Memorandum by the National Pensioners
Convention (SC 22)
SOCIAL CARE
SUMMARY
— Social Care has long been the "Cinderella
Service" of the welfare state; often finding itself overlooked
and under-funded. The publication of the new green paper entitled
Shaping the Future of Care Together offers the chance to
properly address these issues.
— The proposal to create a National Care
Service which will clearly set out entitlements is welcome, but
the green paper's instant dismissal of a tax-funded payment option
undermines such a proposal. The fairest and most equitable way
of providing a universal, free at the point of need National Care
Service is through general taxation (rather than through any of
the other models put forward or the use of existing care or disability
benefits) and there is wider support for this amongst the public
and other stakeholders than the government seems prepared to acknowledge.
— The personalisation of care must not
be seen as the same as individual budgets. Individual budgets
raise serious concerns about personal safety, the quality of care
and unacceptable burden of responsibility that will be placed
on many vulnerable older people.
— There needs to be greater recognition
of the role and value carers provide, including payment of the
carer's allowance to older people.
— There should be an acknowledgement of
the changing and weakening nature of the regulation of care services
that has taken place. Any new National Care Service should be
properly regulated with regard to registration, standards, monitoring
and inspection of care providers and those employed in the care
sector.
1. INTRODUCTION
1.1 For years, social care has been the
"Cinderella" service of the welfare state; often lacking
sufficient funds or enough political interest to raise its profile.
Now, with the publication of the long awaited green paper on care,
entitled Shaping the Future of Care Together, it is finally
the focus of national debate. The green paper identifies a number
of problems with the existing care system, namely its complexity,
the unfairness of means-testing, a postcode lottery of funding
and standards and its lack of personalised services. Alongside
this is the perceived growing pressure of an ageing population.
The one issue on which there can be little doubt, is that the
existing social care system is failing the most vulnerable members
of our society and needs urgent attention.
1.2 A snapshot of social and long-term care
provision in England shows the following:
Domiciliary Care
— Around one million older people receive
some form of care in their own home
— The private and voluntary sector care
providers receive around £9.3 billion a year in public
funding
— An estimated £5.9 billion is
spent by individuals on social care either through private contributions
or through charges
— A huge unmet need and care gap exists
between the services older people require and what they actually
receive because services are being rationed. As a result, only
those with high care needs qualify for assistance. This unmet
need places an additional burden and strain on many relatives
and friends who provide unpaid care (eg. 1.2 million men
and 1.6 million women over 50 are unpaid carers)
— All care in the home is means-tested,
and individuals need an annual income of less than £13,000 to
receive services free
— The charges for those with income above
this level, vary widely depending on each local authority area,
thus creating an unfair postcode lottery
Long-term residential care
— In 2003, out of 500,000 care places:
69% were in the private sector, 17% in the public sector and 14%
in the voluntary sector
— Private care is worth around £6.9 billion
a year
— One in four care workers leave their
jobs every year and this high turnover is almost entirely due
to poor pay and conditions of employment
— Within care homes, only one member of
staff is required to have an appropriate care qualification (but
even they do not have to be situated on-site)
— Those with assets (including the value
of their property) of more than £23,000 must fund their
own care. Those between £13,000 and £23,000 are
means-tested and pay a proportion whilst those below £13,000 have
their charges paid by their local authority. Average charges are
around £800 a week
1.3 This submission will conclude by proposing
an alternative vision of social care provision which acknowledges
that the real challenge facing today's social care system is a
lack of funding and a short-term political approach to the care
of older people in their own homes and the wider community.
2. THE COST
OF SOCIAL
CARE
2.1 In the year 2006-07, local authorities
spent £14.2 billion on social care for all adults, of
which 61% went on services for older people. The amount spent
on home care was around £2.3 billion, reaching just
over 1 million adults, with around £6.3 billion
being spent on residential services. From 2001-02 to 2005-06,
the percentage of gross expenditure on care services with private
and voluntary providers grew from 59% to 72%—amounting to
£9.3 billion in total. Further grants were also made
by local authorities to over 5000 voluntary organizations
providing care services in the community.
2.2 The green paper states that: "Two
in every three women and one in two men can expect to have high
care needs (difficulty getting dressed, bathing etc) during their
retirement." It goes on to argue that the average lifetime
care cost for a 65-year-old in England is currently £30,000—claiming
that at least 50% of pensioners have costs of £25,000 to
£100,000 and over. For example, just four years of care
and accommodation in a care home could cost over £100,000.
