) and social work students (of whom there are
approximately 16,000). It was anticipated that regulation would
be progressively extended to the entire social care workforce,
with the next groups to register being homecare workers and their
managers (numbering about 500,000).
344. In 2004 our predecessor committee recommended
in a report on elder abuse that:
when the General Social Care Council opens the register
to domiciliary care workers it should also ensure that care workers
who are employed through direct payments are also able to register
should they wish to do so, and indeed should be so encouraged.
We anticipate that over time this would lead to many such personal
assistants choosing to register because of the advantage that
it would offer in demonstrating their competence and reliability
to a prospective employer.
345. In April 2009 the GSCC was given the go-ahead
to open the register for homecare staff in England (initially
on a voluntary basis) in early 2010.
The Council also planned to consult on options for possible regulation
of PAs. However, the Government has, for the time being at least,
indicated that the GSCC will operate solely as the professional
regulator for social workers. Questions about whether and how
regulatory models for other parts of the social care workforce
will develop have still to be addressed.
346. In 2008 Skills for Care published research
showing that people using Direct Payments to employ PAs were in
favour of a formal register but evenly divided on whether registration
should be compulsory.
347. Independent sector providers informed us
that they found it irksome that (as with vetting) there was not
consistency between them and the PA market. The UK Homecare Association
took the view that:
It seems entirely illogical that government should
have brought about a highly regulated sector [
], with proposals
for further regulating by the General Social Care Council (GSCC)
] while at the same time, promoting a cash payment system
for the engagement of untrained, unqualified, unsupported and
unregulated personal assistants
Nestor Healthcare Plc-Social Care Division argued
that "Regulation of personal assistants needs to be considered."
348. Mr Low, from UNISON, told us that the union
was more open to the idea of compulsory registration of PAs than
it was to compulsory vetting. He told us:
At the moment, I believe [
] the General Social
Care Council are not currently going to proceed with pushing registration
into domiciliary care. If they had done, we would have felt that
they should have also done personal assistants too, to create
a level playing field.
349. The union thought that one helpful way to
give people choice whilst avoiding some of the pitfalls of an
unregulated workforce was for councils to take on "banks"
of PAs. Another was the implementation of a model code of practice
on the employment of PAs.
350. SCIE acknowledged there were concerns about:
the emergence of unregulated 'grey' markets, the
effects of migrant labour, quality assurance and employment and
However, it seemed to have no clear view on whether
or not further regulation was needed:
These concerns need to be discussed with people employing
and planning to employ PAs, representatives of PAs who are becoming
a significant part of the social care workforce, and the workforce
and service regulators who will need to consider new approaches
to regulation that fit the new diversified world of personalisation.
351. Professor Beresford warned that formal registration
or regulation (or vetting) could give people employing PAs "a
false sense of security" and quoted one employer's comment
that "What really works for me is my gut feeling about [a
prospective PA] as a human being". Professor Beresford did
not, though, rule out establishing some kind of registration or
regulation, in association with employers, once the PA role had
had time to develop and become established.
352. Although there is effectively
unanimous agreement in principle with personalising care and support,
the pace of change remains slow. However, "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.
353. 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 the less ambitious model of 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.
354. The Secretary of State
told us that personalising social care is part of an aspiration
to remodel drastically all public services "over the next
20 years" and the "implications of all of this are pretty
vast". The Government appears to have a goal of bringing
together all disability-related expenditure while giving individual
disabled people control of all the sums available to them, so
they are better able to use them to meet their particular needs.
There is a logic to this, but it will raise some contentious and
difficult issues. For instance, personal health budgets, which
are currently being piloted in the NHS, raise the thorny questions
of top-ups and vouchers (on which basis the Government itself
ruled out individual budgets for healthcare as recently as 2006).
355. The idea of reforming disability
benefits for older people (Attendance Allowance and Disability
Living Allowance) by merging the budget for these into social
care funding has been particularly controversial. Many of the
concerns that have been expressed about the likely consequences
of this demand careful attention. It is feared that some people
would be left worse off if universal, needs-based and entitlement-led
social security benefits are replaced with means-tested, rationed
and cash-limited social care provision. The Government has given
assurances that there would be "no cash losers" under
transitional guarantees for existing benefit recipients. However,
no such guarantees would apparently extend to people who develop
a care need in future, who could be worse off under a new system
than they would have been under the current one.
