Social Care - Health Committee Contents

Conclusions and recommendations

Meeting future demand and costs

1.  A compelling argument for thoroughly reforming the social care system is that in its current form it will struggle to meet people's needs under the pressure of future growth in demand and costs. However, we recognise that anticipating these is a far from exact science and there is much uncertainty. Projections are made from observed trends, based on a series of plausible assumptions about a number of variables, but within a considerable "funnel of doubt", which expands into the future. (Paragraph 69)

2.  In order to minimise that doubt, the best possible evidence base is needed. We are, therefore, extremely disappointed that, fourteen years after our predecessor committee called on the then Government to commission better data on healthy life expectancy, the delay in doing so means the available data are still inconclusive. The Cognitive Function and Ageing Study and the English Longitudinal Study of Ageing are expected in due course to yield cohort data and we recommend that the DH take full account of these as soon as they become available. (Paragraph 70)

3.  Despite the degree of uncertainty about future demand and cost, it is nonetheless clear that, on all reasonable assumptions, the social care system will face considerable increased pressures in the decades to come. It is important, though, to avoid demographic despair and alarmism. Population ageing is far from being a new phenomenon, nor is it unique to this country. Its effects have not yet proved catastrophic and there is no compelling reason to suppose that they will in the future, provided the right political decisions are made now. (Paragraph 71)

4.  We note that, in its presentation of the data on life expectancy, the DH has confused period and cohort measures of life expectancy, as well as life expectancy at birth and at age 65. In so doing, there is a danger of overstating the extent of demographic change and potentially discrediting the projections used. In an area that is characterised by uncertainty, it is essential that care is taken to interpret existing data accurately. (Paragraph 72)

5.  The Department has also not made clear that part of the demographic challenge facing the social care system is the transient "cohort effect" of the ageing of the population "bulge" born during the post-war "baby boom". The fact that the first "baby boomers" will not enter their mid-80s until the early 2030s means that there is still a 20-year "window of opportunity" in which to prepare for this. This is not an argument for complacency, far from it; but there is a chance to address the challenge systematically so as to ensure comprehensive and lasting reform, rather than being led by panic into further incremental reform of marginal and temporary value. (Paragraph 73)

6.  We are concerned that an ageing population is too often seen in public debate as something negative, a problem to be solved, with older people regarded as a burden. The fact that many more people can expect to live well into old age is one of society's greatest achievements and something to be celebrated rather than lamented. (Paragraph 74)

7.  Longer life expectancy does not inevitably mean more years lived with ill health and disability; people can live lives that are healthier as well as longer, and many older people are living proof of this. Future healthy life expectancy is not fixed; actions taken now could help to make the "compression of morbidity" more likely. The importance of research to develop curative or mitigating interventions for long-term conditions should not be underestimated. Such research could pay major dividends, in terms of health outcomes and public spending, as well as in individuals' quality of life, and must be adequately supported and funded. Similarly, the importance of public health interventions must be acknowledged. The health risks posed by smoking, drinking, poor diet and lack of exercise have important implications for future social care demand. This reinforces the need for interventions to address these issues, although their effectiveness must be rigorously evaluated. It also reinforces the importance of coordinating health and social care services. (Paragraph 75)

8.  We would also counsel against pessimism regarding the affordability of care and support in the future. The old-age "support ratio" or "dependency ratio" is not the most important factor to take account of in determining the likely future affordability of social care. Our society must not underestimate its ability to become more productive and wealthier, nor indeed the contribution that the growing numbers of older people will continue to make to that. (Paragraph 76)

Shortcomings of the present social care system

9.  The multiple shortcomings of the existing social care system provide powerful arguments for fundamental reform. Too often when people approach the system for help they do not receive even information and advice on what is available and how to access it. The system is also often poorly co-ordinated with other help (not least NHS services and care provided voluntarily, as well as the housing support and social security benefits systems). People who need care and support encounter various forms of rationing, including by eligibility criteria, means-testing and charging, with much local variation. Where people are able to access care, it can be insufficiently focused on helping them to remain independent and avoid developing greater needs, as well as being limited in scope and not always of good quality. In these respects too, there is marked variation between local areas. The result is a social care system that:

—  excludes many people with less severe care needs;

—  penalises people with relatively modest financial means;

—  places unfair and unreasonable demands on carers; and

—  varies geographically to an extent that is strongly perceived as unfair.

