denotes premium content | Jan 9 2009 Feature
posted 15 Nov 2000 in Volume 6 Issue 1
A Long Term in Care?By Ray Avards
The government has responded to the recommendations of the Royal Commission on long-term care by combining changes for funding care with its proposals for the redevelopment of the health service in the NHS Plan. How will these changes appear to older people, their relatives, friends and carers facing hard and difficult choices about long term care needs?
They will need to consider the consequences for personal welfare of individual options for care as carefully as any clarification of the rules for benefits or funding entitlements obtained. For those needing a lot of care, a future enabling some quality of life may be at stake. The choice may be a matter of life and death.
Community care
The future of community care may also be at stake in relation to these issues of long-term care. The NHS Plan has drawn critics, who have pointed out that it is still not clear who will ultimately pay for long term care (Tessa Harding Community Care 3-9 August “The Hole in the Plan”). I believe the first, and key, question that older people and their carers and relatives ask is not who will pay for the care I need, but where can I get it? Can I get the care I need at home?
The government’s decisions regarding long-term care are a continuation of a theme apparent since the genesis of community care. Older people with substantial physical or mental needs and without substantial resources of their own or commitment from relatives, friends or neighbours around them, face the prospect of entering a care home. Continuing care at home is unlikely as resources to meet it are very limited. This issue has been overlooked in the rush to analyse the consequences of the NHS Plan and changes in funding for local authorities and professionals or for benefits advisors. Community care funding remains synonymous with meeting the costs of fees in a care home.
The decision to go into care is only made as a definite or positive step by a small minority of older people. In most cases that decision is forced upon users or carers through lack of viable available or affordable alternatives. Often it is the result of a crisis in health, care or social circumstances. Once a move is made into a care home the situation appears irreversible.
The NHS Plan implies more intensive home care services and rapid response teams. It also proposes wider access to private care and nursing home beds to relieve hospitals of that care and provide rehabilitation. I share the concerns already surfacing about what this entails, if these are health services they will be treatment based. They will not provide long term care for chronic physical and mental needs at home. They will provide for the care of a few who can rehabilitate progressively and rapidly or who need help over a temporary crisis.
The Government has previously expressed a wish to see more patients transferred out of hospital and into care homes to relieve the pressure upon hospital beds. It is recognised that many older people receive inappropriate care in relation to their needs through inadequate provision or placement in different care settings. Those who enter care homes can face very different circumstances affecting the quality and levels of healthcare they receive compared to that in hospital. Moreover they do so without the umbrella of NHS responsibility, inadequate though that may be in individual instances. The possibility of returning home becomes more remote the longer they are in care. I wonder how many times government ministers have visited care homes, even well-run ones, and found active and effective rehabilitation programmes aimed at returning residents to their own homes? Imagine a bank that got those customers with ailing finances back on their feet then sent them off elsewhere. Units dedicated to recovery and rehabilitation are a different proposition and have already achieved successes independently in different areas of the country. It is not so much rapid reaction that is required for many older people, contrary to the government’s plans for intermediate care, it is the provision for ongoing care and support especially at home.
Benefits in care – Residential Allowance?
The planned revision of financial assessment under community care is about changing the system of charging for residential accommodation. As part of that change, Preserved Rights (PR) to income support and the Residential Allowance (RA) will cease in April 2002.
RA is intended to contribute to the cost of institutional care in the same way that housing benefit, for example, contributes towards the cost of sheltered housing. It is an element of income support making up an applicable amount for residents entitled to income support in commercially run residential care homes and nursing homes (for those over age 16). It is not payable for residents in local authority homes. It is worth £61.30 or £68.20 in Greater London in addition to income support personal allowances and premiums. In effect, RA enables local authorities to recoup the RA from the benefits agency towards the cost of care in private and voluntary homes.
Residents in local authority homes entitled to Income Support receive an amount equivalent only to the basic retirement pension, £67.50 of which £15.45 is for personal expenses. This has been a contributory factor in the transfer of many of these homes into private hands for, in addition to overheads such as maintenance, renewal of buildings and staff wages, local authorities face the responsibility for nearly all the costs of care for residents who do not have resources of their own above £16,000.
RA is a financial incentive that encourages local authorities and statutory agencies to favour the placement of older people in independent care homes. The government has proposed to transfer the RA to local authorities to enable more money to be available to use for alternative care options; a care allowance instead of an RA? Such a transfer of resources from social security payments to local authorities fits with proposals contained in the report by the Royal Commission favouring much greater support and rehabilitation for older people living independently in the community. The Government is also to do away with PR to higher levels of income support that still applies to residents who entered homes before the application of the NHS and Community Care Act to funding for fees in this respect in April 1993.
The survival until now of the PR to income support for fees in homes should not be a surprise, as community care charging against those with resources above statutory limits is derived from the means-tested benefits system. The guidance local authorities are required to apply to charges for fees in homes rests heavily upon the general regulations for income support under social security law. It is a system that is geared to the provision for subsistence at least cost, not as a provision for the actual cost of care.