356. In justifying this proposal,
the DH told us about wealthy claimants allegedly using AA payments
to fund Saga cruises. We believe this kind of "policy-making
by anecdote" is not helpful and risks disparaging people
who have genuine care and support needs. Research by Professor
Ruth Hancock and her colleagues indicates that disability benefits
are a lifeline to many people, with significant needs and without
great wealth, who often don't receive help from the social care
system, enabling them to meet costs of daily living. If the DH
has hard evidence to the contrary, it should be published. We
also note that there appears to be a tension, if not a contradiction,
in the Government's policy in that, while it says it is committed
to more universalism in care and support, in this case it appears
to be intent on going in the opposite direction.
357. Adequate funding is clearly
vital to personalisation, which must not be seen as a cost-saving
exercise; it may well cost more to provide adequate personalised
care and support. Some people in receipt of Direct Payments have
found that inadequate funding and inflexible Resource Allocation
Systems make it difficult for them to meet their needs without
topping up from their own resources. Personalisation must not
mean that people who use services are simply turned into rationers
of their own care and support, having to make choices which compromise
their ability to meet their needs or to maintain their dignity.
358. It must be recognised that
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. Nor should it be assumed that taking on
such a role is the only means by which people can be empowered
and made full partners in their own care. The potential of "co-production"
(i.e. full partnership between providers and people who use services)
to allow personalisation of mainstream services, including residential
care, should be fully explored within the "transformation"
359. There are concerns about
the right of people who use services such as day care centres
to continue doing so, if that is their preference. Such services
should not simply be shut down with people being told that it
is now down to them to act as commissioners. In some cases it
may be appropriate to "ringfence" services for those
people who wish to continue using them, although this should not
be an excuse to protect outmoded and poor quality services.
360. Where people do act as
their own commissioners, information, advice, advocacy and brokerage
services must be available and must not be funded from people's
own resource allocations. Offloading such responsibilities and
costs onto people who use services could seriously curtail or
negate the potential benefits of personalisation.
361. People commissioning their
own services in some areas may find that the market fails and
they are unable to procure the care and support they need, particularly
in rural areas. It is not certain that councils will necessarily
have the capacity or the capability to act as effective market
managers in such situations.
362. Personalisation necessarily
entails enabling people who use services to take risks on their
own behalf, as part of assuming control of their own care and
support. However, there are contentious issues concerning the
nature and extent of such "risk transfer". Adult-protection
and safeguarding policies (consistent with councils' duty of care)
must be tailored to situations where people are directing their
own care and support. Many people will be comfortable with managing
risks themselves and should be free to do so, but it is imperative
that others are able to access appropriate safeguarding mechanisms.
The risk of placing unreasonable demands on carers, either as
care providers or as care managers, must also be acknowledged
363. 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, which people may choose to commission
from if they wish, may be one way of addressing such concerns.
There seems to be agreement that people employing PAs should always
be given the option of running Criminal Records Bureau checks
on prospective employees. Beyond this, however, there are differing
views on whether PAs should be subject to mandatory regulation
and obliged to register with the Independent Safeguarding Authority
under the new Vetting and Barring System. Without a "level
playing field" in regulation 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 free
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. Strong safeguards must, though,
be put in place to protect the vulnerable.
The social care workforce
364. The social care workforce has begun to change
significantly, and is likely to change much more, particularly
as a result of personalisation. This is reflected in several strands
of DH policy.
365. In 2003, the DH commissioned Skills for
Care to undertake work to identify new roles in social care. The
New Types of Worker project has shed important light on how the
social care workforce is changing as new modes of care and support
develop, with "about 14 new kinds of jobs" being found
in social care.
Skills for Care has identified that a disproportionately high
number of social care workers have difficulty with basic skills,
including reading, writing and simple maths. One way it is addressing
gaps in social care workers' skills is through developing a National
366. In April 2009, the DH published Working
to Put People First: The Strategy for the Adult Social Care Workforce
in England. This only sketched out priorities for the development
of the workforce in the context of personalisation and left much
detail to be filled in on key issues, notably: training and career
pathways for PAs; and the future role of social workers.