In consequence of all these factors, there is a great deal of unmet need. (Paragraph 157)

10.  These shortcomings are all indicative of a system that: provides a residual or "safety net" service, rather than a universal one; is chronically underfunded; and is insufficiently focused on the needs and aspirations of the individual people who actually need care and support. (Paragraph 158)

11.  On the particular issue of quality, we note that the effectiveness of regulatory systems in uncovering and addressing poor quality care is an issue. (Paragraph 159)

12.  We have also concluded that more needs to be known about the role of particular factors in compromising standards. The staffing issues that we heard about (lack of training and career-development, inadequate staffing levels and high staff turnover), and their relationship to low pay levels, need to be investigated fully. The apparent quality "gradient" between for-profit and non-profit providers of care services is also of concern and this too needs to be fully examined. (Paragraph 160)

13.  Pervading the whole system of social care is a persistent ageism, both overt and covert. We welcome the fact that the Government and the Equality and Human Rights Commission have finally recognised this and begun to address it but we are appalled that this has taken so long. (Paragraph 161)

Plans for reform

14.  Social care reform has two interrelated strands: the first concerned with how care and support are funded and the second with how they are commissioned and provided. When the Government took office in 1997, it stated that the first of these was one of its major priorities. Yet it took until 2009 for the Government to set out a range of options for fundamental reform, in the Green Paper Shaping the Future of Care Together. This came so late in the present Parliament that the White Paper containing the Government's plans for change will be published just weeks before a general election, with no prospect of legislation until the next Parliament. The problems, and the options for solving funding reform, have long been known; and prime opportunities to initiate reform (a Royal Commission in 1999 and major reform proposals resulting from independent reviews) have been squandered. The failure to grasp this nettle is sadly indicative of the low priority given to social care by successive administrations and this must not continue. (Paragraph 221)

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

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

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

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

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

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

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

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

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

—  Building a sound evidence base on the effectiveness and cost effectiveness of different forms of care and support. (Paragraph 223)

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

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


19.  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. (Paragraph 266)

20.  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. (Paragraph 267)

21.  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. (Paragraph 268)

22.  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 older. (Paragraph 269)

23.  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 be. (Paragraph 270)

24.  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:

—  The capital thresholds in the means test must be substantially raised in order to ease the burden on people of relatively modest means.

—  Consideration should be given to some form of "cap" to limit people's liability to pay from their own resources before they qualify for public support.

—  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. (Paragraph 271)

Free Personal Care at Home Bill

25.  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. (Paragraph 293)

26.  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. (Paragraph 294)

27.  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. (Paragraph 295)

28.  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. (Paragraph 296)

29.  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. (Paragraph 297)

"Fully national" or "part local/part national" system

30.  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. (Paragraph 305)


31.  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. (Paragraph 352)

32.  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. (Paragraph 353)

33.  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). (Paragraph 354)

34.  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. (Paragraph 355)

35.  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. (Paragraph 356)

36.  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. (Paragraph 357)

37.  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" agenda. (Paragraph 358)

38.  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. (Paragraph 359)

39.  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. (Paragraph 360)

40.  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. (Paragraph 361)

41.  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 and considered. (Paragraph 362)

42.  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. (Paragraph 363)

The social care workforce

43.  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. (Paragraph 370)

The way forward

44.  While there is welcome consensus on several aspects of social care reform, a number of key issues remain highly contentious and insufficiently addressed. Many witnesses agreed that worthwhile and lasting reform will only be achieved if consensus can be reached on these issues too, so that the necessary tough decisions can be taken with broad popular support. (Paragraph 371)

45.  Achieving consensus on all these difficult and enduring issues requires calm, rational deliberation and an informed national debate. We would have liked to see all the political parties come together in that spirit to map out a programme of sustainable reform. Instead, regrettably, the Government is hastily drafting a White Paper while also rushing through Parliament a hurriedly concocted Bill that cuts across its own Green Paper, in a febrile atmosphere of unedifying pre-election party-political squabbling and point-scoring. (Paragraph 372)

46.  There is still an opportunity, in advance of the demographic challenges to come with the ageing of the "baby boomers", to reform the social care system, achieving consensus and creating a lasting solution that would represent a "Beveridge" model for our time. Current and future generations will be betrayed if the failure to achieve consensus means that social care reform is once more left to languish near the bottom of Government's list of priorities in the next Parliament. (Paragraph 373)

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