2.3 An estimated £5.9 billion
is already spent by individuals on social care either through
private contributions or through charges. In a recent NPC social
care survey[85]
(see Fig 1), almost half of all users were paying up to £50 a
week for home care; with up to 20% paying between £100 and
£200.
FIGURE 1
2.4 In the Comprehensive Spending Review
2007, the government announced a 1% real terms increase to the
revenue support grant for local government—with Department
of Health funding for adult social care of £190 million
by 2010-11. However, these amounts are insufficient to provide
care for all those in need and the fact that the government's
introduction of individual budgets is actually anticipated to
save 3% continues to show how little financial and political priority
this issue is given.
3. FAIR ACCESS
TO CARE
SERVICES?
3.1 In 2003, the Fair Access to Care Services
(FACS) guidelines were introduced as a response to the outcry
against the "postcode lottery" which allowed local authorities
to use different criteria for assessing the need for care. The
guidelines state that every local authority in England must use
four standard criteria: critical, substantial, moderate and low
to assess and deliver social care. These are described as being:
— Critical—where life is in danger;
or serious abuse or neglect has or might occur
— Substantial—where abuse or neglect
has occurred or might occur; or the individual is unable to carry
out the majority of personal care or domestic routines and there
is no-one available to assist
— Moderate—where the individual is
unable to carry out several personal care or domestic routines;
or several of their family and social roles
— Low—where the individual is unable
to carry out one or two personal care or domestic tasks; or one
or two of their family and social roles
3.2 However, the Commission for Social Care
Inspection (CSCI)[86]
in one of its last reports before it became part of the Care Quality
Commission, stated that "most councils now only help people
with substantial or critical needs, leaving many needing help
to fend for themselves or rely on friends and family for support."
Furthermore, the CSCI found that:
— 75% of local authorities do not provide
the moderate and low criteria
— 160,000 households are denied help
— 1.2 million men and 1.6 million
women over 50 are unpaid carers, saving the country £87 billion
3.3 The recent National Coalition on Charging
report[87]
also revealed that rising charges for people receiving care in
their own homes, were causing disabled and older people in England
to reduce or even stop their support services. The report found
that:
— 80% of people surveyed who no longer
use care services say charges contributed to their decision to
stop their support
— 29% of respondents did not feel their
essential expenditure (related to impairment/health condition)
was taken into account in financial assessments to pay charges,
meaning they have to choose between essential support and equally
essential food, heating or utility bills
— nearly three quarters (72%) of people
surveyed believe the government should think about the charges
people pay for support at home in any plans to reform adult social
care
— a fifth (22%) of people surveyed who
currently use support suggested they would stop if charges increased
further
3.4 By contrast, those with low and moderate
needs are forced to either rely on voluntary organisations or
family members to help, or go without. Naturally, this situation
can lead to a worsening of their condition and their needs may
eventually reach a substantial or critical level. The cost of
providing this extreme level of care is therefore more expensive
in the long term than would have been the case with earlier intervention;
when needs are at a lower level.
3.5 This point was clearly evidenced by
the Prime Minister's recent announcement at his party's conference,
when he stated that in the interim from next October those with
the highest needs would receive free personal care in their own
homes. However, the estimated annual spending of £670 million
would work out at just £38 of care a week for each of
the 350,000 people affected—far short of the estimated
£165 cost of the average 11-hour package of domiciliary
care provided in 2007. Furthermore, the failure to also help those
with less severe needs will ultimately lead to a worsening of
their condition and a subsequent greater demand on higher levels
of care and support.
3.6 In addition to providing care to all
in need, there should also be the active promotion of prevention,
low level care, advice and advocacy to enable older people to
retain their ability to live independent lives as long as possible
and to obtain the services they need. Advice and advocacy should
be available both for people who need publicly funded care and
for those who under the existing system fund their own care.
4. THE CARE
GAP
4.1 A shortfall in care can occur when people
either do not access services (eg. due to cost or ineligibility)
or when the services they do receive fall short of their requirements.