367. Lin Hinnigan, Director of Strategy at the
GSCC, told us there needed to be funding available to help with
the training of PAs, but she pointed out that it would be contrary
to the idea of personalisation to try and oblige people to have
their PAs trained:
Do you start to impose upon them, "Your partner
must have this particular sort of training"? The person who
is employing that person may say, "Their knowledge and their
learning has been learning about my needs and me and how best
to meet them". They are very complex questions to try and
set out what are the requirements. We need to unpack this, but
we will need to move to certain standards and have the ability
for people as part of their choice to say, "I don't want
to take those standards".
368. The future of social work is under active
consideration at the moment. In December 2008, the DH and the
Department for Children Schools and Families established the Social
Work Task Force to conduct a "nuts and bolts" review
of the profession and to advise on the shape and content of a
comprehensive reform programme. This was done on the grounds that
social work is facing some acute challenges and concerns, including
the quality of initial training, recruitment and vacancy rates,
and the status of the profession as a whole. The Task Force reported
in December 2009, recommending a series of measures to be implemented
through a single national reform programme for social work.
369. The GSCC envisages social workers "tak[ing]
on the new roles aimed at supporting people to design their own
care packages" as social care becomes more personalised.
However, there are differing views as to whether social workers
will still have a significant role to play in social care once
personalisation really takes hold.
370. It is clear that the social
care workforce as a whole is increasingly in a state of flux,
with existing roles changing and others emerging as new models
of care and support provision develop. The role of social workers
in particular in a radically changed social care system is still
unclear, with contending views being expressed. Plans to extend
regulation to the rest of the social care workforce now seem to
be in disarray. We are concerned at what appears to be the apparent
lack of an overarching strategic vision for the future social
care workforce, and we recommend that this be addressed as part
of social care reform.
264 Department of Health, Shaping the Future of
Care Together, Cm 7673, 2009, p 100 Back
Ibid., p 18 Back
Department of Health, "Impact Assessment of the Care and
Support Green Paper", July 2009, p 46 Back
Q 42 Back
The PSSRU has calculated that on average at age 65 a person can
expect to need (FACS eligible) social care, of all types, worth
£31,700 (not including "hotel costs" in residential
care) during the rest of their life. Around a quarter will need
no care, or support with a minimal cost (equipment only); 10%
(mostly long-stay care home residents) will need care worth many
tens of thousands of pounds (Julien Forder and José-Luis
Fernández, Analysing the costs and benefits of social
care funding arrangements in England, 2009, Table 21, p 26). Back
Q 16 Back
Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, p 16. In taking this position, the DH is actually
following the same line as the Royal Commission on Long-Term Care.
The current system effectively makes even the poorest of residents
contribute towards "hotel costs" by taking all their
income, bar the nominal amount represented by the PEA. Back
Ibid., p 20 Back
In 2007-08 around 80% did so, according to data supplied by councils
in response to Freedom of Information requests (www.channel4.com/news/articles/society/elderly+forced+to+sell+homes+to+pay+care+costs/2913557). Back
Immediate needs care annuities are bought at the point when a
person has developed a care and support need and they provide
a guarantee of care until death. The product is individually underwritten,
