Care and welfare of older people

The political and legislative changes ahead

Sacrificing a number of its other clauses after opposition in the House of Lords the Government got the Health and Social Care Act through before the General Election so paving the way for free nursing care to be available in nursing homes by October thus meeting the promise in last summer’s NHS Plan.

Beyond that we know very little. The legislation passed by both Houses tackled the issue by prohibiting local authorities from paying for nursing care – a rather obtuse way of giving people enhanced rights. The method to deliver free nursing care is still an unresolved matter but the Department of Health approach is to assess people’s needs against four broad bands. If you are assessed as a high user of nursing services you could qualify for a subvention of £100 per week. A low user would qualify for £25 and intermediate bands would be set at £50 and £75. The assessment will be made against ‘services provided by a registered nurse involving either the provision of care or the planning supervision or delegation of the provision of care other than services that do not need to be provided by a registered nurse.’ The funding will come from health authorities and primary care trusts funds which have already been allowed for in the overall cash-limited allocation.

Clearly this will be almost unworkable. People’s needs vary over time and an assessment today however well conducted (and the process remains opaque) will not necessarily apply tomorrow. The sums of money seem rather arbitrarily selected and will lead to endless complaints from people who feel they have been assessed unfairly. The care home owners are unaware of how and when they will be paid and what they should be charging their residents. The idea that all the assessments will be in place by October when so much still remains undecided is a fantasy so we will have all the problems of backlogs and back payments. This is a poisoned chalice for incoming long term care minister Jacqui Smith.

Two other financial arrangements in the NHS Plan are rolling forward. The capital limits for receiving the Residential Allowance were increased in April to £11 500 and £18 500 but what will happen to these in 2003 is also unclear. In 2003 when Pension Credit is due to be implemented the notion is that capital limits for MIG applicants will be abolished with applications being assessed and MIG and Pension Credit awards being based on people’s real incomes. How this regime will dovetail with funding long term care costs is presumably still under consideration though in practice most people qualifying for MIG and Pension Credit would probably have capital assets of less than £11 500. The disregard on housing equity for three months (why three months? – is this going to prove anther controversial arbitrary calculation?) was introduced in April too but there is some evidence that some local authorities are not implementing it. Indeed so tight are local authorities’ budgets for the provision of care that all sorts of delaying devices are being deployed to restrict the numbers of people going into care homes at public expense.

Meanwhile the Coughlan judgement still stands though since it flowed from a judicial review the onus remains on individuals to argue that their circumstances are parallel. But another interesting development on the health front is that the Government intends that primary care trusts will be responsible for 75% of NHS expenditure which potentially impacts on the provision of nursing care. The emerging role of primary care trusts is going to need more clarification and possibly legal initiatives to determine the extent of their duties and responsibilities. There will be more legislation in the NHS Reform Bill to be introduced in this Parliamentary Session.

The providers of care home services are going through a lean time and there is a steady decline of beds available in the sector as a lot of the smaller homes close. Perhaps as many as 50 000 beds were lost and some 800 home closures during the course of last year. This will obviously have a bearing on consumer choice particularly in rural areas with more limited populations. The combination of rising wage levels and the drive for higher standards of care (heralded by minimum income legislation and the Care Standards Act – both good strategies in their own right) is adding inexorably to the cost of care provision whilst local authorities buying well over half of it are facing budgetary constraints. The National Care Standards Commission cannot arrive too soon and start to play its role as a referee of how the sector is performing overall. It will need to articulate authoritatively that we have been kidding ourselves about the real costs of providing good care and that it is urgent that we make a more realistic assessment of the money available for care provision.

This will not be the message the Government wants to hear. Its preferred strategy outlined in the NHS Plan is to develop Intermediate Care – another policy which is good in its own right but is quite wrongly positioned as a way of dealing with long term care. The concept is to put enough resources into rehabilitation and the support of independent living so that people will not need long term care but crucially it is envisaged that this help will be provided for a period of up to six weeks. The policy will doubtless be good from the perspective of improving convalescence and arrangements around hospital discharge and should prevent the all too frequent readmission to hospital because of the inadequacy of current practice in this area. It ought to ease pressure on the hospital system. But what it will not do is provide the long term community support and investment which may reduce the numbers of people presently looking for a care home place. It completely misreads the nature of the disabilities and the degree of dependency of the people who now use the services of the care home sector. And being located within the NHS it perpetrates the medical model of care which inevitably marginalises the role of social support such as help with shopping transport and improvements or adaptations to an individual’s home.