This is particularly a problem amongst those with moderate or
low care needs. Over a three year period up to 2006, the number
of older people using services dropped from 867,000 to 840,000—at
a time when the population aged 75 and over increased by
nearly 3%. Since 1997, the number of households receiving supported
home care has fallen from 479,000 to 358,000 in 2006.[88]
It is also further estimated that the number of older people who
get no care or informal care, despite being in need, is 381,000.
4.2 Even more concerning, is the poverty
of expectation expressed by many older people. The CSCI found
that individuals had low expectations and modest desires about
what help they might get when entering the social care system.
Many said they were receiving less support than they felt they
needed—or were trying to muddle through the system without
any help or guidance.
4.3 The exclusion of lower bands of eligibility
means that people have particular difficulty in getting support
with practical—yet vitally important tasks—such as
housework, gardening and shopping. The NPC social care survey
found the care gap included a lack of help with cooking, gardening,
housework, visiting day centres, going out, shopping, DIY/maintenance,
adaptations to property (ramps, showers etc) and bathing.
4.4 Recent changes to the Supporting People
Fund allocated to local authorities have also led to cuts in care
services and support for older and disabled people. The decision
not to ring-fence budgets has, amongst other things, hastened
the unpopular removal of many on-site wardens from many sheltered
housing complexes.
4.5 Ultimately, the burden of the care gap
is felt by the individual's family and carers. Despite a commitment
to "valuing" carers through a Carers' Strategy which
will come into reality by 2018, there is no suggestion of changing
the current rules on the carer's allowance which prevents someone
in receipt of a state pension from claiming. Many support services
are also unavailable to existing carers. This can lead to passive
neglect of their loved ones, because they are unable to cope.
5. A POSTCODE
LOTTERY IN
CARE CHARGES
5.1 Despite the introduction of the FACS,
a postcode lottery within the provision and cost of social care
still exists. The NPC social care survey found there were clear
variations in the amounts charged for an hour's worth of care
(see Fig 2).
FIG 2
5.2 For example, whilst in one London borough
the charge for home care was £17.50 an hour, in another
it was £25. What is also clear from the survey is that the
lack of a nationally agreed set of care charges (including a maximum
charge) damages the legitimacy and credibility of the whole social
care system.
6. FUNDING OF
CARE
6.1 The green paper outlines five possible
funding options, two of which; individuals paying for everything
and tax-funded care are instantly ruled out of the debate. The
three remaining options, Partnership, Insurance and Comprehensive
all continue to involve an element of means-testing and unfairness.
By contrast, the Caring Choices Report[89]
in 2008 found widespread demand for change. In particular
90% rejected the present means-tested system, preferring a stronger
universal element determined by care need rather than income or
wealth.
6.2 It is our view that the state should
provide a high quality, comprehensive system of social care that
meets national standards and is available to everyone, based on
their care needs. Despite the green paper's claim, the tax-funded
option should therefore be reintroduced into the debate.
7. THE PERSONALISATION
OF CARE
7.1 The new care green paper makes it clear
that the personalisation of care is at the heart of the government's
proposals for reform. Under the Conditional Resource Enhancement
(CRE) scheme, an assessment is made of the user's needs in terms
of hours, which is converted into the £s required to deliver
that care, and this is provided in the form of an individual budget
which is given to the user to spend as they choose. Local authorities
are therefore gradually handing over responsibility to individuals
to enter into the commissioning process.
7.2 However, the introduction of individual
budgets raises serious concerns. Many people will be met with
a bewildering choice of care providers, consisting of local authority
services, private companies and the voluntary sector. The individual
budget holder therefore has to be directed to the "experts"
offering advice and services and is inevitably drawn into the
growing "market" where private companies, the voluntary
sector and charities compete for contracts to supply such services.
7.3 Ultimately, this will transfer risk
and responsibility either to the individual who needs social care
or to their relative(s). They must now take on management tasks
or deal directly with the private companies which will provide
their advice or care for profit. However, there is no clear guidance
for the individual when becoming an employer.
7.4 Fundamentally, expecting some of our
most vulnerable older people to take on the responsibility of
employers—recruiting, dealing with payroll matters, contracts,
employment rights and discipline—is simply unrealistic.
In effect, rather than giving choice, individual budgets open
up opportunities for abuse by those who manage the individual's
affairs and those organisations who see it as a chance to win
contracts and make profits.