so the premium can vary substantially, but it can cost as much
as £80,000. The main provider of this product has insured
just 5,000 people in 10 years (Ev 97-99; Qq 549, 555-561 and 644-646). Back
Q 579 Back
Ev 65 Back
Ev 14, 15, 16, 46, 61, 65, 66, 67, 72, 84, 102, 104, 106, 107
and 134; Qq 458, 642, 729, 760, 766, 808-809; SC 19A Back
Q 16 Back
Q 924 Back
Q 255 Back
Ev 46 Back
Q 760 Back
Q 552 Back
Q 237 Back
Q 273 Back
Q 273. The JRF suggested that the state should pay 80% of each
person's costs under a co-payment model. Back
Q 233; cf. Ev 78 Back
Q 240 Back
Ev 25, 67-68, 70, 104, 119, 125 Back
Ev 125; Qq 647-649 Back
Consensus Statement, Care and Support Conference, 19 February
Ev 65, 134 Back
Ev 46 Back
Q 760 Back
Ev 114 Back
Ev 116; cf. 644-646 Back
Q 251 Back
Ev 67; Qq 653-659 Back
Q 263 Back
Q 287 Back
Ev 103 Back
Ev 104; cf. Q 256, Ev 144 Back
Department of Health, "Impact Assessment of the Care and
Support Green Paper", 2009, pp 9, 11. The Impact Assessment
also gives the slightly different additional cost of £3.3
billion for the Comprehensive and Tax-funded options (ibid.,
p 46). Back
HC Deb, 12 October 2009, col 758W Back
Q 67 Back
Ev 42 Back
Ev 114, 115 Back
Q 651 Back
Q 609 Back
Q 912 Back
Q 660 Back
Q 274 Back
Ev 73 Back
Derek Wanless, Securing Good Care for Older People, 2006,
p 232 Back
Royal Commission on Long-Term Care, With Respect to Old Age,
1999, paras 69-77 Back
Ev 77, 125, 141-142 Back
Ev 135 Back
Ev 90-91, 134 Back
Q 274 Back
HC Deb, 27 January 2009, col 16WS Back
Under section 15 of the Community Care (Delayed Discharges etc.)
Act 2003 regulations can be made requiring certain social care
services (including personal care at home) to be provided by local
authorities free of charge, but not for a period longer than six
weeks. The Bill amends the 2003 Act to enable regulations to be
made requiring personal care to be provided free to persons in
their own homes for an indefinite period. Back
On how this is defined, see Annex 1. Back
The Government proposes the following options: the setting of
an indicative cash sum; the setting of an indicative range in
cash terms; or allowing discretion to local authorities in each
individual case. Back
The Government proposes the following options: using the existing
Adult Social Care RNF; using amended Adult Social Care RNF; or
using a new formula based on ELSA. Back
Department of Health, "Impact Assessment of the Care and
Support Green Paper", 2009, p 7 Back
"Cancer research at risk in scramble for care funds",
The Times, 25 November 2009 Back
Qq 907-911 Back
Q 905; cf. Q 901 Back
HM Treasury, Securing the recovery: growth and opportunity
- Pre-Budget Report, Cm 7747, December 2009, p 110; cf.
HC Deb, 6 January 2010, cols 470-471W Back
Q 900; cf. HC Deb, 14 December 2009, col 665 Back
Q 899 Back
Q 44 Back
Letters from the Secretary of State for Health to the Chairman
of the Health Committee, 10 November 2009 and 8 December 2009 Back
Q 902 Back
"Labour peers savage Brown's free care plan", The
Times, 19 November 2009 Back
Q 900 Back
Q 45 Back
Q 459 Back
Q 766 Back
Q 608 Back
Q 766 Back
Q 609 Back
Q 828 Back
Qq 46-53 Back
Q 54 Back
Q 901 Back
Q 833; cf. Qq 766 and 821 Back
Q 822 Back
Qq 901 and 906. A recent press report has queried whether this
policy is succeeding ("Free home care council diverting money
from other vulnerable groups", Guardian, 18 February
Q 826-827; cf. Q 608 [Mr Burke] Back
Q 835 Back
Q 829 Back
Q 814 Back
Q 15 Back
Ev 109; cf. Ev 9, 6-7 Back
Q 86 Back
Q 877 Back
Health Committee, Sixth Report of Session 2004-05, NHS Continuing
Care, HC 399-I Back
Q 780 Back
Q 782 Back
Ev 146 Back
Q 944. The Minister of State for Care Services, Phil Hope MP,
has told the House: "The terms Individual Budget and Personal
Budget were used synonymously during the pilot stage of the personalisation
project. However, Personal Budget is the term now being used for
national implementation and relates to social care funding only.
