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)
Funding
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)
Personalisation
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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