Social care has never been free at the point of delivery in the same way as health care. There has always been a means test for social care. And the distinction between health and social care has meant that more and more care, especially in cases such as dementia, has been redefined as social care by stealth.
The first decade of the 21st century saw an assault on older people’s care.
Eligibility criteria were tightened. In 2005 half of all councils provided support to people assessed as having moderate care needs; by 2011 that figure had fallen to just 18 per cent of councils. Moreover it is a reflection of the last government’s priorities that while spending on older people’s social care increased by less than one per cent between 2004 and 2010, the NHS saw increases of 27 per cent, the police of 20 per cent and schools 12 per cent.
Home care and residential care were increasingly privatised. There is nothing wrong with that in principle, but the budgets were not sustainable given the demographic changes. Local Authorities were, and still are, paying rates significantly less than the cost of provision.
The means test for residential care is a cliff face. If your savings, including your home, exceed £23,250 you are liable for the cost of care. It is this injustice that the Dilnot Commission seeks to remedy. Amongst many improvements recommended by Dilnot is the raising of the threshold to £100,000 and a cap on the total amount any one person would pay at between £25,000 and £50,000. The Dilnot Commission has costed its proposals at £1.7 billion. Those working at the front line however are nervous of how this new money will be found.
There are already insurance products that can be taken out on retirement (and later) that will protect people against having to sell their assets at a later date to fund residential care. But this is a limited market at the moment. The Government needs to discuss with insurers the scope for improving this market. It is not unreasonable to expect people who can afford to do so to contribute to the costs of any residential accommodation they require, either through insurance or via direct co-payment.
There should also be more care home places available for purchase on a leasehold basis. For instance, some of the new Extra Care housing that is now in place can be purchased. This model enables an older person needing care to purchase an asset which, although it might decline with the amount of care required, will not dissipate at the same rate as money spent in care home fees.
The funding structure proposed by Dilnot is an improvement even if the actual numbers are not necessarily affordable. If the structure was introduced at a lower threshold with a higher cap, the system would be fairer than the current means test at least.
Lord Warner, the former Labour health minister and member of the Dilnot Commission, argued in his evidence to the Health Select Committee at the end of last year that some of the savings in the NHS budget could be used to supplement the adult social care budget.
One of the many positive aspects of the Government’s NHS reforms is the integration of health and social care budgets. The new Health and Wellbeing Boards, which bring together health professionals and local authorities, will exercise influence over the commissioning of services. They should champion the redirecting of money and services into what has traditionally been the remit of adult social care. The Health Select Committee went further this week and recommended fully joined up commissioning for health and social care. The committee proposed a single process for the commissioning of older people’s health, social care and housing services.
There is no new money. But there is a large and protected NHS budget that needs to be better spent through a shift of resources from acute to preventive care. This can be seen clearly in my borough of Dudley where, according to figures from the Department of Health, just 3 percent of the Primary Care Trust’s £500 million budget will be given to the local authority for public health. Dudley spend approximately £100m on adult social care which equates to considerably less than 20% of health expenditure when health spending at Strategic Health Authority and nationally commissioned NHS services are factored in.
The targeted £20 billion of NHS savings currently being delivered is a good place to start. Directing ten or twenty percent of those savings into adult social care would reap dividends by preventing more expensive interventions later on in life. We simply cannot afford to carry on short changing social care.