Individual Budgets is now the term used for a notional amount
of funding from a variety of sources which may include social
care funding as well as other sources" (HC Deb, 18 January
2010, col 115W). Back
Q 945 Back
Mr Wittenberg, of the PSSRU, told us:
An analysis that colleagues did of the
data set known as ELSA [
] found that only 26% of the Attendance
Allowance group received social care, either publicly or privately
funded, and that 29% of the Attendance Allowance people received
neither formal nor informal care (Q 213). Back
The lower rate of AA is payable if the recipient needs help with
personal care frequently or supervision continually throughout
the day only, help with personal care or someone to watch over
them during the night only, or someone to be with them when they
are on dialysis. The higher rate is payable if the recipient needs
help with personal care, or someone to supervise or watch over
them frequently throughout the day and also during the night. Back
Department for Work and Pensions, Benefit Expenditure by Country,
Region and Local Authority 2008-09 Back
Provisional data supplied by the Department for Work and Pensions Back
HC Deb, 30 November 2009, 527W; www.dh.gov.uk/en/News/Speeches/DH_107455 Back
Q 70 Back
Q 620 Back
SC 52 Back
Department of Health, Shaping the Future of Care Together,
Cm 7673, 2009, p 15 Back
Qq 71, 935 Back
Q 936 Back
Q 71 Back
Ev 30 Back
Ev 131 Back
Qq 621, 623 Back
Ev 73, 113, 131; Qq 730, 731 Back
Qq 627, 927 Back
Ev 56 Back
Ev 77; Q 620 Back
Q 623. The Secretary of State told us the Government intended
to develop an "integrated assessment that takes stuff from
the benefits side and the local authority side" (Q 929). Back
Ev 133; Q 621.There is already said to be significant underclaiming
of disability benefits, particularly among the very old. Back
Q 627; Ev 115. The Government insists that there is no age discrimination
in treating DLA for people aged under 65 differently from disability
benefits for older people. Ms Norrish told us that "people
who are receiving DLA under 65 are almost exclusively on very
low incomes", being "frequently [
] unable to work",
and so without assets, whereas disabled people aged over 65 "potentially
have worked all of their lives" (Q 72-73; cf. Q 931). Back
Q 295 Back
Ev 115; Q 624. Twenty-six per cent of people polled by the Parkinson's
Disease Society said they "would be happy for AA to be abolished
if all their disability-related costs were met" (SC19A). Back
Ev 114; cf. Ev 59 Back
Ev 7; cf. Qq 102, 776 Back
Ev 80 Back
Ev 10 Back
Ev 80 Back
Q 365 Back
Q 788 Back
Ev 80; cf. Ev 122 Back
Q 789 Back
Qq 789 and 790 Back
Q 783 Back
Q 792 Back
Ev 8, 10, 11, 72, 74, 80-81, 90, 91, 94, 108, 109, 114, 116, 117,
121, 132, 145, 146, 147; Qq 372, 394, 667-669, 672, 733-734, 741,
776, 791, 860-865 Back
Q 113 Back
Ev 35 Back
Ev 52, 54, 55 Back
Ev 156 Back
Ev 36 Back
"Nearly all adult social workers want personal assistants
to be regulated", Community Care, 23 October 2008 Back
Ev 36; cf. Ev 55 Back
Ev 81,83; Qq 369-371 Back
Ev 121 Back
Health Committee, Second Report of Session 2003-04, Elder Abuse,
HC 111-I, para 152 Back
Department of Health, Working to Put People First: The Strategy
for the Adult Social Care Workforce in England, April 2009 Back
The extension of registration was one issue examined in 2009 by
the Council for Healthcare Regulatory Excellence in a report commissioned
by the DH as a result of concerns about the backlog of conduct
cases built up by the GSCC. The report recommended consideration
of other approaches in respect of domiciliary care workers "such
as a statutory licensing scheme or an employer-led approach based
on codes of conduct and practice and induction standards"
(Council for Healthcare Regulatory Excellence, Report and Recommendations
to the Secretary of State for Health on the conduct function of
the General Social Care Council, September 2009, para 8.28). Back
Q 405; www.scie.org.uk/publications/ataglance/ataglance14.asp Back
Ev 55 Back
Ev 34 Back
Ev 363 Back
Ev 81; Q 362 Back
Ev 147 Back
Qq 796, 797 Back
Ev 139, 163; Q 400 Back
Ev 383, 784, 797 Back
Q 405 Back
Ev 163 Back