7.5 In addition, individual budgets raise
serious concerns about the safety and protection of vulnerable
individuals who will be responsible for employing their own care
workers, who at present are exempt from registration, regulation
and inspection. This dangerous and alarming situation must therefore
be addressed as a matter of urgency, particularly when considering
that such a major shift in policy has never been approved by Parliament.
8. MONITORING
AND REGULATION
8.1 In recent years there has been a systematic
weakening of the rules and regulations surrounding the provision
of care. The CQC would seem to have uprated many care homes in
an attempt to reduce the number of site inspections required,
whilst at the same time downgrading the standards for regulating
and inspecting domiciliary care in an individual's own home.
8.2 It is estimated that 60-70% of home
care in future will be provided by individuals (either directly
employed by the user or self-employed) because they will be able
to get more money than if they worked for an agency or contractor.
However, they will not be regulated by the CQC and there will
be no requirement for a CRB check, training or qualifications.
8.3 A return to proper regulation and standards
is therefore essential to any proposals for reform. New requirements
for registration of care providers should be re-introduced (drawing
on previous CSCI guidelines) for 50% of staff in care homes and
all new staff working in domiciliary care to be suitably qualified.
In addition, care staff who are employed either by an individual,
local authority, agency or care home company should have an appropriate
qualification as a minimum standard as an essential requirement
for registration and the General Social Care Council should be
required to register, inspect and regulate all paid care workers.
9. AN ALTERNATIVE
NATIONAL CARE
SERVICE
9.1 It is a matter for celebration that
people live longer and that this demands that society should provide
for their needs, even if it means reordering the priorities for
public spending. We see no evidence that today's workers are not
willing to pay sufficient taxes to fund the kind of system that
they wish for their own parents and for themselves in due course.
Reordering public spending priorities and addressing the need
for increased taxation, diverting money from private health care
and introducing a windfall tax on their profits would provide
sufficient resources for a 21st century social care system worthy
of the name. Such an alternative National Care Service is summarised
below:
1. Prevention services
Care, support and advocacy will be available to enable individuals and their carers to stay independent, well and socially included for as long as possible in their own homes, including sheltered housing.
| Those living in their own homes, or prior to returning home from hospital or residential care, will receive the necessary preventative and care services and support appropriate to their needs. This should include home adaptations and equipment, as well as domiciliary care, support and leisure services that would help individuals and their family carers to manage in their own homes.
|
2. National assessment
There will be nationally determined assessment criteria which will be used throughout England to assess care needs.
| Individuals will have the right to have their needs (critical, substantial, moderate and low) assessed and receive the appropriate care from a universal menu of services. At the same time family carers' needs will also be assessed. The postcode lottery in the quality, availability and cost of services will cease under the tax-funded National Care Service.
|
3. A joined-up service
Individuals and their family carers will be entitled to receive a variety of care services from a range of regulated providers, which will be of the highest standard.
| There will no longer be a divide between health and social care
provision and the process of accessing care will be transparent and easily understood. All services will operate to nationally agreed standards which will be properly regulated and enforced. These shall include issues of staffing, pay and training requirements.
|
4. Information and advice
Individuals and their carers will be able to easily access
straightforward information and advice about their entitlements to services at every stage of their care, and advocacy when required.
| Whether in the community, care home or hospital, individuals and their family carers will be entitled to receive information which clearly explains their entitlements to care, how to access the services available and their rights as a service user. Recognition will also be given to those who need assistance from a third party/advocate/friend to help them exercise their entitlements.
|
5. Personalised care and
support
There will be a range of care and support services made available that can be tailored to individual personal circumstances and needs.
| Care and support will be designed and delivered around an individual's needs through a regulated provider, whilst the responsibility for managing budgets will lie with the local authority or NHS. Additional financial and practical support will also be available to family carers.
|
6. Fair funding
Society will share the cost of
providing care for those in need.
| A tax-funded universal National Care Service will entitle individuals to free non-means-tested care, support and accommodation appropriate to their needs.
|
October 2009
| |
85
NPC Survey of Social Care Users and Providers 2007 Back
86
The State of Social Care 2006-07, Commission for Social Care Inspection. Back
87
Charging into Poverty, National Centre for Independent Living,
2008. Back
88
The State of Social Care 2006-07, Commission for Social Care Inspection. Back
89
The Future of Care Funding: time for a change, Caring Choices
Consortium, 2008. Back
|
