Examination of Witnesses (Question Numbers
224-239)
MR RICHARD
HUMPHRIES, MR
JAMES LLOYD
AND MR
DONALD HIRSCH
5 NOVEMBER 2009
Q224 Chairman: Good morning gentlemen.
May I welcome you to what is our second evidence session in our
inquiry into social care? For the record, may I just ask you to
introduce yourselves and the current position you hold?
Mr Humphries: My name is Richard
Humphries. I work at The King's Fund. I am a Senior Fellow in
Social Care.
Mr Lloyd: My name is James Lloyd.
I am a Senior Research Fellow at the Social Market Foundation.
Q225 Chairman: We are expecting David
Hirsch to join us at some stage in this session but I am not sure
what time he is likely to appear. I should like to start with
a question to both of you. Is it widely agreed that the existing
social care system is significantly underfunded? The Department
of Health told us last week that they did not know the extent
of unmet need. Are you able to help us in any way in relation
to this?
Mr Humphries: I would certainly
agree that the system is underfunded. The Green Paper came up
with that figure of a £6 billion shortfall by 2026, did it
not? The question of how much need is unmet is an altogether more
problematic one and the short answer I have is that we do not
know. First, it is difficult to define what need and unmet need
are. Second, there do not appear to be any systematic attempts
to collect that information anyway, either by local authorities
generally or by Department of Health or central government. Clearly
what we do know is that around 72% of councils do not meet needs
other than in the very critical and substantial categories. We
know from lots of evidence from people like carers' organisations
that that leaves lots of people either to make their own way,
to make private arrangements, or to rely excessively and inappropriately
on family and carers or simply to go without. However, it is difficult
to put numbers around the scale of that need. We do know that
is it a real problem.
Mr Lloyd: I would agree with that;
projecting that need is difficult. I would draw the attention
of the Committee to a report published in 2007 by the then CSCI[1]
and they did estimate that the number of older people with unmet
needs who have received no care at all, either formal or informal,
is around 6,000. The number of older people receiving no care
with less intensive needs was 275,000.
Q226 Chairman: There are six different
areas where you can measure need and a lot of it is not met. Is
it all measured? If a local authority does not provide the service,
do they still measure it? Do they know how many people could have?
Mr Humphries: Some local authorities
might but not all.
Q227 Chairman: Is there no national
pattern on this at all?
Mr Humphries: No.
Q228 Chairman: So the unmet need
will always be unknown basically if you do not measure it all.
Mr Humphries: Absolutely. If we
look at the demographics of the population in terms of the income
and wealth profile of people who need care and support, we know
that more and more are falling outside that public funding criteria
and are therefore, in the words of one report on the subject,
lost to the system. They do not appear anywhere on the radar of
need.
Q229 Chairman: You mentioned the
dependency on informal care; normally family members but it can
be others as well. How much does the system depend on informal
care really? Is it too much or do you think current levels are
sustainable? Is the pattern shifting in informal care?
Mr Humphries: First of all I think
you would find wide consensus if not unanimous agreement that
the system does rely heavily on informal care. You only have to
look at the fact that we have one and a half million people in
the paid social workforce and probably at least four times that
number providing unpaid informal care. To give you an idea of
the scale of the extent to which without that informal care services
would be in real trouble, in many cases—and carers' organisations
could give you chapter and verse on this—expectations are
too heavy, too unrealistic and that leads to breakdowns in care
arrangements which could be avoided. Actually it would be much
better from a preventative point of view to provide good support
to carers in the first place because that is the most cost-effective
and appropriate way of meeting their needs.
Mr Lloyd: Carers UK published
some research from the University of Leeds which estimated in
2006 or 2007 that the equivalent cost of total informal care provision
across the whole of society was around £87 billion per year.
Q230 Chairman: I find this quite
interesting. If you look at our social care network, which really
comes out of what we call the welfare state, of course 150 years
ago this did not exist. We had family units which cared for people,
did not think there was any obligation on the state or that anybody
else should or indeed that they could be rewarded for looking
after a member of the family. Do you think we are posing and measuring
the right things here? Is it not the case that you have responsibilities
as a parent or maybe as a son to an elderly parent to look after
them or look after young children. How do we get the measure of
what informal care means and what it should mean? I know it is
possibly an ethical or potentially moral judgment but what is
your view on it?
Mr Humphries: We are having to
find new answers to that question because the nature and structure
of families have changed.
Q231 Chairman: Absolutely.