RA is fundamental for anyone going through the fabled care home fees ‘benefits loophole’. For those with £10,000 or less, £241.10 (£248.00 in Greater London) can be obtained when RA is included with severe disability premium (under income support), and higher rate attendance allowance. In some parts of the country this remains sufficient to pay residential care home if not nursing home, fees.
The ‘benefits loophole’ enables local authorities to advise older people and their relatives to capitalise upon entitlement to attendance allowance. For those whose savings are below £16,000 and expecting to sell a house, it is an alternative to interim funding by the local authority. There will not be the necessity of seeking to reclaim AA later as a self-funder. In addition, income support, unlike local authority funding, will not have to be repaid.
As a result, individual older people and perhaps couples are still going into care without care assessments or consideration of alternative options; local authorities are well aware those who make their own arrangements can be treated as the exercise of private options for which they are not responsible. Their advisers in local authority financial assessment departments can argue they need to provide the public with advice about alternative options to pay for care. However, when residents go through the ‘loophole’ the real savings lie with the Local Authority which can seek to avoid responsibilities for needs and for costs of care altogether. In these situations where care assessment is not carried out, different options for care may remain effectively off the map of choice.
Costs of care at home
How will care at home be afforded as a real alternative to entering a care home? Each situation is very individual. The independent living fund is not open to older people and substantially less can be obtained in help at home under community care. Direct payments, available to older people in England are much more problematic for them to employ and may produce a few extra resources when related to the cost of employing carers to help with chronic, continuing and, especially, increasing needs. The burden of organising care is also much more likely to fall to spouses and relatives, usually women.
Let’s take the position of someone on AA/DLA with low income and savings, living within a generous local authority. Social Services could provide a maximum of 25 hours care at a minimum charge of £25pw. The average amount of qualified care for someone who is entitled to the higher rate of AA is likely to be at the very least 35 hours a week or 5 hours a day to manage getting washed and dressed, having a main meal dealing with medication and toilet needs, and going to bed again. As a comparison, for a carer (must be under 65 when first claiming) to qualify for the invalid care allowance from the benefits agency he/she must contribute 35 hours of care a week. This figure is related to the assumed care required for someone who is a recipient of AA/DLA.
The need for an additional 10 hours at least from a private agency in the above situation is likely to be at a rate of £10 an hour as a minimum, pushing care costs up to well over £100. There would be little change from the higher rate AA (£53.55) and RA (£61.30) combined. Once night cover is required the situation gets rapidly out of hand financially.
Any transfer of additional resources is likely to be reflected in increasing charges for care at home as authorities relate their costs ever more closely to the market. Local authorities already cross subsidise the care they provide, with those paying higher charges financing those paying less under the means test. The cost of this subsidy would simply buckle under the strain if a greater number were able to exercise this option. In addition these are open-ended commitments to meet the costs of increasing needs. This is why voluntary organisations pulled out of even limited charitable payments towards home care a long time ago.
The real costs of care at home are very individual in each case and difficult to judge or aggregate. The value bet is that local authorities will increasingly relate charges to actual cost and to charges by private agencies in the market. The floodgates will open once local authorities feel they will bear the burden of higher care costs at home in comparison to the economies of scale offered by residential care and nursing homes.
The NHS Plan for care
The plans introduced to scrap the RA and PR to higher levels of income support as part of the Government’s response to the Royal Commission’s long-term care proposals are not the forward looking measures they appear. In relation to the funding of care for older people they deal with anachronisms in the finance of care through income support. Local authorities must take up their role in assessment and funding under community care fully. Without substantial additional resources and support from health services and alternative housing provision they are unlikely to change their approach to their responsibilities for care and the costs of care which is to reduce both. Indeed, the need to scrap PR is a result of the inability of pre-1993 residents, whose care needs have increased, to afford the cost of nursing homes.
The NHS shifted the costs of longer-term care to the DSS in the 80s as higher levels of income support and contributions to shortfalls in fees by voluntary organisations, enabled people to be encouraged to enter care homes of their own volition. In the 90s local authorities have sought to use the benefits system and the so-called benefits loophole with similar results. They will also seek to minimise their responsibility for care at home. Their actions, in particular in relation to the rising costs of care at home are likely to continue to result in the transfer of responsibilities into the hands of the private care home providers, whatever the intentions of the government to the contrary in the new NHS plan.
The NHS Plan implies more resources for support in the community and more rehabilitation after hospital discharge and reflects the Royal Commission in this respect. Without more resources for direct care at home the outcome will still be more people in care homes and more money paid to providers of these facilities.
Waiting lists may be reduced as may acute beds occupied by those who may not need them in hospital, but the agony may continue for many older people sent to residential care and nursing homes for the rest of their days whether they need it, like it or not.
By Ray Avards
