Health CommitteeWritten evidence from Savitri Hensman (SC 53)

1. Summary

More funding is indeed needed for social care.

The Dilnot Commission proposals however are flawed in several ways.

It would be unhelpful to charge “hotel costs” for NHS continuing care.

The actual costs of care are often far higher than the notional costs (especially if the value of carers’ time is counted), and the costs of care would still be excessive for many people.

Adopting a “more consumerist” model of care may raise expectations, and lead to tension between users and carers on one hand and commissioners and providers on the other if these are not fulfilled.

Universal taxation principles would be more just in paying for care, as happens with other public services.

The principles of personalisation seem positive, but it needs to be adequately resourced and service users should not be pressured into receiving direct payments, though support should be available to those who want this. User-led organisations may have a valuable role.

2. Background

2.0 I live and work in London. I have been a carer for about 23 years, supporting family members of various ages, including managing direct payments for a relative (now deceased). I am head of research and policy at a social enterprise, and much of my work focuses on health and social care policy and involvement at a local and national level, but I am writing in a personal capacity.

3. Practical and Policy Implications of the Government’s Plans for Funding Social Care and Dilnot Commission Proposals

3.0 While successive governments have been reluctant to introduce any measures that will substantially increase public funding for social care, it is important to act boldly. The current situation is unsustainable.

3.1 The Dilnot Commission proposals seek to improve an unjust and inadequately resourced system. However some of the proposals are likely to cause injustice and practical problems.

3.2 Key flaws in the recommendations result from weaknesses in the body of the report, in particular:

the notion that “shared responsibility” between individuals or families and the state involves additional payments for public services, whereas social care users and carers have usually paid National Insurance and other tax, and often pay extra (in cash or kind) even for partly state-funded care, and contribute to society in other ways;

making calculations on notional costs of care, based on assessments by cash-strapped local authorities and sometimes inadequate even to meet basic human rights standards let alone ensure a reasonable quality of life for frail older and disabled people. The actual cost of support may be far higher;

failure to take account of the raised expectations that would result from a more “consumerist” model;

failure to recognise the seriousness of introducing payment for NHS-funded care that was hitherto free at the point of delivery;

focusing on housing as a resource of financial value, rather than somewhere to live and a place to which residents and families feel emotionally connected;

failure adequately to address health inequalities; the proposals are regressive, most benefiting those who are wealthier. But widespread poverty among many older and other disabled people and their families is a serious social problem.

3.3 If “hotel cost” charges were introduced for NHS continuing healthcare if delivered outside people’s homes, this could potentially open to the door to further charges for, say, longer hospital stays. This is problematic. It might also cause problems in hospital discharge. Suppose, say, that a man had a stroke, and after receiving acute care was invited to move to a rehabilitation unit funded through NHS continuing care, but knew he would have to pay “hotel costs” until, hopefully, he was well enough to return home, he might be hesitant, especially since he might also face additional expenses relating to his impairment (eg aids and adaptations).

3.4 Because of the enormous uncertainties about the overall costs of funding care (which fluctuate with demography, technology, social expectations, property values etc), insurance companies might well be reluctant to sell schemes that would not require very high premiums, which many people on low and middle incomes would find prohibitively expensive. In general, ensuring that adequate and affordable financial products were on offer would be difficult. It is likely that many individuals and families would hope that they would not need longer-term care (which in many cases would be correct), and those who did become disabled in later life might then have to pay the full costs.

3.5 While the Dilnot Commission proposals would generally reduce these (at least for people requiring residential care), many people would still have to sell their homes. It should also be noted that the cap applies to notional rather than real costs of care and does not take account of “hotel costs”, so in reality families might pay far more than £35,000 for care. If carers (other than spouses or civil partners) live with the person cared for, they might still be left homeless.

3.6 If paying substantially for care at the point of delivery, or taking out insurance or other costly financial products, users might well expect more hours of, and higher standards in, care than many currently receive, as well as a lower eligibility threshold. And carers who already put in many hours of care unpaid (both those on carers’ allowance and others who also carry out paid work or are pensioners) may feel that they should have far more time off than will in practice be available, if care is still heavily rationed. They may continue to feel “conned” if they do not get “value for money”. And confrontations with care managers would be likely to escalate.

3.7 The “potential future changes” include counting housing value as an asset in future financial assessments for home care and NHS continuing care users (some of whom live in their own homes). This would badly affect numerous service users with low cash savings but their own homes. To begin with, where would they live if they were forced to sell their homes to pay for care? This should be dropped.

3.8 Universal taxation principles, where the cost burden was proportional to earnings, other income or assets, would be more just, and easier to manage. So, for instance, people might pay more if earning well in their middle years, or if they received a substantial share income, towards their care in later life. The wealthy would still benefit from not being at risk of losing their houses, but the cost would be better adjusted to people’s ability to pay.

4. Personalisation

4.1 The principle of tailoring care to individuals, and giving them more control is praiseworthy. However it is important that funding for care is transparent and at least sufficient to ensure a basic level of support, which some resource allocation systems do not achieve.

4.2 People should not be pressured to accept direct payments unless they wish to do so, especially since many have depression, dementia or other mental health problems. There should however be more support available from social services and user-led organisations to enable brokerage and other measures t give users more control, without necessarily giving them greater legal liability (eg as employers) and administrative burden.

October 2011

Prepared 13th February 2012