Mr Humphries: We no longer have
big extended families. Instead we have these very long vertical
families where you have great grandparents, grandparents, parents,
their children and their children's children. You have what some
people call sandwich carers who are actually caring for their
ageing parents and helping their own children look after their
children with childcare as well. The whole nature of the caring
task has become more complex in a fast changing society. That
is one of the pressures that reform of the system has to address.
Q232 Chairman: Is it easy to measure
what informal care is then?
Mr Humphries: I hesitate to comment
authoritatively on that because the carers' organisations would
be much better placed to give you an answer to that.
Mr Lloyd: The question I suppose
is to what extent is it appropriate or ethical as a society to
rely on the excessive provision of informal care in which, for
example, somebody might be providing pretty much close to 24/7
care. Certainly there is hard quantitative evidence that excessive
informal care provision does impact negatively on people's outcomes,
whether in terms of quality of life or health. There are obviously
numerous mediating factors: hours of care provided per week, household
income, access to transport, social support networks and indeed
the characteristics of the person who is receiving care. I did
some research a couple of years ago with the National Centre for
Social Research and we analysed some social survey data, hard,
quantitative, rigorous data and it did find that individuals who
provided more than 20 hours of care per week particularly to a
partner—this is in the older population—did show a
statistically significant lower quality of life than equivalent
non carers. I would emphasise that this was not really just a
sort of woolly question asking about their quality of life. This
was using a scientifically developed set of measures incorporating
19 questions to provide a very detailed, accurate, scientific
measure of quality of life. I would also say another interesting
aspect of that research was that the outcomes of the carer were
particularly related to the memory functioning of the person receiving
care. In short, if somebody has Alzheimer's in various stages
the effect on the informal carer will be that much worse than
other types of condition.
Q233 Dr Stoate: I should like to
look at some of the options in the Green Paper and see where we
go from there. The Department of Health told us last week that
the voluntary co-payment options in the Green Paper were based
largely on the work by Derek Wanless which of course he did for
The King's Fund but they also said there were some important differences.
Can you help us with those differences?
Mr Humphries: Yes; certainly.
The Green Paper does echo the main principles of the partnership
model which was put forward in The King's Fund review carried
out by Sir Derek Wanless. The central idea is that funding of
care should be a shared responsibility between the individual
and the state. That was what the Wanless review said and that
is what the Green Paper has echoed in its partnership model. There
are some differences however. The first one is that in The King's
Fund proposal the proposal was that 66% of the cost of the care
would be met by the state. The Green Paper is putting that proportion
lower; putting it between one quarter and one third. The other
very significant difference is that in the original King's Fund
proposal, on top of that 66% there was a proposal that for every
pound the individual contributed on top of that towards the cost
of their care the state would match fund. That aspect is not present
in the Green Paper version of the partnership option. We think
that is an important component of the original partnership.
Q234 Dr Stoate: I was just going
to ask you whether you thought that mattered and you think it
does.
Mr Humphries: Yes. Certainly the
review team which carried out that review thought it mattered
and I am inclined to agree with that. One of the sources of unhappiness
about the current system is that it penalises people who make
provision for themselves and it does not actually encourage or
incentivise people to contribute towards the cost of their care.
Q235 Dr Stoate: And you think the
Derek Wanless model does?
Mr Humphries: Yes.
Q236 Dr Stoate: So what you are saying
is that the Derek Wanless model would actually encourage more
people effectively to make arrangements for themselves.
Mr Humphries: It would and that
gave it a significant advantage; not an overwhelming advantage
but a significant advantage when compared with other ways of paying
for care.
Q237 Dr Stoate: That is interesting.
Some people say that the co-payment model is flawed because anyone
with high needs and high assets could still end up with an uncapped
bill. Is that a good situation or a situation that you recognise?
Mr Humphries: It is the only way.
Yes, I think that is the case but the only way you can avoid an
uncapped bill is by putting a cap on it and that means either
a voluntary or a compulsory insurance arrangement. I do not see
any way round that for people with very large assets.
Q238 Dr Stoate: Presumably people
with completely uncapped possible liabilities are not going to
be very happy with effectively funding other people's care. Surely
the incentive for them would just be to opt out because they face
unlimited care costs anyway.
Mr Humphries: Yes and that is
one of the tradeoffs which the funding reform option has to address.
Q239 Dr Stoate: One of the advantages
of the Green Paper effectively is that those with higher means
and lower need will effectively fund those with lower means and
higher need and that would go counter to that view.
Mr Humphries: Yes.
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