Scotland is paddling its own canoe. The concept of providing personal care (as defined by the Royal Commission) free is under examination by the Care Development Group. This is due to report to the Scottish Parliament in August and a Long Term Care Bill will follow. The politicians in Edinburgh are enthusiastic about going down this route and though there has been considerable pressure from Westminster there will be a lot of embarrassing words to eat if the decision does not go this way. The First Minster is on record as expecting free personal care to be in place by April 2002. The Finance Minister has announced to the Scottish Parliament that money is in the budget for the next two years (£200m) to support the recommendations of the Care Development Group. But if this is rolled out as expected it will create a number of anomalies not least around the financial responsibility for people who chose to move into or out of Scotland. It also raises the issue of the Attendance Allowance which as a social security benefit is a reserved power of Westminster so we could have an interesting situation where Scots both receive free personal care and qualify for an Attendance Allowance. The whole nature of the devolution settlement may need to be re-examined.

The Liberal Democrats of course had free personal care as a manifesto promise and laid considerable weight in their election campaign on their proposals for older people. As the Party with most to show from an election result which was otherwise fairly static this could be said to have been a successful and popular strategy. If the introduction of free nursing care in England is as complicated and confusing as seems probable and Scotland goes ahead with the broader definition of free personal care we could see the whole issue develop as a major political debate. Older people will be in the spotlight in this parliamentary session anyway as the Government will be introducing its Pension Credit Bill. This too has several aspects which at present are far from clear. It is uncertain how the Pension Credit will interact with Housing Benefit and Council Tax Benefit and there is the mighty administrative problem of drawing half our retired population some 5.5m people into the means-tested system. This latter point is likely to generate the greatest controversy since it is a clear and massive shift to means testing and the abandonment the redistributive flat-rate pension. Anticipated to reach £77 pw by 2003 the state pension will meander on linked to prices whilst MIG (at £100 pw) and Pension Credit soar upwards in line with earnings so drawing more and more people into its trawl every year. Calculating future entitlements and therefore doing any serious forward planning will be inspired guesswork. Meanwhile some actuaries are saying it will be unsustainable after a few years so we will have another upheaval over pensions.

The Government is also committed to developing the domiciliary option and supporting carers and backing the Direct Payments scheme. This last was extended to older people (over 65) last February and although take-up has been slow there are plans to make it mandatory for local authorities to offer Direct Payments. Slow take-up may at least be due to the complexity of organising one’s own care package involving finding potential service providers and dealing with tax sick pay holiday pay national insurance etc. Agency services can take a lot of the aggravation out of that process perhaps at the cost of charging slightly more and so delivering slightly less care. Agencies have hitherto been totally outside the formal care sector but from April 2002 those wishing to contract with local authorities (probably the majority) will be subject to inspection and registration. This may give potential customers more confidence and could herald a more widespread development of Direct Payments. But Direct Payments of course come out of the same local authority care pot which is already under severe stress.

New guidance on continuing care has now emerged from the Department of Health. It helps to draw together several strands from previous guidance notes and re-affirms the Government’s wish to make progress in this area.

But overall hopes of progress would appear slim whilst the funding seems so grudgingly and haphazardly delivered. Older people probably for the first time were a conspicuous part of the rhetorical exchanges in the General Election and certainly there are enough issues affecting older people which will command attention in the new Parliament. Labour clearly has an unchallengeable majority but the Prime Minister had to acknowledge during the campaign that taking pensioners for granted with the 75p pension award had been a mistake. There are grounds for believing that the free nursing project will turn out to be a mistake too. Pension Credit will deliver quite substantial increases to the least well off but at a price of complexity and means testing which may depress take-up and create new anomalies. The Pensions Service (the name by which the DSS is re-inventing itself) will be launched in June 2003 and will be adopting a whole new approach to benefit information and claims procedures. Altogether there will be a lot to watch with probably a few fireworks included.

Mervyn Kohler Help the Aged